LIMPRINT in Specialist Lymphedema Services in United Kingdom, France, Italy, and Turkey

Integrated lymphoedema and tissue viability service: improving patient and wound outcomes

This article will focus on the integration of tissue viability and lymphoedema services to improve outcomes for patients with leg ulceration. It will highlight why there is a need for lymphoedema specialist knowledge within the care of patients with leg ulceration and how the services are closely aligned. Lymphoedema can adversely affect wound healing and the article will provide case studies that highlight how developing a hybrid tissue viability and lymphoedema clinician or integration of the specialists can provide effective patient-centred care at reduced cost. The article offers potential strategies and suggestions on how to address inequalities in care and how to improve service provision.

UK survey on experiences of men with non-cancer-related lymphoedema: part one

This initial article delves into the methodology, methods and theories, while the subsequent article will centre on the discoveries, discussion and conclusion. The study aimed to address the research question: how do men perceive their engagement in the self-management of non-cancer-related lymphoedema? An interpretivist qualitative methodology was employed, utilising an online survey based on the validated lymphoedema quality of life tool (LYMQoL). The data underwent inductive narrative inquiry. The study incorporated theories such as hegemonic masculinity and the health, illness, men and masculinities (HIMM) framework. The findings will be detailed in the second article in this series. This article has delineated the objective, methodologyand methods, employing a qualitative interpretivist approach through narrative inquiry. The study incorporated masculinity theories, including hegemonic masculinity and HIMM. The second article will present the findings and their significance within the broader literature.

Vascular Diseases in Women: Do Women Suffer from Them Differently?

According to the World Health Organization, cardiovascular disease (CVD) is the leading cause of death among women worldwide, yet its magnitude is often underestimated. Biological and gender differences affect health, diagnosis, and healthcare in numerous ways. The lack of sex and gender awareness in health research and healthcare is an ongoing issue that affects not only research but also treatment and outcomes. The importance of recognizing the impacts of both sex and gender on health and of knowing the differences between the two in healthcare is beginning to gain ground. There is more appreciation of the roles that biological differences (sex) and sociocultural power structures (gender) have, and both sex and gender affect health behavior, the development of diseases, their diagnosis, management, and the long-term effects of an illness. An important issue is the knowledge and awareness of women about vascular diseases. The risk of cardiovascular events is drastically underestimated by women themselves, as well as by those around them. The purpose of this review is to draw attention to improving the medical care and treatment of women with vascular diseases.

A Snapshot of Lymphedema in Ireland: Results from LIMPRINT

Background: To estimate the prevalence and impact of chronic edema (CE) in two Irish health care settings as part of LIMPRINT, an international study developed and co-ordinated by the International Lymphoedema Framework (ILF), and researched in Ireland by the National Lymphoedema Framework Ireland (NLFI). Methods and Results: Data were collected using clinical assessment tools previously validated by the ILF. Three hospital settings were chosen, both an in-patient and out-patient oncology unit in Galway and a vascular out-patient unit in Dublin. Patients attending an oncology clinic or in an in-patient ward on a specified day were invited to participate as desired, and all patients attending vascular out-patients for a 4-week period were included in the study. All patients were assessed for the presence of CE, and if present, patients were asked to answer several questionnaires regarding diagnosis, available services, quality of life, and wound care where appropriate. The collection of data was anonymized and was inputted to a central database (Clindex). A total of 152 patients were assessed, 76 from the oncology service and 76 from the vascular service. Eighty-seven (57%) patients were female and 65 (43%) patients were male. The mean age was 65 years with a range 15-93 years. Twenty-five patients (16%) had CE, 8 (11%) in the oncology service and 17 (22%) in the vascular service. All the oncology patients were normal weight while almost 60% (n = 10) of the vascular patients were obese. Two (25%) of the oncology patients had a history of cellulitis, whereas seven (41%) of the vascular patients had a history of cellulitis. Four of the oncology patients (50%) received full lymphedema management whereas two oncology patients (20%) received no treatment at all. In contrast, in the vascular group, only two patients (12%) received full lymphedema management. Eight patients (47%) were receiving no treatment at all and seven (41%) were in compression garments and received skin care advice only. Conclusion: Though number of patients are small, these results highlight the high prevalence of CE in both oncology and vascular service patients as well as the disparities in management. In addition, there is a high incidence of cellulitis reported that is possibly not surprising given the low number of patients receiving full lymphedema care. Good data collection is essential if we are to provide and fund a comprehensive service in the future.

LIMPRINT in Italy

Background: To define the profile of patients presenting with chronic edema (CE) in three centers in Italy (Lymphoedema IMpact and PRevalence INTernational). Methods and Results: Data were collected in patients referred for CE between September 2016 and July 2017. A total of 1637 were recruited, 86.7% (1419) outpatients and 13.3% (218) inpatients with 80.6% (1319) female and mean age 54 years. Primary lymphedema occurred in 28.2% (461). In the 71.8% (1176) with secondary CE cancer occurred in 72% (846) and 28% (330) due to other causes. Data showed that 84.2% (226) had full upper body mobility, 15.5% (41) had limited mobility and 0.2% (2) had lost all mobility. Lower limb mobility status: 90.4% (1205) complete mobility, 8.4% (112) reduced mobility and 1.2% (21) wheelchair bound. Concurrent leg ulceration occurred in 32.9% (322) with 3.1% (51) having antibiotics. Treatment patterns varied with only 32.4% (530) receiving instructions in skin care, 61.2% (1002) multilayer compression and a further 67.8% (1110) compression garment with 17.6% (288) having sequential pressure therapy. Only 1.4% (23) had received psychological support. Out of the total 481/1637 (29.4%) were not prescribed any treatment. Only 50.4% (825) had access to subsidized treatments within the National and Regional Health Care System, whereas 49.6% (81) had to pay themselves with only half (50.9%) having access to treatment centers that were near their home. Conclusion: Results from this study and active lobbying have led to changes in reimbursement of care for primary and secondary lymphedema in Italy; this has led to a much more optimistic picture for those affected.

Prevalence and Impact of Chronic Edema in Bariatric Patients: A LIMPRINT Study

Background: Chronic edema (CO) is a complex condition, arising from different factors, including immobility and obesity. Edema and obesity can have a significant impact on quality of life of patients and their families. Understanding how to manage edema in obese patients is an increasing challenge for both patients and clinicians. As effective treatment options are limited for this population, it is more cost-effective for patients to lose weight before starting treatment. When patients cannot maintain weight loss, one option is to have bariatric surgery. This study was part of LIMPRINT: Lymphedema IMpact and PRevalence INTernational, a study with the aim of identifying the prevalence and impact of CO in different countries and health care settings. Study Purpose: To evaluate the prevalence and impact of CO among patients in a United Kingdom bariatric surgical service. Methods and Results: The gold standard pitting test assessed the presence of edema. General (EuroQOL-5 Dimensions [EQ-5D], RAND 36-Item Short Form Health Survey, Version 1.0 [SF-36], Generalized Anxiety Disorder 7-Item Scale [GAD-7] and Patient Health Questionnaire-9 [PHQ-9]), and edema-specific (Lymphedema Quality of Life [LYMQOL]) quality-of-life questionnaires were used to evaluate impact of edema. The prevalence of edema was 52.1% (25 of 48 participants had edema), potentially linked to obesity, immobility, and medications. Most participants had International Society of Lymphology (ISL) Stage I edema. There were no statistically significant differences between the quality of life of participants with and without edema. However, comparing SF-36 results and normative population data indicated that quality of life was much lower than those in the normative population. Conclusions: This study highlights the high prevalence of edema and low quality of life of this bariatric population. ClinicalTrials.gov ID: NCT03154593.

Wounds in chronic leg oedema

Wounds and chronic oedema are common disorders, but rarely studied together. The objective of this cross-sectional study was to investigate the point-prevalence and risk factors of wounds on the leg, in chronic leg oedema. Forty sites in nine countries were included. Of 7077 patients with chronic leg oedema, 12.70% had wounds. Independent risk factors were: peripheral arterial disease (odds ratio (OR) 4.87, 95% confidence intervals (CI) 3.63-6.52), cellulitis within the past 12 months (OR 2.69, 95% CI 2.25-3.21), secondary lymphoedema (OR 2.64, 95% CI 1.93-3.60), being male (OR 2.08, 95% CI 1.78-2.44), being over 85 years of age (OR 1.80, 95% CI 1.23-2.62), underweight (OR 1.79, 95% CI 1.14-2.79), bed bound (OR 1.79, 95% CI 1.01-3.16), chair bound (OR 1.52, 95% CI 1.18-1.97), diabetes (OR 1.47, 95% CI 1.23-1.77), and walking with aid (OR 1·41, 95% CI 1.17-1.69). 43.22% of those with wounds had clinically defined well-controlled oedema, associated with a significantly lower risk of wounds (OR 0.50, 95% CI 0.42-0.58, P < .001). Hard/fibrotic tissue (OR 1.71, 95% CI 1.19-2.48), and a positive Stemmers sign (OR 1.57, 95% CI 1.05-2.35) were associated with wounds. The study reinforces the importance of measures to control oedema, as controlled swelling was associated with a 50% lower risk of wounds.

Cellulitis risk factors for patients with primary or secondary lymphedema

BACKGROUND

Limb lymphedema is a chronic disease with primary and secondary forms, with the latter occurring essentially after cancer treatment. In the present study, we retrospectively analyzed the cellulitis frequency and its associated risk factors for patients with primary or secondary limb lymphedema.

METHODS

Information from all 1991 patients referred to a specialized lymphedema center from January to June 2018 was collected, including previous cellulitis episodes and the clinical and lymphedema characteristics.

RESULTS

Of the 1846 patients whose information could be analyzed, 695 (37.6%) had experienced one or more cellulitis episodes, and 23.3% had had recurrent cellulitis. Cellulitis occurred in 39.5%, 30.5%, and 38.6% (P = .02) of the patients with secondary upper limb, secondary lower limb, and primary lower limb lymphedema, respectively. The corresponding duration of lymphedema was 106.5, 97, and 243.1 months. For secondary upper limb lymphedema, a long interval from lymphedema onset to the first consultation at our specialized center, younger age at lymphedema onset, and the use of radiotherapy were independently associated with cellulitis. However, axillary lymph node excision, the use of chemotherapy, and segmentation of the upper limb lymphedema were not associated with cellulitis. A longer interval from lymphedema onset to the first consultation and lymph node excision were associated with cellulitis in those with lower limb secondary lymphedema but higher body mass index and younger age at lymphedema onset were not. For primary lower limb lymphedema, male sex, greater body mass index, and younger age at lymphedema onset were associated with cellulitis.

CONCLUSIONS

Different risk factors for cellulitis were identified for patients with lymphedema at risk. Awareness of those factors is important for physicians to recognize lymphedema promptly and refer patients to specialized centers to optimize treatment.

Biology of Lymphedema

Simple Summary

Lymphedema is a chronic, debilitating disease of the lymphatic vasculature. Although several reviews focus on the anatomy and physiology of the lymphatic system, this review provides an overview of the lymphatic vasculature and, moreover, of lymphatic system dysfunction and lymphedema. Further, we aim at advancing the knowledge in the area of lymphatic system function and how dysfunction of the lymphatic system—as seen in lymphedema—affects physiological systems, such as the cardiovascular system, and how those might be modulated by lymphedema therapy.

Abstract

This narrative review portrays the lymphatic system, a poorly understood but important physiological system. While several reviews have been published that are related to the biology of the lymphatic system and lymphedema, the physiological alternations, which arise due to disturbances of this system, and during lymphedema therapy, are poorly understood and, consequently, not widely reported. We present an inclusive collection of evidence from the scientific literature reflecting important developments in lymphedema research over the last few decades. This review aims at advancing the knowledge on the area of lymphatic system function as well as how system dysfunction, as seen in lymphedema, affects physiological systems and how lymphedema therapy modulates these mechanisms. We propose that future studies should aim at investigating, in-detail, aspects that are related to fluid regulation, hemodynamic responses, and endothelial and/or vascular changes due to lymphedema and lymphedema therapy.

Lymphoedema, a significant health problem in Israel: A descriptive community-based study

Lymphoedema (LE) is recognised as a chronic disabling disease. Knowledge on patient characteristics, treatments, and outcomes in Israel is lacking. The aim of the study was to (a) describe demographic and health characteristics, treatments, utilisation, and functional outcomes of patients receiving physical therapy due to LE in a large nationwide healthcare provider in Israel; and (b) assess the feasibility of conducting a future practice-based evidence (PBE) study. This is a retrospective observational cohort study. Descriptive analyses of an electronic medical record database were performed. Data from 6013 patient episodes were analysed. A high proportion of patients had two or more comorbidities (80%) and chronic medication use (85%) with increasing rates over the 8-year period. The most frequent LE classification was stage 2 (45%). A majority of LE was in the lower limbs (51%) with increasing rates over the years. The most frequent treatment-related activity was measuring limb circumference and the most frequent intervention was educating for self-management. This study provides a first comprehensive description of patient characteristics receiving physical therapy for LE in Israel. The available database offers an opportunity for PBE studies. Recommendations for improvements in specific data collection processes were identified.

Fluid Shifts Induced by Physical Therapy in Lower Limb Lymphedema Patients

Complete decongestive therapy (CDT), a physical therapy including manual lymphatic drainage (MLD) and compression bandaging, is aimed at mobilizing fluid and reducing limb volume in lymphedema patients. Details of fluid shifts occurring in response to CDT are currently not well studied. Therefore, we investigated fluid shifts before, during and after CDT. Thirteen patients (3 males and 10 females, aged 57 ± 8.0 years, 167.2 ± 8.3 cm height, 91.0 ± 23.4 kg weight) diagnosed with stage II leg lymphedema participated. Leg volume, limb and whole-body fluid composition (total body water (limbTBW/%TBW), extracellular (limbECF/%ECF) and intracellular (limbICF/%ICF fluid), as well as ECF/ICF and limbECF/limbICF ratios were determined using perometry and bioelectrical impedance spectroscopy. Plasma volume, proteins, osmolality, oncotic pressure and electrolytes were assessed. Leg volume (p < 0.001), limbECF (p = 0.041), limbICF (p = 0.005) and limbECF/limbICF decreased over CDT. Total leg volume and limbTBW were correlated (r = 0.635). %TBW (p = 0.001) and %ECF (p = 0.007) decreased over time. The maximum effects were seen within one week of CDT. LimbICF (p = 0.017), %TBW (p = 0.009) and %ICF (p = 0.003) increased post-MLD, whereas ECF/ICF decreased due to MLD. Plasma volume increased by 1.5% post-MLD, as well as albumin and the albumin-to-globulin ratio (p = 0.005 and p = 0.049, respectively). Our results indicate that physical therapy leads to fluid shifts in lymphedema patients, with the greatest effects occurring within one week of therapy. Fluid shifts due to physical therapy were also reflected in increased plasma volume and plasma protein concentrations. Perometry, in contrast to bioelectrical impedance analysis, does not seem to be sensitive enough to detect small fluid changes caused by manual lymphatic drainage.