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Libson K, Barba J, Henning A, Fisher K, Kirven RM, Korman AM, Plaza JA, Kaffenberger BH, Chung C. Acute Interstitial Inflammation on Skin Biopsies and Positive Tissue Cultures in Cellulitis Patients Are Associated a Worse Prognosis. Am J Dermatopathol 2024:00000372-990000000-00348. [PMID: 38842316 DOI: 10.1097/dad.0000000000002753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024]
Abstract
BACKGROUND Cellulitis is a significant public health burden and lacks a gold standard for diagnosis. Up to 1/3 of patients are incorrectly diagnosed. The skin biopsy has been proposed as the gold standard. OBJECTIVE In this study, we evaluate the histopathologic characteristics and tissue culture positivity of biopsies in patients diagnosed with cellulitis seen by our inpatient dermatology consultation service. METHODS This retrospective cohort study examined patients who were hospitalized with a skin and soft tissue infection at our institution between 2011 and 2020 and underwent a skin biopsy. RESULTS Those with a positive tissue culture were more likely to die within 30 days compared with those with negative tissue cultures (26% vs. 6%, P = 0.048). Patients who died within 30 days were more likely to have acute interstitial inflammation as a feature on histopathology (38%, P = 0.03). LIMITATIONS Single institutional design, unintentional exclusion of patients with organism-specific diagnosis, and selection for a medically complex patient population because of the nonroutine collection of biopsies. CONCLUSION Positive tissue cultures and histopathology showing acute interstitial space inflammation on skin and soft tissue infection (SSTI) biopsies are associated with increased mortality and thus may serve as indicators of poor prognosis.
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Affiliation(s)
- Karissa Libson
- The Ohio State University College of Medicine, Columbus, OH
| | - Johnny Barba
- The Ohio State University College of Medicine, Columbus, OH
| | - Ania Henning
- Department of Pathology, Summa Health, Akron, OH
| | - Kristopher Fisher
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Rachel M Kirven
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Abraham M Korman
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Jose A Plaza
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Benjamin H Kaffenberger
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
| | - Catherine Chung
- Department of Dermatology, The Ohio State University Wexner Medical Center, Columbus, OH; and
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Thomas M, Morgan K, Humphreys I. Lymphoedema specialists embedded into community nurse and wound services: impacts and outcomes. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2024; 33:360-370. [PMID: 38639747 DOI: 10.12968/bjon.2024.33.8.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Lymphoedema is a progressive condition causing significant alterations to life, exerting pressures on unscheduled care from complications including cellulitis and wounds. An on the ground education programme (OGEP) was implemented to raise knowledge, competence and confidence in lymphoedema management in community clinical services. The aim of this study was to explore the impact and outcomes of the OGEP intervention. METHODS Data were captured before and after OGEP on 561 lymphoedema patients in the community setting. Data recorded included resource use, costs and outcomes (EQ-5D-5L and LYMPROM). RESULTS Data demonstrated statistically significant reductions in resource allocations including staff visits (P<0.001), cellulitis admissions (P<0.001), compression consumables and wound dressing costs (P<0.001). Overall, the total mean per patient cost decreased from £1457.10 to £964.40 (including intervention) with outcomes significantly improved in EQ-5D-5L/LYMPROM scores. CONCLUSION The analysis suggests the OGEP intervention may offer reductions in resource costs and improvements in patient outcomes. OGEP may therefore provide an innovative solution in future care delivery.
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Affiliation(s)
| | - Karen Morgan
- Clinical Lead, Lymphoedema Wales Clinical Network
| | - Ioan Humphreys
- Senior Researcher, School of Health and Social Care, Swansea University
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3
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Stanton J, Knowles A, Russell L, Bevis C. Integrated lymphoedema and tissue viability service: improving patient and wound outcomes. Br J Community Nurs 2024; 29:S19-S26. [PMID: 38578928 DOI: 10.12968/bjcn.2024.29.sup4.s19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2024]
Abstract
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.
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Affiliation(s)
- Julie Stanton
- Director of Nursing (community telehealth), Pioneer Wound Healing and Lymphoedema Centres
| | - Aaron Knowles
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
| | - Laura Russell
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
| | - Claire Bevis
- Tissue Viability and Lymphoedema Consultant, Pioneer Wound Healing and Lymphoedema Centres
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4
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Zaleska MT, Krzesniak NE. High Pressure 3 × 30 Minute Compression Methods for Advanced Lower Limb Lymphedema Patients. Lymphat Res Biol 2024; 22:153-162. [PMID: 38593454 DOI: 10.1089/lrb.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Introduction: In advanced lymphedema of lower limbs, stage III bandaging under the routinely applied pressure of 40-60 mmHg remains largely ineffective. This is caused by skin and subcutaneous tissue stiffness due to fibrosis. Edema fluid accumulates deep in the subcutaneous tissue. Evacuating this fluid requires a high external compression force to overcome the resistance of fibrous tissue. We aimed to investigate the effectiveness of the compression method, with high pressure lasting for 3 days. Methods and Results: Twenty-one patients with lower limb lymphedema, stage III, of the postinflammatory type were included. Patients with acute inflammatory symptoms, venous thrombosis, profuse varicose veins, diabetes, and cardiac insufficiency with edema were excluded. A 10-cm-wide rubber bandage was applied to the foot and calf. The interface pressure measured using PicoPress ranged from 58 to 120 mmHg. Skin and deep tissue tonometry, skin water concentration, leg circumference, and drop of interface pressure were measured. Ultrasound examination was done before and after each compression session. The calf circumference decreased by 15.9 ± 5.4%, deep tissue stiffness by 58.9 ± 18.9%, skin stiffness by 69.6 ± 13.5%, and skin water concentration by 43.8 ± 11.5%. Interface pressure dropped to 66.3 mmHg (28-110 mmHg); ultrasonography images showed less fluid in the tissue. Conclusions: High-pressure 30-minute leg compression can remove excess edema fluid within 3 days and enable adjustment of nonstretch compression stockings. This method is more effective in advanced lymphedema at the beginning of therapy than the standard 30-50-mmHg bandaging as it provides an immediate effect.
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Affiliation(s)
- Marzanna T Zaleska
- Clinical and Research Department of Applied Physiology, Mossakowski Medical Research Institute, Polish Academy of Sciences, Warsaw, Poland
- Department of Vascular Surgery, Central Clinical Hospital of the Ministry of Internal Affairs, Warsaw, Poland
| | - Natalia E Krzesniak
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Warsaw, Poland
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5
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Devoogdt N, Thomis S, Belva F, Dickinson-Blok J, Fourgeaud C, Giacalone G, Karlsmark T, Kavola H, Keeley V, Marques ML, Mansour S, Nissen CV, Nørregaard S, Oberlin M, Ručigaj TP, Somalo-Barranco G, Suominen S, Van Duinen K, Vignes S, Damstra R. The VASCERN PPL working group patient pathway for primary and paediatric lymphoedema. Eur J Med Genet 2024; 67:104905. [PMID: 38143023 DOI: 10.1016/j.ejmg.2023.104905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 12/18/2023] [Indexed: 12/26/2023]
Abstract
Lymphoedema is caused by an imbalance between fluid production and transport by the lymphatic system. This imbalance can be either caused by reduced transport capacity of the lymphatic system or too much fluid production and leads to swelling associated with tissue changes (skin thickening, fat deposition). Its main common complication is the increased risk of developing cellulitis/erysipelas in the affected area, which can worsen the lymphatic function and can be the cause of raised morbidity of the patient if not treated correctly/urgently. The term primary lymphoedema covers a group of rare conditions caused by abnormal functioning and/or development of the lymphatic system. It covers a highly heterogeneous group of conditions. An accurate diagnosis of primary lymphoedema is crucial for the implementation of an optimal treatment plan and management, as well as to reduce the risk of worsening. Patient care is diverse across Europe, and national specialised centres and networks are not available everywhere. The European Reference Network on Rare Multisystemic Vascular Diseases (VASCERN) gathers the best expertise in Europe and provide accessible cross-border healthcare to patients with rare vascular diseases. There are six different working groups in VASCERN, which focus on arterial diseases, hereditary haemorrhagic telangiectasia, neurovascular diseases, lymphoedema and vascular anomalies. The working group Paediatric and Primary Lymphedema (PPL WG) gathers and shares knowledge and expertise in the diagnosis and management of adults and children with primary and paediatric lymphoedema. The members of PPL WG have worked together to produce this opinion statement reflecting strategies on how to approach patients with primary and paediatric lymphoedema. The objective of this patient pathway is to improve patient care by reducing the time to diagnosis, define the best management and follow-up strategies and avoid overuse of resources. Therefore, the patient pathway describes the clinical evaluation and investigations that lead to a clinical diagnosis, the genetic testing, differential diagnosis, the management and treatment options and the patient follow up at expert and local centres. Also, the importance of the patient group participation in the PPL WG is discussed.
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Affiliation(s)
- Nele Devoogdt
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Thomis
- Centre for Lymphedema, Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | - Janine Dickinson-Blok
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Caroline Fourgeaud
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | | | - Tonny Karlsmark
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Heli Kavola
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Vaughan Keeley
- Derby Lymphedema Service, University Hospitals of Derby and Burton NHS Trust, Derby, UK
| | | | - Sahar Mansour
- Department of Lymphovascular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christoffer V Nissen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Susan Nørregaard
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Michael Oberlin
- European Centre for Lymphology, Földi Clinic, Hinterzarten, Germany
| | | | | | - Sinikka Suominen
- Department of Plastic Surgery, Helsinki University Hospital, Helsinki, Finland
| | - Kirsten Van Duinen
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands
| | - Stéphane Vignes
- Department of Lymphology and Reference Center for Rare Vascular Diseases, Cognacq-Jay Hospital, 15, Rue Eugène-Millon, 75015, Paris, France
| | - Robert Damstra
- Expert Center for Lymphovascular Medicine, Nij Smellinghe Hospital, Drachten, the Netherlands.
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Mangion A, Ivasic B, Piller N. The Utilization of e-Health in Lymphedema Care: A Narrative Review. Telemed J E Health 2024; 30:331-340. [PMID: 37527411 DOI: 10.1089/tmj.2023.0122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023] Open
Abstract
Background: Electronic health (e-Health), refers to technologies that can be utilized to enhance patient care as well as collect and share health information. e-Health comprises several umbrella terms, including telehealth, mobile health, e-Health, wearables, and artificial intelligence. The types of e-Health technologies being utilized in lymphedema (LE) care are unknown. Method: In this narrative review, a search of published research on the utilization of e-Health technologies in LE-related care was conducted. Results: Five different types of e-Health modalities were found (robotics, artificial intelligence, electronic medical records, smart wearable devices, and instructive online information) spanning 14 use cases and 4 phases of care (preventative, diagnostic, assessment, and treatment phases). Broad e-Health utilization examples were found including robotic-assisted surgery to reduce the likelihood of LE after lymphadenectomy, machine learning to predict patients at risk of filarial-related LE, and a novel wearable device prototype designed to provide lymphatic drainage. Conclusions: e-Health has reported merit in the prevention, diagnoses, assessment, and treatment of LE with utilization demonstrating cutting edge applicability of e-Health for achieving optimal patient care and outcomes. As technology continues to advance, additional research into the utilization of e-Health in LE care is warranted.
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Affiliation(s)
- Andrea Mangion
- Lymphoedema Clinical Research Unit, Flinders University, Adelaide, Australia
| | - Bruno Ivasic
- Lymphoedema Clinical Research Unit, Flinders University, Adelaide, Australia
| | - Neil Piller
- Lymphoedema Clinical Research Unit, Flinders University, Adelaide, Australia
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7
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Newton H. Diagnosing, assessing and managing cellulitis. Nurs Stand 2024; 39:39-44. [PMID: 38044818 DOI: 10.7748/ns.2023.e12187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 12/05/2023]
Abstract
Cellulitis is an acute bacterial infection that affects the deep dermis and surrounding subcutaneous tissue. Although it is a common condition, it is often misdiagnosed because it can mimic a range of conditions that also cause inflamed, red, irritated and painful skin. Such misdiagnoses may lead to unnecessary hospital admissions and antibiotic overuse, with most alternative diagnoses being non-infectious. Undertaking a holistic patient assessment, skin assessment and thorough clinical history is important in the diagnosis of cellulitis, and it is vital to use a collaborative multidisciplinary approach in its acute management and to prevent recurrence. This article defines the term cellulitis and explores its presenting features. The author also discusses the associated risk factors, clinical assessment techniques and effective management strategies, as well as outlining the actions that nurses can take to prevent recurrence.
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8
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Burian EA, Franks PJ, Borman P, Quéré I, Karlsmark T, Keeley V, Sugama J, Cestari M, Moffatt CJ. Factors associated with cellulitis in lymphoedema of the arm - an international cross-sectional study (LIMPRINT). BMC Infect Dis 2024; 24:102. [PMID: 38238718 PMCID: PMC10797905 DOI: 10.1186/s12879-023-08839-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/22/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Lymphoedema is a globally neglected health care problem and a common complication following breast cancer treatment. Lymphoedema is a well-known predisposing factor for cellulitis, but few have investigated the risk factors for cellulitis in this patient cohort on an international level. The aim of this study was to identify the frequency of cellulitis in patients with lymphoedema of the arm, including potential risk factors for cellulitis. METHODS An international, multi-centre, cross-sectional study including patients with clinically assessed arm lymphoedema. The primary outcome was the incidence of cellulitis located to the arm with lymphoedema within the last 12 months, and its potential associated risk factors. The secondary outcome was life-time prevalence of cellulitis. Adults with clinically-assessed arm lymphoedema/chronic oedema (all causes) and able to give informed consent were included. End-of-life-patients or those judged as not in the patient's best interest were excluded. Both univariable and multivariable analysis were performed. RESULTS A total of 2160 patients were included from Australia, Denmark, France, Ireland, Italy, Japan, Turkey and United Kingdom. Secondary lymphoedema was present in 98% of the patients; 95% of these were judged as related to cancer or its treatment. The lifetime prevalence of cellulitis was 22% and 1-year incidence 11%. Following multivariable analysis, factors associated with recent cellulitis were longer swelling duration and having poorly controlled lymphoedema. Compared to having lymphoedema less than 1 year, the risk increased with duration: 1-2 years (OR 2.15), 2-5 years (OR 2.86), 5-10 years (OR 3.15). Patients with well-controlled lymphoedema had a 46% lower risk of cellulitis (OR 0.54, 95% CI 0.39-0.73, p < 0.001). More advanced stages of lymphoedema were associated with cellulitis even after adjustment for swelling duration and control of swelling by logistic regression (stage II OR 5.44, stage III OR 9.13, p = 0.002), demonstrated in a subgroup analysis. CONCLUSION Patients with advanced arm lymphoedema are at particular risk of developing cellulitis. Prevention of lymphoedema progression is crucial. The results lend towards a positive effect of having well-treated lymphoedema on the frequency of cellulitis.
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Affiliation(s)
- Ewa Anna Burian
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark.
| | - Peter J Franks
- Centre for Research and Implementation of Clinical Practice, London, UK
| | - Pinar Borman
- Medical Faculty, Department of Physical Medicine and Rehabilitation, Ankara Medipol University, Ankara, Turkey
| | - Isabelle Quéré
- CHU Montpellier, University of Montpellier, IDESP, Montpellier, France
| | - Tonny Karlsmark
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Trust, Derby and University of Nottingham Medical School, Nottingham, UK
| | - Junko Sugama
- Research Centre for Implementation Nursing Science Initiative, Research Promotion Headquarters, Fujita Health University, Aichi, Japan
| | | | - Christine J Moffatt
- Department of Dermato-Venereology & Wound Healing Centre, Bispebjerg Hospital, Bispebjerg Bakke 23, Copenhagen, 2400, Denmark
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Thomas M, Pike C, Humphreys I, Bragg T, Ghattaura A. Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months. J Plast Reconstr Aesthet Surg 2023; 85:104-113. [PMID: 37473641 DOI: 10.1016/j.bjps.2023.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/22/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Lymphoedema is a chronic condition affecting daily activities of life, causing significant alterations and adjustments. Since 2015, lymphaticovenous anastomosis (LVA) has been available on the National Health Service for people with lymphoedema in Wales, United Kingdom. This study aimed to explore the impact and outcomes after LVA over a 24-month follow-up. METHODS Data were prospectively captured before and after LVA surgery on 150 patients with unilateral upper or lower limb lymphoedema. The same team (three lymphoedema specialists and two plastic surgeons) assessed/operated on all patients. Data captured included a quality of life tool (EQ5D5L), circumferential measurements (tape measure/perometer), compression garment usage, occurrence of cellulitis and a range of patient-reported outcome measures. RESULTS People who underwent LVA surgery had predominantly cancer-related lymphoedema (n = 118). Reviewing baseline data and 24-months after LVA, quality of life statistically improved (p = <0.005), as well as pain, heaviness, anxiety, impact on hobbies, work, purchasing clothes and intimacy/desirability. Mean perometer and circumferential measurements did not reduce over the 24 months. Number of days per week and hours that the patient wore compression garments did lessen and was statistically significant (p = <0.001). The quantity of cellulitis episodes captured from two years before and two years after LVA decreased from 4.22 to 0.10 (p = <0.001). Significant results (p = <0.001) were also found in a reduction in patients taking days off work due to cellulitis (5.81 to 0.16). CONCLUSION LVA resulted in significant improvements in patient-reported outcome measures, cellulitis episodes and reduced need for compression garments. Limb circumference via tape measure/perometer did not alter, yet the patient's quality of life considerably improved.
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Affiliation(s)
- M Thomas
- Swansea Bay UHB - Lymphoedema Wales Clinical Network, United Kingdom.
| | - C Pike
- Swansea Bay UHB - Lymphoedema Wales Clinical Network, United Kingdom
| | - I Humphreys
- School of Health and Social Care, Swansea University, United Kingdom
| | - T Bragg
- Swansea Bay UHB - Plastic and Reconstructive Department, United Kingdom
| | - A Ghattaura
- Swansea Bay UHB - Plastic and Reconstructive Department, United Kingdom
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Hettrick H, Ehmann S, McKeown B, Bender D, Blebea J. Selecting appropriate compression for lymphedema patients: American Vein and Lymphatic Society position statement. Phlebology 2023; 38:115-118. [PMID: 36609200 DOI: 10.1177/02683555221149619] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Lymphedema is a significant and disabling disorder affecting millions of people worldwide. Compression therapy is an important component of lifelong treatment but the specifics of appropriate compression garment selection and prescribing is not always well understood by practitioners and payers. METHOD An expert panel of the American Vein and Lymphatic Society was convened to write a Position Statement with explanations and recommendations for the appropriate compression therapy to be used in the treatment of lymphedema patients. RESULT A Position Statement was produced by the expert panel with recommendations for documentation and compression therapy treatment. Their recommendations were reviewed, edited, and approved by the Guidelines Committee of the society. CONCLUSION This societal Position Statement provides a useful document for reference for medical care providers for the appropriate compression therapy selection and treatment of patients with lymphedema.
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Affiliation(s)
- Heather Hettrick
- College of Health Care Sciences, 2814Nova Southeastern University, Ft. Lauderdale FL, USA
| | - Suzie Ehmann
- 23765Grand Strand Medical Center, Myrtle Beach, SC, USA
| | - Brandy McKeown
- International Lymphedema and Wound Training Institute, Tifton, GA, USA
| | - Dean Bender
- 576988American Vein and Lymphatic Society, Chicago, IL, USA
| | - John Blebea
- Department of Surgery, 367854Central Michigan University College of Medicine, Saginaw, MI, USA
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11
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Kruger N, Plinsinga ML, Noble-Jones R, Piller N, Keeley V, Hayes SC. The Lymphatic System, Lymphoedema, and Medical Curricula-Survey of Australian Medical Graduates. Cancers (Basel) 2022; 14:cancers14246219. [PMID: 36551705 PMCID: PMC9777454 DOI: 10.3390/cancers14246219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
The aim of this study was to survey the perceptions of recent (i.e., within the past 12 months) Australian medical graduates regarding (i) their understanding of the lymphatic system and lymphoedema, and (ii) the extent to which the lymphatic system and lymphoedema were covered as part of their medical degree. Medical graduates were invited to participate in a 17-item online survey that asked respondents to rate their level of agreement (using a 5-point Likert scale; higher scores = higher agreement) to statements that explored their understanding and comprehensiveness of their medical degree. Responses to each item were described using n (%). Subscale scores for understanding and medical degree were computed by summing scores of individual items, described using means (SD) and compared by participant characteristics. Medical graduates (n = 230) perceived their understanding of the lymphatic system and lymphoedema to be low, and comprehensiveness of medical curricula specific to the lymphatic system and lymphoedema to be lacking. Subscale scores did not differ by participant characteristics. Improvement of medical graduates understanding of lymphoedema may facilitate greater awareness of lymphoedema, thus optimizing the timeliness of diagnosis and access to treatment.
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Affiliation(s)
- Natalie Kruger
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
- Physiotherapy Department, Royal Brisbane and Women’s Hospital, Nathan, Brisbane, QLD 4006, Australia
- Correspondence:
| | - Melanie L. Plinsinga
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
| | - Rhian Noble-Jones
- Lymphoedema Clinical Network Wales, Swansea University, Swansea SA2 8PP, UK
| | - Neil Piller
- School of Medicine, Flinders University, Adelaide, SA 5042, Australia
| | - Vaughan Keeley
- Lymphoedema Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, UK
| | - Sandra C. Hayes
- Menzies Health Institute Queensland, Griffith University, Nathan, Brisbane, QLD 4111, Australia
- School of Health Sciences and Social Work, Griffith University, Brisbane, QLD 4111, Australia
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12
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Webb E, Bissett B, Neeman T, Bowden F, Preston E, Mumford V. Compression Therapy Is Cost-Saving in the Prevention of Lower Limb Recurrent Cellulitis in Patients with Chronic Edema. Lymphat Res Biol 2022; 21:160-168. [PMID: 35997601 PMCID: PMC10125391 DOI: 10.1089/lrb.2022.0029] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Cellulitis is a common and often recurrent infection that causes substantial financial burden and morbidity. Compression therapy reduces the risk of recurrent cellulitis episodes for adults with chronic edema; however, little is known about the cost-effectiveness of the intervention. Methods and Results: A cost analysis was undertaken during a randomized controlled trial (RCT) involving 84 participants with lower limb chronic edema and a history of recurrent cellulitis. The intervention group received compression therapy and education, while the control group received education only. A clinical audit and survey were used to measure health service and patient resource use for (1) the most recent episode of cellulitis, and (2) compression therapy over 18 months. Australian reference costs were used to calculate cellulitis and compression therapy costs, and the mean expenditure in both the RCT groups. Of the 84 RCT participants, 43 were surveyed and audited on the cost of cellulitis, and 40 on the cost of compression therapy. The mean cost of a hospitalized and nonhospitalized episode of cellulitis was $9071 and $506 from a health service perspective, and $4496 and $1320 from a patient perspective. The mean cost of compression therapy per participant over 18 months was $1905 and $421 from health service and patient perspectives, respectively. During the RCT, the mean annual cost per participant was $4972 in the experimental group and $26,382 in the control group, giving a cost-saving of $21,483 (95% confidence interval, 3136-48,176) per participant. Conclusion: For patients with lower limb chronic edema and recurrent cellulitis, compression therapy is both efficacious and cost-saving. Trial Registration: ACTRN12617000412336.
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Affiliation(s)
- Elizabeth Webb
- Physiotherapy Department, Calvary Public Hospital Bruce, Canberra, Australia.,Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Teresa Neeman
- Biological Data Science Institute, the Australian National University Joint Colleges of Science, Health, and Medicine, Australian National University, Canberra, Australia
| | - Francis Bowden
- Medical School, Australian National University, Canberra, Australia
| | - Elisabeth Preston
- Discipline of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia
| | - Virginia Mumford
- Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
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13
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Ong BS, Dotel R, Ngian VJJ. Recurrent Cellulitis: Who is at Risk and How Effective is Antibiotic Prophylaxis? Int J Gen Med 2022; 15:6561-6572. [PMID: 35983462 PMCID: PMC9379124 DOI: 10.2147/ijgm.s326459] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/27/2022] [Indexed: 11/23/2022] Open
Abstract
Recurrent cellulitis following successful treatment is common and prevention should be a major component in the management of cellulitis. Conditions that increase the risk of recurrence include chronic edema, venous disease, dermatomycosis and obesity. These risk factors should be actively managed as further episodes of cellulitis increases the risk of recurrence. The role of non-antibiotic measures is important and should be first-line in prevention. Antibiotic prophylaxis is effective, but its role is limited to non-purulent cellulitis where risk factors are appropriately managed.
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Affiliation(s)
- Bin S Ong
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Ravindra Dotel
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - Vincent Jiu Jong Ngian
- Department of Ambulatory Care, Division of Medicine, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
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14
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Weiss R. Cost of a lymphedema treatment mandate - 16 years of experience in the Commonwealth of Virginia. HEALTH ECONOMICS REVIEW 2022; 12:40. [PMID: 35870018 PMCID: PMC9308910 DOI: 10.1186/s13561-022-00388-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Treatment of chronic illness accounts for over 90% of Medicare spending. Chronic lymphedema places 3-10 million Americans at risk for recurrent cellulitis. Without convincing predictions of the costs and benefits of lymphedema treatment, insurers are reluctant to fully cover treatment of this common condition. Earlier papers discussed the costs and benefits of the first 5, 7, and 10 years of a lymphedema treatment mandate in Virginia. This paper updates these costs and benefits to 16 years of experience, and includes the impacts of the Patient Protection and Affordable Care Act of 2010 and the transition to ICD-10-CM diagnostic codes in 2015. It provides added confidence that costs of a lymphedema treatment mandate are reasonable, and can result in health insurance contract savings for reduced medical visits and hospitalizations for lymphedema patients. METHODS Virginia requires annual reporting of the segregated costs of each of its 30 medical mandates. Data on Virginia's lymphedema treatment mandate for the years 2004 to 2019 have been collected from the series of annual reports. These data include actual lymphedema treatment claims data, utilization data, and claims-based estimates of the premium impact. RESULTS The average actual lymphedema claim cost was $2.03 per individual contract and $3.54 per group contract for the years reported, representing 0.05 and 0.08% of average total claims. The estimated premium impact was 0.16-0.32% of total average premium for all mandated coverage contracts. While lymphedema claim costs increased 3-6% per year over the study period, generally following the rise of health care costs, claim costs as a percent of average contract claims fell at a rate of 1.26-1.52% per year over that period. Medical office visits for lymphedema-related services fell from 0.10 to 0.02 visits per year per contract from the beginning to the end of the study period, and hospitalizations for lymphedema or lymphedema-related cellulitis fell to almost zero. CONCLUSIONS The Virginia data confirmed previous conclusions that the costs of treatment of lymphedema are a small part of a typical health insurance contract, and that treatment of lymphedema by managing swelling results in lower overall medical costs and fewer hospitalizations. This is a potent model for reduction in healthcare costs while improving the quality of care for cancer survivors and others suffering with this chronic progressive condition.
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Affiliation(s)
- Robert Weiss
- Independent Lymphedema Patient Advocate, 10671 Baton Rouge Avenue, Porter Ranch, CA, 91326, USA.
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15
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Obesity and loss of ambulation are associated with lower extremity oedema in Duchenne muscular dystrophy. Cardiol Young 2022; 33:597-602. [PMID: 35549789 DOI: 10.1017/s1047951122001342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Patients with Duchenne muscular dystrophy have multiple risk factors for lower extremity oedema. This study sought to define the frequency and predictors of oedema. Patients aged 15 years and older were screened by patient questionnaire, and the presence of oedema was confirmed by subsequent physical exam. Twenty-four of 52 patients (46%) had oedema, 12 of whom had swelling extending above the foot and two with sores/skin breakdown. There was no significant difference in age, frequency, or duration of glucocorticoid use, non-invasive respiratory support use, forced vital capacity, cardiac medication use, or ejection fraction between patients with and without oedema (all p > 0.2). Those with oedema had a greater time since the loss of ambulation (8.4 years versus 3.5 years; p = 0.004), higher body mass index (28.3 versus 24.8; p = 0.014), and lower frequency of deflazacort use (67% versus 89%; p = 0.008). Multivariate analysis revealed a longer duration of loss of ambulation (p = 0.02) and higher body mass index (p = 0.009) as predictors of oedema. Lower extremity oedema is common in Duchenne muscular dystrophy but independent of cardiac function. Interventions focused on minimising body mass index increases over time may be a therapeutic target.
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16
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Senet P. Quoi de neuf en dermatologie clinique ? ANNALES DE DERMATOLOGIE ET DE VÉNÉRÉOLOGIE - FMC 2021. [PMCID: PMC8675603 DOI: 10.1016/s2667-0623(21)01524-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- P. Senet
- Service de dermatologie, AP-HP, hôpital Tenon, Paris
- Adresse e-mail : (P. Senet)
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17
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Colgan MP, Kyne N, Hannon B, Grehan E, Morris K, Conway M, Murray N, Carney O, Mac Sweeney M. A Snapshot of Lymphedema in Ireland: Results from LIMPRINT. Lymphat Res Biol 2021; 19:473-478. [PMID: 34672791 DOI: 10.1089/lrb.2021.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
| | - Norah Kyne
- Furbo Hill, Spiddal, Co. Galway, Ireland
| | | | - Elaine Grehan
- Tiaquin, Colmanstown, Ballinasloe, Co. Galway, Ireland
| | - Kay Morris
- Primary Care Strategy and Planning, HSE, Model Business Park, Cork, Ireland
| | - Monica Conway
- Bio-Health Centre, Mary Street Medical Centre, Clonmel, Ireland
| | - Nina Murray
- Local Government and Heritage, Wexford, Ireland
| | - Olive Carney
- Centre for Nurse Education, Mater Misericordiae University Hospital, Dublin, Ireland
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18
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Gibson L, Moffatt CJ, Narahari SR, Kabiri L, Ikhile D, Nchafack A, Dring E, Nursing D, Kousthubha SN, Gorry J. Global Knowledge Gaps in Equitable Delivery of Chronic Edema Care: A Political Economy Case Study Analysis. Lymphat Res Biol 2021; 19:447-459. [PMID: 34672793 DOI: 10.1089/lrb.2021.0063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Most existing research in chronic edema (CO) care takes place in high-income countries and is both clinically and medically focused, although often accorded low prestige and status. A myriad of challenges define the problems and important gaps in understanding and translating what we know into sustainable practice. Less considered, however, are the consequences and socioeconomic significance of this "knowledge gap" in an increasingly globalized world. This article seeks to address this lacuna by suggesting a political economy approach across three different income settings, the United Kingdom (high), Kerala in India (middle), and Uganda (low), to learn from international practice and understand the contribution of local (community-specific) health traditions. Methods and Result: We used a comparative case study approach. In the three case studies we demonstrate how particular thinking, sets of power relationships, and resource distributions influence and structure the provision of CO management more generally. We demonstrate how these intertwined and often invisible processes reflect a market-led biomedical hierarchization that focuses on high-interventionist, high-cost approaches that are then imposed on lower income settings. At the same time, low-cost but evidence-based local knowledge innovation in wound and CO care from low- or middle-income countries is neither recognized nor valued. Conclusion: We conclude that unpacking these dynamics is a necessary route to providing a more equitable health delivery accessible for the many rather than the few.
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Affiliation(s)
- Linda Gibson
- Institute of Health and Allied Professions, Nottingham Trent University, Nottingham, United Kingdom
| | - Christine J Moffatt
- Centre for Research and Implementation of Clinical Practice, London, United Kingdom.,Copenhagen Wound Healing Centre, Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.,Institute of Nursing and Midwifery Care Excellence, City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - S R Narahari
- Institute of Applied Dermatology, Kasaragod, India
| | - Lydia Kabiri
- School of Health Sciences, Makerere University, Kampala, Uganda, Africa
| | - Deborah Ikhile
- Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Almighty Nchafack
- Institute of Health and Allied Professions, Nottingham Trent University, Nottingham, United Kingdom
| | | | - Dip Nursing
- Institute of Nursing and Midwifery Care Excellence, Nottingham University Hospitals, Nottingham, United Kingdom
| | - S N Kousthubha
- Shri Dharmasthala Manjunatheshwara College of Medical Sciences, Dharwad, India
| | - Jonathan Gorry
- School of Social Sciences, Nottingham Trent University, Nottingham, United Kingdom
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19
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Newman A, Keeley V, Pinnington L, Green C, Riches K, Franks PJ, Idris I, Moffatt CJ. Prevalence and Impact of Chronic Edema in Bariatric Patients: A LIMPRINT Study. Lymphat Res Biol 2021; 19:431-441. [PMID: 34672794 DOI: 10.1089/lrb.2021.0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Amy Newman
- University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom
| | - Vaughan Keeley
- University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom.,School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Derby, United Kingdom
| | - Lorraine Pinnington
- School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Derby, United Kingdom
| | - Carol Green
- University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom
| | - Katie Riches
- University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom
| | - Peter J Franks
- Centre for Research and Implementation of Clinical Practice, London, United Kingdom
| | - Iskandar Idris
- University Hospitals of Derby and Burton NHS Foundation Trust, Royal Derby Hospital, Derby, United Kingdom.,School of Medicine, Royal Derby Hospital Centre, University of Nottingham, Derby, United Kingdom
| | - Christine J Moffatt
- Centre for Research and Implementation of Clinical Practice, London, United Kingdom.,Copenhagen Wound Healing Centre, Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.,Institute of Nursing and Midwifery Care Excellence, City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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20
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Brouillard P, Witte MH, Erickson RP, Damstra RJ, Becker C, Quéré I, Vikkula M. Primary lymphoedema. Nat Rev Dis Primers 2021; 7:77. [PMID: 34675250 DOI: 10.1038/s41572-021-00309-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Pascal Brouillard
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium
| | - Marlys H Witte
- Department of Surgery, Neurosurgery, and Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert P Erickson
- Department of Pediatrics, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Robert J Damstra
- VASCERN PPL European Reference Centre; Department of Dermatology, Phlebology and Lymphology, Nij Smellinghe Hospital, Drachten, Netherlands
| | | | - Isabelle Quéré
- Department of Vascular Medicine, Centre de référence des Maladies Lymphatiques et Vasculaires Rares, Inserm IDESP, CHU Montpellier, Université de Montpellier, Montpellier, France
| | - Miikka Vikkula
- Human Molecular Genetics, de Duve Institute, University of Louvain, Brussels, Belgium. .,VASCERN VASCA European Reference Centre; Center for Vascular Anomalies, Division of Plastic Surgery, University Clinics Saint-Luc, University of Louvain, Brussels, Belgium. .,Walloon Excellence in Lifesciences and Biotechnology (WELBIO), de Duve Institute, University of Louvain, Brussels, Belgium.
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21
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Thomas M, Morgan K, Lawrence P. Introducing the new Chronic Oedema Wet Leg Pathway. Br J Community Nurs 2021; 26:S16-S21. [PMID: 34542314 DOI: 10.12968/bjcn.2021.26.sup10.s16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Reticence to apply compression therapy has been widely observed in clinical practice, compounded by an absence of evidenced-based pathways for application of prompt compression prior to measuring ankle brachial pressure index (ABPI). Importantly, delaying compression therapy for patients with chronic oedema and lymphorrhoea causes many avoidable complications. In 2017, Lymphoedema Network Wales (LNW) developed an evidenced-based pathway to improve the management of chronic oedema and wet legs (lymphorrhoea) for community nurses. During the past 4 years, the Chronic Oedema Wet Leg Pathway has been presented, published and used internationally, as well as being translated into different languages. It is commonly used in community nursing Teams as an evidenced-based document. However, like all documents and guidelines, when more evidence becomes available, the pathway needs updating. Therefore, this clinical focus article will present the new and enhanced Chronic Oedema Wet Leg Pathway, introducing a new level four compression section, which increases the layers of compression bandaging for patients with venous insufficiency or who are morbidly obese.
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Affiliation(s)
| | - Karen Morgan
- National Lymphoedema Education Lead in Wales: Lymphoedema Network Wales
| | - Paula Lawrence
- National Lymphoedema Community Educator Lead in Wales; Lymphoedema Clinical Nurse
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22
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Burian EA, Karlsmark T, Nørregaard S, Kirketerp-Møller K, Kirsner RS, Franks PJ, Quéré I, Moffatt CJ. Wounds in chronic leg oedema. Int Wound J 2021; 19:411-425. [PMID: 34258856 PMCID: PMC8762561 DOI: 10.1111/iwj.13642] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 12/31/2022] Open
Abstract
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.
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Affiliation(s)
- Ewa Anna Burian
- Department of Dermato-Venereology, Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Tonny Karlsmark
- Department of Dermato-Venereology, Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Susan Nørregaard
- Department of Dermato-Venereology, Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Klaus Kirketerp-Møller
- Department of Dermato-Venereology, Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark
| | - Robert Scott Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Peter John Franks
- Centre for Research and Implementation of Clinical Practice, London, UK
| | - Isabelle Quéré
- Department of Vascular Medicine, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Christine Joy Moffatt
- Department of Dermato-Venereology, Wound Healing Centre, Bispebjerg Hospital, Copenhagen, Denmark.,Centre for Research and Implementation of Clinical Practice, London, UK.,Nottingham University Hospitals NHS Trust, Nottingham, UK
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23
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Mortimer PS. Cellulitis in chronic oedema. Br J Dermatol 2021; 185:10-11. [PMID: 33764505 PMCID: PMC8327126 DOI: 10.1111/bjd.20047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 11/29/2022]
Abstract
Linked Article: Burian et al. Br J Dermatol 2021; 185:110–118.
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Affiliation(s)
- P S Mortimer
- Molecular and Clinical Sciences Institute (Dermatology Unit), St. George's, University of London, London, UK
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