Clinical characteristics and treatment modalities in uremic and non uremic calciphylaxis - a dermatological single-center experience

Calciphylaxis (CP) is a serious, potentially life-threatening disease that presents with medial calcification of small-sized vessels and painful ischemic ulcerations. Although calciphylaxis is frequently seen in patients with end-stage kidney disease on dialysis (calcific uremic arteriolopathy, CUA), there are reported cases of nonuremic calciphylaxis (NUC), which often remain undiagnosed. We conducted a retrospective chart review at our dermatological hospital and evaluated data concerning the epidemiology, comorbidities, medication, laboratory abnormalities, and therapeutic approaches of 60 patients diagnosed with calciphylaxis between 01/2012 and 12/2022. We identified 21 patients diagnosed with NUC and 39 with kidney disease. The predilection sites of skin lesions were the lower legs in 88% (n = 53), followed by the thigh and gluteal regions in 7% (n = 4). Significant differences were identified in comorbidities, such as atrial fibrillation (p < 0.001) and hyperparathyroidism (p < 0.01) accounting for CUA patients. Medication with vitamin K antagonists (p < 0.001), phosphate binders (p < 0.001), and loop diuretics (p < 0.01) was found to be associated with the onset of calciphylaxis. Hyperphosphatemia (p < 0.001), increased parathyroid hormone (p < 0.01) and triglyceride levels (p < 0.01), hypoalbuminemia (p < 0.01) and decreased hemoglobin values (p < 0.001) in the CUA cohort were significantly different from those in the NUC group. All patients with CUA received systemic medication. In contrast, only 38% (n = 8) of patients with NUC received systemic treatment. Striking discrepancies in the treatment of both cohorts were detected. In particular, NUC remains a disease pattern that is still poorly understood and differs from CUA in several important parameters.

Efficacy and Safety of Repeated Use of Ulipristal Acetate in Uterine Fibroids

Uterine fibroids are benign tumor of the uterus that often appear during child bearing ages. Medical treatments are considered the first-line treatment to preserve fertility, avoid or delaying surgery. This randomized control study was carried out in OPD of Obstetrics and Gynecology Department of BSMMU, Dhaka, Bangladesh from May 2018 to March 2019 to evaluate the efficacy and safety of ulipristal acetate (5mg) once daily in reproductive women with three months treatment courses. Total 52 samples with symptomatic uterine fibroids for treatment course-1, among them 36 were needed for treatment course-2 which was slow or non-responding in treatment course-1. Main outcome measures were amenorrhea, controlled bleeding, fibroid volume, anaemia, quality of life. Sixty one percent (61.0%) of patients were achieved amenorrheic during both treatment courses. Ninety percent (90.0%) patients were control of bleeding during both treatment courses. In treatment course-1, reductions from baseline in fibroid volume were 62.70%, whereas in course-2, reductions in fibroid volume were 75.33%. Five percent (5.0%) of patients were discontinuing Ulipristal acetate due to adverse effects. Renal and liver function tests were performed before and after each course of treatment. The level of creatinine, SGPT in the blood for both treatment courses had no statistically significant effects. Ulipristal acetate may be an alternative to surgical treatment, the safety profiles and prolong effects with improvement of symptoms, quality of life after cessation of drugs. Repeated use of drugs reduces the size and also improves the patient's condition.

Efficacy and Safety of Intravaginal Misoprostol for Mid-trimester Medical Termination of Pregnancy

Misoprostol has been widely used in Obstetrics and Gynecology for cervical priming, medical abortion and induction of labour. The purpose of the present study was to evaluate the efficacy and safety of intravaginal misoprostol in mid-trimester medical termination of pregnancy. This non-randomized clinical trial was carried out in the Department of Obstetrics and Gynecology at Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2007 to June 2008 for a period of one year. Primi- or multigravid women with 13 to 28 weeks of singleton pregnancy, fetal congenital malformation and missed abortion who were selected for medical termination of pregnancy were included in this study. Women with spontaneous labour, low laying placenta, ruptured membrane with or without chorioamnionitis, acute bronchial asthma, glaucoma, history of hypersensitivity of PGs, uncontrolled hypertension, cardiac disease, jaundice, renal disease were excluded from this study. The selected patients received 200μg of misoprostol 6 hourly pervaginally upto 48 hours. The outcome variables were induction of delivery time, number of doses within 48 hours, result of induction, surgical evacuation, bleeding after induction, requirement of blood transfusion and Dinoprostone gel; side effect & complication of misoprostol were recorded. A total number of 30 women were recruited for this study. Delivery within 24 and 48hours were 43.3% cases and 38.3% cases respectively. Surgical evacuation was needed in 23.33% cases. Cramping (26.7%), had nausea (10.0%), vomiting (10.0%) and fever (26.7%) were reported. Out of all respondents 90.0% had average and 10.0% had more than average bleeding. For termination of pregnancy 200μg of intravasinat misoprostol are safe and effective in mid-trimester.

Cancer cervix: An uncommon malignancy in Kashmir, India

OBJECTIVE

To study the distribution of cancers among females with particular emphasis on cancer cervix in Kashmiri population, which is geographically and socio-culturally distinct from the rest of India.

MATERIALS AND METHODS

All patient records were screened from January 1, 2009 to December 31, 2011 at Regional Cancer Centre, Srinagar. Most common cancers among females were recorded and analysis of cancer cervix cases was performed.

RESULTS

Female cancers comprised of 40% of total cancers with oesophageal and breast cancer as most common malignancies. Cancer cervix did not figure in top ten cancers and only 45 (0.01%) cases were recorded of the total of 3084 adult female cancers.

CONCLUSION

We conclude that due to different socio-cultural and sexual practices, this cancer is highly uncommon in Kashmir and screening or possibly should be directed specifically at only high risk selective subjects.

Regioselective synthesis and crystal structure of ethyl-4-acetyl-5-((2- ethoxy-2-oxoethyl)thio)-3-hydroxythiophene-2-carboxylate, C13H16O6S2

C13H16O6S2, triclinic, P1̅ (no. 2), a = 7.979(1) Å, b = 9.189(1) Å, c = 10.263(1) Å, ɑ = 72.876(2)°, β = 71.485(2)°, γ = 76.655(2)°, V = 674.0 Å3, Z = 2, Rgt(F) = 0.0360, wRref(F2) = 0.0962, T = 273 K.

Resveratrol protects spinal cord dorsal column from hypoxic injury by activating Nrf-2

Damage from oxidative stress plays a critical role in spinal cord injury. Nuclear factor erythroid 2-related factor (Nrf-2) signaling pathway can be activated by cellular oxidative stress. Resveratrol, a plant-derived polyphenolic compound found in red wine, has antioxidant properties. In the present study, we have examined the neuroprotective effect of resveratrol and the role of Nrf-2 in spinal cord hypoxic injury. The spinal cord was removed from adult male Wistar rats from T2-T10 and the dorsal column was used to induce hypoxic injury in vitro with and without treatment with resveratrol (50μM). Significant changes were found in the compound action potential (CAP) of spinal cord dorsal column, and hematoxyline and eosin (H&E) staining showed that resveratrol significantly improved neuronal injury. The biochemical assays showed significant changes in lipid peroxidase (LPO), reduced glutathione (GSH), superoxide dismutase (SOD), protein carbonyl (PC), mitochondrial ATP content, and mitochondrial Ca(++). Furthermore, using immunohistochemistry and Western blot, we found that after resveratrol treatment during hypoxic injury there was a significant activation of NrF-2 and down regulation of the glial fibrillary acidic protein (GFAP) content. The results show that resveratrol treatment has neuroprotective effects on CAP, Ca(++) loading, and biochemical parameters after hypoxic injury. The neuroprotective effect is likely to be exerted by increased activation of transcription factor Nrf-2 by resveratrol along with its direct antioxidant effect to ameliorate the oxidative damage and preserve mitochondrial function.

Post-stroke infections exacerbate ischemic brain injury in middle-aged rats: immunomodulation and neuroprotection by progesterone

We investigated the effect of delayed, prolonged systemic inflammation on stroke outcomes and progesterone (P4) neuroprotection in middle-aged rats. After transient middle cerebral artery occlusion/reperfusion (MCAO) surgery, rats received P4 (8 or 16 mg/kg) or vehicle injections at 2h, 6h and every 24h until day 7 post-occlusion. At 24h post-injury systemic inflammation was induced by giving three doses of lipopolysaccharide (LPS; 50 μg/kg, at 4h intervals) to model post-stroke infections. We measured serum brain-derived neurotrophic factor (BDNF), pro-inflammatory cytokines, and behavioral parameters at multiple times. Serum BDNF levels decreased more in the vehicle+LPS group compared to vehicle-alone at 3 and 7 days post-injury (P<0.05). Vehicle-alone showed a significant increase in interleukin-1β, interleukin-6, and tumor necrosis factor alpha levels at different times following stroke and these levels were further elevated in the vehicle+LPS group. P4 at both doses produced a significant (P<0.05) decline in cytokine levels compared to vehicle and vehicle+LPS. P4 restored BDNF levels at 3 and 7 days post-stroke (P<0.05). Behavioral assessment (rotarod, grip strength, sensory neglect and locomotor activity tests) at 3, 5 and 7 days post-stroke revealed that the vehicle group had significant (P<0.05) deficits in all tests compared to intact controls, and performance was worse in the vehicle+LPS group. P4 at both doses produced significant functional improvement on all tests. Systemic inflammation did not show an additive effect on infarct volume but P4 at both doses showed significant infarct reduction. We suggest that post-stroke infection exacerbates stroke outcomes and P4 exerts neuroprotective/modulatory effects through its systemic anti-inflammatory and BDNF regulatory actions.

2-[(E)-(Naphthalen-2-yl)imino-meth-yl]phenol

In the title compound, C(17)H(13)NO, the azomethine double bond adopts an E conformation. The naphthyl ring system and the benzene ring form a dihedral angle of 8.09 (10)°. The near-planar conformation of the molecule is consolidated by an intra-molecular O-H⋯N hydrogen bond, which forms an S(6) ring. In the crystal, mol-ecules are arranged in a zigzag fashion parallel to the c axis.

Multiple cavernous haemangiomas of the the orbit and conjunctiva: A rare association

Cavernous haemangioma(CH) is mostly intraconal, single and unilateral in location. A 32 year old female presented with painless progressive growth near the inner canthus of right eye along with swelling of right upper eyelid and superomedial quadrant of the right orbit for five years. MRI showed lesions involving the preseptal space and extraconal compartment of the orbit at the superomedial aspect continous with the conjunctival swelling. Excision biopsy of the growths via anterior orbitotomy (vertical eyelid split technique) was done. Histopathological findings confirmed orbital cavernous haemangioma along with conjunctival CH.

We report a rare case of multiple cavernous haemangiomas arising from the conjunctiva as well as the superomedial orbit. Complete removal of the tumour is possible even in such difficult cases as the CH is totally encapsulated and meticulous surgical dissection can give good cosmetic result to the patient.

2-[(2-Methoxybenzylidene)amino]phenol

In the title compound, C₁₄H₁₃NO₂, the azomethine double bond adopts an E conformation and the benzene rings form a dihedral angle of 77.70 (7)°. In the crystal, mol­ecules are linked by O—H⋯N and C—H⋯O hydrogen bonds and arranged in a zigzag fashion, forming infinite chains parallel to the c axis, resulting in a graph-set R₂²(9) motif.

5-(Prop-2-yn-yl)-5H-dibenzo[b,f]azepine

The asymmetric unit of the title compound, C₁₇H₁₃N, contains two independent butterfly-shaped mol­ecules. The seven-membered azepine rings both adopt a boat conformation. The dihedral angles between the benzene rings in the two mol­ecules are 46.95 (11) and 52.21 (11)°.

{2-[(3-Bromo-benzyl-idene)amino]-5-chloro-phen-yl}(phen-yl)methanone

In the title compound, C₂₀H₁₃BrClNO, the azomethine double bond [C=N = 1.246 (4) Å] adopts an E conformation. The bromo- and chlorophenyl rings are inclined to one another by 13.70 (11)°, and form dihedral angles of 76.68 (10) and 74.24 (7)°, respectively, with the phenyl ring. In the crystal, mol­ecules are linked by C—H⋯O hydrogen bonds to form double stranded chains propagating along the b-axis direction.

17-(Pyrimidin-2-yl)-8,16-dioxa-17-aza-tetra-cyclo-[7.7.1.0.0]hepta-deca-2,4,6,10,12,14-hexa-ene

In the title compound, C(18)H(13)N(3)O(2), the benzene rings form a dihedral angle of 78.49 (9)°. The dihedral angles between the benzene rings and the pyrimidine ring are 76.53 (10) and 27.73 (11)°. The two cis-fused six-membered heterocyclic rings adopt half-chair confirmations. In the crystal, mol-ecules are linked by C-H⋯O hydrogen bonds, forming chains parallel to the b axis.

{5-Chloro-2-[(2-hy-droxy-benzyl-idene)amino]-phen-yl}(phen-yl)methanone

The title Schiff base compound, C₂₀H₁₄ClNO₂, adopts an E configuration about the azomethine bond. The phenol and chloro­benzene rings form dihedral angles of 84.71 (9) and 80.70 (8)°, respectively, with the phenyl ring and are twisted by 15.32 (8)° with respect to one another. The mol­ecular conformation is stabilized by an intra­molecular O—H⋯N hydrogen bond, which forms an S(6) ring motif. In the crystal, mol­ecules are linked by C—H⋯O hydrogen bonds, forming columns parallel to the a axis.

{5-Chloro-2-[(4-nitro-benzyl-idene)amino]-phen-yl}(phen-yl)methanone

The mol­ecule of the title Schiff base compound, C₂₀H₁₃ClN₂O₃, assumes an E configuration about the C=N bond. The aromatic rings of the nitro­benzene and chloro­benzene groups are twisted by 13.89 (13)° and form dihedral angles of 76.38 (13) and 84.64 (13)°, respectively, with the phenyl ring. In the crystal, mol­ecules are linked into chains parallel to the b axis by C—H⋯π inter­actions.

3α-Dimethylamino-20-(N-methylacetamido)pregn-5-ene

The title compond, C₂₆H₄₄N₂O, is an steroidal alkaloid isolated from the medicinally important plant Sarcococca saligna. The mol­ecule consists of four fused rings (A–D), having chair, half-chair, chair and envelope conformations, respectively. The dimethyl­amino group is axially oriented on ring A, whereas the (N-methyl­acetamido)­ethyl group is attached equatorially on ring D. The crystal structure is stabilized only by van der Waals forces.

(E)-1-(3-Nitro-phen-yl)ethanone (2-methyl-phen-yl)hydrazone

In the title Schiff base compound, C₁₅H₁₅N₃O₂, the azomethine double bond adopts an E configuration. The dihedral angle between the two aromatic rings is 13.4 (12)°. In the crystal, mol­ecules are arranged in wave-like layers parallel to (100) without any classical hydrogen bonding.

21-Hydroxypregna-1,4-diene-3,20-dione

The title compound, C₂₁H₂₈O₃, is a fungal transformed metabolite of decoxycorticosterone acetate, consisting of four fused rings A, B, C and D. Ring A is nearly planar, with a maximum deviation of 0.010 (3) Å from the least-squares plane, while the trans-fused rings B and C adopt chair conformations. The five-membered ring D is in an envelope conformation. The orientation of the side chain is stabilized by an intramolecular O—H⋯O hydrogen bond. In the crystal, adjecent mol­ecules are linked by C—H⋯O hydrogen bonds into extended zigzag chains along the a axis.

3,5-Diamino-4H-1,2,4-triazol-1-ium hydroxonium bis-(pyridine-2,6-di-carboxyl-ato)cobaltate(II) pyridine-2,6-dicarb-oxy-lic acid monohydrate

The asymmetric unit of the title complex, (C₂H₆N₅)(H₃O)[Co(C₇H₃NO₄)₂]·C₇H₅NO₄·H₂O, contains a Co^II ion coordin­ated by four O atoms and two N atoms from two dipicolinate ligands in a disorted octa­hedral environment, a protonated triazole mol­ecule, a neutral pyridine-2,6-dicarb­oxy­lic acid mol­ecule, a hydroxonium ion and a solvent water mol­ecule. In the crystal, the components are linked into a three-dimensional framework by inter­molecular O—H⋯O, N—H⋯O and N—H⋯N and weak C—H⋯O hydrogen bonds. In addition, π–π stacking inter­actions with centroid–centroid distances in the range 3.4809 (7)–3.8145 (6) Å are observed.

Absolute configuration of (2S)-4-(4-hydroxyphenyl)butan-2-ol

The title compound, C₁₀H₁₄O₂, was isolated from the chloro­form extract of Taxus wallichiana Zucc. In the crystal, mol­ecules are linked by inter­molecular O—H⋯O hydrogen bonds, forming sheets parallel to (100). There are weak inter­molecular C—H⋯π inter­actions between the sheets.

A cocrystal of 3α-hy-droxy-tirucalla-8,24-dien-21-oic acid and 3β-fluoro-tirucalla-7,24-dien-21-oic acid (0.897:0.103)

The title compound, 0.897C₃₀H₄₈O₃.0.103C₃₀H₄₇O₂F is a co-crystal of two triterpenes isolated from the resin of Canarium schweinfurthiiand Engl. Both triterpenes consists of four trans-fused rings having chair/half-chair/half-chair and envelope conformations. The mol­ecular conformations are stabilized by intra­molecular C—H⋯O hydrogen bonds, forming rings of S(7) graph-set motif. In the crystal, mol­ecules are linked by inter­molecular O—H⋯O and C—H⋯O inter­actions, forming sheets parallel to (001). All atoms. excepting the axially-oriented hydroxyl group in the major component and the equatorially-oriented fluorine atom in the minor component, are overlapping.

3,5-Diamino-4H-1,2,4-triazol-1-ium (6-carb-oxy-pyridine-2-carboxyl-ato)(pyridine-2,6-dicarboxyl-ato)cuprate(II) trihydrate

In the complex anion of the title compound, (C₂H₆N₅)[Cu(C₇H₄NO₄)(C₇H₃NO₄)]·3H₂O, the Cu^II atom is coordinated by tridentate 6-carb­oxy­pyridine-2-carboxyl­ate and pyridine-2,6-dicarboxyl­ate ligands and is surrounded by four O atoms in the equatorial plane and two N atoms in axial positions in a distorted octa­hedral geometry. In the crystal, the components are linked into a three dimensional network by O—H⋯O, N—H⋯O, N—H⋯N and C—H⋯O hydrogen bonds and a π–π inter­action with a centroid–centroid distance of 3.6080 (8) Å.

3α-Hy-droxy-tirucalla-8,24-dien-21-oic acid

The title compound, C₃₀H₄₈O₃, a triterpene isolated from the resin of canarium schweinfurthiiand, is an isomer of the previously reported triterpene 3α-hy­droxy­tirucalla-7,24-dien-21-oic acid [Mora et al. (2001 ▶). Acta Cryst. C57, 638–640], which crystallizes in the same trigonal space group. The title mol­ecule consists of four fused rings having chair, half-chair, half-chair and envelope conformations for rings A, B, C and D, respectively (steroid labelling). An intra­molecular C—H⋯O hydrogen bond generates an S(7) ring. In the crystal, mol­ecules are linked by O—H⋯O and C—H⋯O inter­actions, forming (001) sheets.

1,2,4-Trimethoxydibenzo[b,d]furan-3-ol

The title compound, C₁₅H₁₄O₅, is a natural product, isolated from Sorbus lanata Syn. Pyrus lanata (D. Don) found in Pakistan. The compound is composed of three spiro-fused rings. The dihedral angle between the mean planes of the benzene rings is 4.81 (13)°. The meth­oxy groups are oriented at dihedral angles of 74.44 (14), 83.0 (2) and 66.3 (2)° with respect to the planes of the benzene rings to which they are attached. The mol­ecule is consolidated by three intra­molecular O—H⋯O and C—H⋯O hydrogen bonds. In the crystal, mol­ecules are linked by inter­molecular O—H⋯O hydrogen bonds, forming infinite chains along the b axis.

1-(2-Methyl-benzo-yl)-3-m-tolyl-thio-urea

The molecule of the title compound, C(16)H(16)N(2)OS, is not planar; the two aromatic rings are inclined to one another by 37.59 (9)°. There are intra-molecular hydrogen bonds between the benzoyl O atom and the H atom of the thio-amide N atom, and between the thio-urea S atom and the H atom of the tolyl group. These hydrogen bonds stabilize the mol-ecule in such a way that the thio-urea group adopts a trans-cis geometry. In the crystal structure, mol-ecules are linked by N-H⋯S inter-molecular hydrogen bonds, forming centrosymmetric dimers.

2-Methyl-N-[(3-methyl-2-pyridyl)carbamothioyl]benzamide

In the title compound, C₁₅H₁₅N₃OS, the thio­urea group is stabilized by an intra­molecular hydrogen bond between the carbonyl O atom and the thio­amide group. A C—H⋯N intramolecular hydrogen bond is also present. Mol­ecules are linked by inter­molecular N—H⋯O and C—H⋯S hydrogen bonds.

N-[(2,4-Dimethyl-phen-yl)carbamothio-yl]-2-methyl-benzamide

The title compound, C₁₇H₁₈N₂OS, adopts a trans–cis geometry of the thio­urea group which is stabilized by intra­molecular hydrogen bonds between the O atom of the carbonyl group and the H atom of the thio­amide group. A C—H⋯S intramolecular hydrogen bond is also present. In the crystal structure, mol­ecules are linked by inter­molecular N—H⋯S hydrogen bonds to form centrosymmetric dimers.

Photoangioplasty for human peripheral atherosclerosis: results of a phase I trial of photodynamic therapy with motexafin lutetium (Antrin)

BACKGROUND

In photoangioplasty, light activation of a photosensitive drug offers the potential for treatment of long segments of vascular disease. This is a brief description of a study designed to evaluate the safety and tolerability of a new photosensitizer, Antrin (motexafin lutetium), in the endovascular treatment of atherosclerosis.

METHODS AND RESULTS

An open-label, single-dose, escalating drug- and light-dose study was performed in patients with atherosclerotic peripheral arterial insufficiency. Clinical evaluation, serial quantitative angiography, and intravascular ultrasonography were performed. Therapy was well tolerated, and only minor side effects were observed. Treatment produced no deleterious vascular effects. Although this study was not designed to examine clinical efficacy, several secondary end points suggested a favorable therapeutic effect.

CONCLUSIONS

This phase I study demonstrates that photoangioplasty with motexafin lutetium is well tolerated and safe. Preliminary efficacy data suggest a future role for the treatment of flow-limiting atherosclerosis.

Primary health care in Saudi Arabia: applying global aspects of health for all, locally

Primary health care in Saudi Arabia: applying global aspects of health for all, locally This paper describes the application of primary health care principles in the Islamic Kingdom of Saudi Arabia. It arose from a doctoral supervisory experience on a joint programme for women students, operating between a British and Saudi Arabian University. The research looked at nutritional advice given by diploma-level nurses to pregnant women attending primary health care centres in Saudi Arabia. The supervisor supported research that drew on internationally recognized trends in nursing research (the reflexive learner) whilst attending to local requirements and conventions of the culture. The student was encouraged explicitly to site the research within the framework of Islamic teaching and Saudi culture. The Qur'an was used as an overarching framework within which the tenets of primary health care were explored. This was seen to be crucial in addressing World Health Organisation and the International Council of Nurses' views on contextualizing nursing for the greatest benefit of the population. This was of particular relevance in Saudi Arabia where research carried out in the community by women is novel, and as yet there are no nurse theorists from within Saudi culture.

Decongestive lymphatic therapy for patients with cancer-related or primary lymphedema

PURPOSE

A prospective evaluation was undertaken to assess the efficacy of intensive, short-term decongestive lymphatic therapy coupled with focused patient instruction in long-term self-care for the management of lymphedema.

METHODS

The therapeutic responses of 79 patients with lymphedema were analyzed prospectively. Each patient received intensive, short-term decongestive lymphatic therapy, with quantification of the extent and durability of the clinical response. Decongestive lymphatic therapy was performed by therapists trained in these techniques. The mean (+/-SD) duration of therapy was 8+/-3 days. Instruction in self-management techniques was incorporated into the therapeutic regimen by day 3 of the patient's treatment. The mean period of follow-up was 38+/-52 days. Changes in the volume of the affected limb were assessed with a geometric approximation derived from serial measurements of circumference along the axis of the limb.

RESULTS

The mean short-term reduction in limb volume was 44%+/-62% of the excess volume in the upper extremities and 42%+/-40% in the lower extremities. At follow-up, these results were adequately sustained: mean long-term excess volume reductions of 38%+/-56% (upper extremities) and 41%+/-27% (lower extremities) were observed.

CONCLUSION

Decongestive lymphatic therapy, combined with long-term self-management, is efficacious in treating patients with lymphedema of the extremity.