Episodes Of Cellulitis Research Articles

Venous disease progression in western Europe (VENPRO): A prospective cohort study.

Objective: A prospective cohort study aimed to determine factors which influence the progression of chronic venous disease (CVD) in an attempt to aid in the early identification of those at patients who are likely to benefit from early intervention.Methods: A prospective cohort study of patients referred to tertiary vascular services with varicose veins over 7years was conducted. The primary outcome measure was the rate of disease progression from time of referral to time of consultation. The secondary outcome measure was to the rate of venous complications during the same time period.Results: 1000 patients from routine varicose vein waiting lists were included in the study. The mean waiting time was 2.96 ± 1.25years. The majority of patients were female (73% versus 27%), and the average age was 57.8 ± 14.7years. One fifth of the cohort developed a complication or showed evidence of disease progression. Logistic regression showed that advancing age and previous episodes of cellulitis are significant risk factors for the development of CVD progression.Conclusions: Varicose veins are more than a cosmetic issue and can be associated with substantial health and economic costs. Continuous identification of risk factors will enable clinicians to implement treatment strategies earlier for at risk patients.

Higher proportion of cellulitis in severe lymphoedema.

We read with interest the article from Burian et al. which discussed the prevalence and risk factors of cellulitis in chronic leg oedema. We conducted a twelve-year service evaluation at the Norfolk and Norwich University Hospital to investigate the applicability of these results in a real-world setting. Our study found that episodes of cellulitis were more common in patients with more severe lymphoedema, reinforcing the findings of Burian et al. and highlighting the importance of controlling lymphatic swelling to reduce cellulitis risk.

Case series of genital lymphaticovenous anastomosis for genital lymphatic vesicles

BackgroundThe management of lymphatic vesicles is challenging. This study aimed to clarify the lymphatic flow around the genitals and the effect of genital LVA on genital lymphatic vesicles. MethodsWe performed a retrospective study of 34 patients who underwent resection for lymphatic vesicle and LVA. In patients with genital lymphedema, two types of lymphatic inflow existed around the genital area; from the lower extremities (type 1) and from the buttocks (type 2). Lymphoscintigraphy was performed to detect type 1 lymphatics injecting isotope into the first interdigital area. ICG lymphography was performed to detect type 2 lymphatics injecting ICG into the ischial tuberosity. We performed resection of lymphatic vesicles and LVA in the legs and/or in the genitals. Postoperative recurrence rate of lymphatic vesicles and the frequency of cellulitis were evaluated. ResultsType 1 lymphatics were observed in 38.2% of the patients. In ICG lymphography, there was linear inflow to the genitals in 40.9% and DB inflow in 24.2%. In 10 patients (29.4%), both type 1 and 2 lymphatic vessels were observed. Genital LVA was performed in 31 patients and lower extremity LVA was performed in 15 patients. The average follow-up period was 332 days, and recurrence was observed in 8 (25.8%) of 31 patients who underwent total resection. The average number of cellulitis episodes decreased significantly from 2.8 times before surgery to 0.31 times after surgery (p<0.01). ConclusionLVA in the genital area and lower limbs was effective in preventing postoperative recurrence of lymphatic vesicles after resection.

Primary LYmphedema Multidisciplinary Approach in Patients Affected by Primary Lower Extremity Lymphedema.

Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system, leading to its malfunction. Various surgical options, including physiologic and excisional procedures, have been proposed. The aim of this study was to present a comprehensive algorithm for the treatment of primary lower extremity lymphedema: the Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated following the P-LYMA protocol. Patients underwent pre- and postoperative complex decongestive therapy (CDT). A variety of physiologic and excisional procedures were performed, either independently or in combination. The primary outcome was to assess the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of cellulitis episodes, and complications were recorded. Results: The mean CRR was 73 ± 20% at twelve months postoperatively. The frequency of cellulitis episodes per year decreased from a mean of 1.9 ± 0.8 preoperatively to 0.4 ± 0.6 during follow-up. Two patients experienced minor complications. The mean hospitalization time was 5 days. Patients' quality of life, as measured by the LeQOLiS, significantly improved from 70.4 ± 12 preoperatively to 24 ± 14 at twelve months postoperatively. Conclusions: The P-LYMA algorithm maximizes surgical outcomes and improves the quality of life in patients with primary lymphedema. CDT is essential for optimizing results.

Demonstrating the benefit of a cellulitis-specific patient reported outcome measure (CELLUPROM©) as part of the National Cellulitis Improvement Programme in Wales

PurposeDespite a known risk of cellulitis recurrence, the management of the wider impact and risk factors has been neglected. The innovative National Cellulitis Improvement Programme (NCIP) addresses this by providing evidence-based and individualised care to improve patient reported outcomes and reduce the risk of recurrence. The aim of this paper is to examine the longer-term impact of cellulitis and to identify a suitable and clinically relevant Patient Reported Outcome Measure (PROM).MethodsA review of existing cellulitis-specific PROMs was undertaken, alongside literature detailing the patient-focused impact of cellulitis, to identify a suitable PROM for clinical use. A group of expert therapists and patient representatives (n = 14) shared their individual and collective experiences over a series of events to discuss and debate the impact of cellulitis and review available PROMs. CELLUPROM© is introduced with anonymised PROM data and case study information reported to establish the impact of CELLUPROM© within usual NCIP care.ResultsNo cellulitis-specific PROMs were identified. Literature focused on the signs and symptoms of an acute episode of cellulitis, with outcome measures primarily used to evidence the impact of an intervention. An enduring physical, social and emotional impact of cellulitis was identified in this study, providing the basis for the new cellulitis-specific PROM (CELLUPROM©), which has been implemented with good effect in clinical care.ConclusionThis study has highlighted the lasting impact of cellulitis. Using CELLUPROM© within the risk-reduction NCIP has helped develop Value-Based Healthcare and support programme evaluation.

Comparing Different Donor Sites After Vascularized Lymph Node Transfer to the Lymphedematous Upper Limb: A Systematic Review and Meta-analysis of Clinical Outcomes.

Vascularized lymph node transfer (VLNT) involves the microvascular transplantation of functional lymph nodes from a donor site into a limb affected by lymphedema to restore the normal flow of lymphatic fluid. Despite the increasing clinical experience with VLNT, there remains insufficient data to support its routine use in clinical practice. Here, we aim to evaluate the effectiveness and safety of VLNTs for upper limb lymphedema and compare clinical outcomes when using different donor sites. We carried out a systematic search of the literature through PubMed and Scopus databases for studies on VLNT for upper limb lymphedema. Primary and secondary outcomes included circumference reduction rate (CRR) and infection reduction rate by postoperative cellulitis episodes for the efficacy and safety of VLNT. Pooled analysis was performed using the inverse variance weighting meta-analysis of single means using the meta package in R software. Subgroup analyses were performed for donor and recipient sites, age groups, follow-ups, and symptom durations. Quality assessment was performed using the Newcastle-Ottawa Scale for nonrandomized studies. A total of 1089 studies were retrieved from the literature, and 15 studies with 448 upper limb lymphedema patients who underwent VLNT were included after eligibility assessment. The mean CRR was 34.6 (18.8) and the mean postoperative cellulitis episodes per year was 0.71 (0.7). The pooled analysis of CRR was 28.4% (95% confidence interval, 19.7-41.1) and postoperative cellulitis episodes showed a mean of 0.59 (95% confidence interval, 0.36-0.95) using the random-effect model. Subgroup analyses showed significant group differences in recipient site for CRR and postoperative cellulitis episodes with the wrist comprising the highest weights, and patients younger than 50 years showing a lower postoperative infection. Vascularized lymph node transfer using gastroepiploic flaps at the wrists has shown a significant difference in reductions of limb circumference and cellulitis episodes in upper limb lymphedema patients when compared with other donor sites. However, further prospective studies are needed to consolidate this finding.

Serological responses to Streptococcus pyogenes vaccine candidate antigens suggests that Streptococcus dysgalactiae is the predominant cause of lower limb cellulitis

Abstract Background A future Streptococcus pyogenes (Strep A) vaccine will ideally prevent a significant burden of lower limb cellulitis, however, natural immune responses to proposed vaccine antigens following an episode of cellulitis remain uncharacterised. Methods We enrolled 63 patients with cellulitis and 26 with invasive beta haemolytic streptococci (BHS) infection, utilising a multiplexed assay to measure IgG against Strep A vaccine candidate antigens, including: streptolysin O (SLO), deoxyribonuclease B (DNB), group A carbohydrate (GAC), C5a peptidase (ScpA), cell envelope proteinase (SpyCEP), and adhesion and division protein (SpyAD). Responses in the invasive cohort were used to predict the infecting aetiology in the cellulitis cohort. Results Of 41 patients with non-bacteraemic cellulitis and paired serological samples, 68.3% had evidence of BHS infection by conventional anti-SLO and/or anti-DNB criteria. A positive serological response to at least one of the tested antigens was seen in 78.0% of the cellulitis cohort. Individually, anti-SLO (58.5%), anti-SpyAD (46.3%), and anti-ScpA (39.0%) were the most common. Based on principal component analysis, increases in these three antibodies, without responses to DNB, GAC and SpyCEP characterised Streptococcus dysgalactiae subspecies equisimilis (SDSE) infection. Conclusions SDSE appears to be the predominant cause of lower limb cellulitis. Effective Strep A vaccines incorporating antigens which provide additional cross protection against SDSE may prevent a significant burden of lower limb cellulitis.

CHRONIC INFECTION AND SEVERE MITRAL REGURGITATION: A TRICKY CASE REPORT

Abstract Background Techniques of mitral valve repair has improved in the last decades. Percutaneous approach is now a reliable and safe therapy in those patients with high surgical risk. Of note, the presence of implanted prothesis may increase the risk of endocarditis, especially in those patients experiencing recurrent infection. Case Summary We describe a case of a 75–year–old with medical history of chronic lymphedema. It was characterized by periodical episode (yearly) of cellulitis, with a rapid onset of fever (38.5–39° C), lasting for a few days after paracetamol therapy. Patients had severe mitral valve regurgitation due to prolapse of the posterior leaflet (P2). In December 2022, he had percutaneous edge–to–edge mitral valve. Three months later the patient was admitted to the emergency department of our hospital due to fever without any specific symptoms. The patient was well compensated, normal blood pressure, heart rate and oxygen saturation. He had emocolture which revealed the presence of Staphilococcus lugdunensis. Transesophageal echocardiogram confirmed the presence endocarditis, showing a huge (10x12 mm) vegetation at the level of mitral device (Fig 1 and 2). Patients was then referred to cardiac surgery for urgent mitral valve replacement with mitral bioprothesis (Fig 3). He was treated with ev antibiotic for six weeks after cardiac surgery. Additionally, chronic treatment with amoxicillin 500 mg/day was also prescribed at discharge. After six months follow–up, patients had no signs of endocarditis. Conclusion The management and treatment of chronic infection is of paramount importance to reduce the risk of prothesis infection procedure in patients needing a prothesis implantation. The last European Society of Cardiology guidelines on endocarditis do not provide any recommendation regarding a long–term treatment of patients with high risk of infection (i.e. due to chronic infection) and with an implanted cardiac device/prothesis. We believe this represents an important unmeet need.

Longitudinal assessment of health-related quality of life and clinical outcomes with at home advanced pneumatic compression treatment of lower extremity lymphedema

ObjectiveThis prospective, longitudinal, pragmatic study describes at home treatment with a proprietary advanced pneumatic compression device (APCD) for patients with lower extremity lymphedema (LED). MethodsFollowing institutiona review board approval, four participating Veterans Affairs centers enrolled LED patients from 2016 to 2022. The primary outcome measures were health-related quality of life (HR-QoL) questionnaires (lymphedema quality of life-leg and the generic SF-36v2) obtained at baseline and 12, 24, and 52 weeks. The secondary outcome measures were limb circumference, cellulitis events, skin quality, and compliance with APCD and other compression therapies. ResultsBecause a portion of the trial was conducted during the coronavirus disease 2019 pandemic, 179 patients had 52 weeks of follow-up, and 143 had complete measurements at all time points. The baseline characteristics were a mean age of 66.9 ± 10.8 years, 91% were men, and the mean body mass index was 33.8 ± 6.9 kg/m2. LED was bilateral in 92.2% of the patients. Chronic venous insufficiency or phlebolymphedema was the most common etiology of LED (112 patients; 62.6%), followed by trauma or surgery (20 patients; 11.2%). Cancer treatment as a cause was low (4 patients; 2.3%). Patients were classified as having International Society for Lymphology (ISL) stage I (68.4%), II (27.6%), or III (4.1%). Of the primary outcome measures, significant improvements were observed in all lymphedema quality of life-leg domains of function, appearance, symptoms, and emotion and the overall score after 12 weeks of treatment (P < .0001) and through 52 weeks of follow-up. The SF-36v2 demonstrated significant improvement in three domains at 12 weeks and in the six domains of physical function, bodily pain, physical component (P < .0001), social functioning (P = .0181), role-physical (P < .0005), and mental health (P < .0334) at 52 weeks. An SF-36v2 score <40 indicates a substantial reduction in HR-QoL in LED patients compared with U.S. norms. Regarding the secondary outcome measures at 52 weeks, compared with baseline, the mean limb girth decreased by 1.4 cm (P < .0001). The maximal reduction in mean limb girth was 1.9 cm (6.0%) at 12 weeks in ISL stage II and III limbs. New episodes of cellulitis in patients with previous episodes (21.4% vs 6.1%, P = .001) were reduced. The 75% of patients with skin hyperpigmentation at baseline decreased to 40% (P < .01) at 52 weeks. At 52 weeks, compliance, defined as use for 5 to 7 days per week, was reported for the APCD by 72% and for elastic stockings by 74%. ConclusionsThis longitudinal study of Veterans Affairs patients with LED demonstrated improved generic and disease-specific HR-QoL through 52 weeks with at home use of an APCD. Limb girth, cellulitis episodes, and skin discoloration were reduced, with excellent compliance.

The critical role of phlebolymphedema in cellulitis associated with lymphedema: Its incidence and economic impact in a large real-world population

ObjectiveThe aims of this study were: to define the incidence of cellulitis in patients with lymphedema (LED) overall and relate this to the etiology of LED; to determine how this rate might be affected by recurrence of cellulitis; and to quantify the contemporary economic burden of treatment. Understanding these factors is essential in developing targeted cellulitis prevention strategies and reducing health care costs. MethodsThe IBM MarketScan Research Database was examined from April 2013 to March 2019 for patients with a new diagnosis of LED (n = 85,601). Based on International Classification of Diseases (ICD)-9/ICD-10 diagnosis codes, the incidence and cost of cellulitis were ascertained during the 3-year follow-up period. Incidence rates (per 100 patient-years [PYs]) and cost (per patient per year) of cellulitis were evaluated among all patients with LED and within subgroups of LED etiologies. ResultsAmong the three most common morbidities associated with LED (breast cancer-related lymphedema [BCRL], n = 17,954 [20.97%]; gynecological cancer-related LED [GCRL], n = 1256 [1.47%]; and phlebolymphedema [PLED], n = 8406 [9.82%]), rates of cellulitis were markedly lower for BCRL (8.9; 95% confidence interval [CI], 8.7-9.2) and GCRL (14.8; 95% CI, 13.4-16.4) vs PLED (47.7; 95% CI, 46.7-48.8). Patients with a history of cellulitis had markedly higher cellulitis rates during follow-up than those without—overall, 74.0% vs 16.4%; BCRL, 42.9%; 95% CI, 39.7%-46.3% vs 7.6%; 95% CI, 7.3%-7.9%; GCRL, 67.5%; 95% CI, 56.4%-80.8% vs 11.0%; 95% CI, 9.8%-12.4%; and PLED, 81.7%; 95% CI, 79.4%-84.1% vs 30.4%; 95% CI, 29.4%-31.4%, respectively. The mean $/patient/year of cellulitis-related costs for a patient with PLED ($2836; 95% CI, $2395-$3471) was significantly greater than that for BCRL ($503; 95% CI, $212-$1387) and GCRL ($609; 95% CI, $244-$1314). ConclusionsThe incidence of cellulitis associated with LED varies by the etiology of LED. PLED has the highest rates of both an initial cellulitis episode and recurrent cellulitis events. Additionally, PLED has one of the largest cellulitis-related total costs per patient per year. Prevention, as well as early identification and treatment of PLED-associated cellulitis, could significantly decrease health care costs and improve patient quality of life.

Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients.

The exact knowledge of the local biological and immunological effects of vascularized lymph node transfer (VLNT) continues to be an emerging science but a positive control positive control over infectious and immune-mediated processes is often advocated. Knowing the characterization of the inflammatory infiltrate associated with lymphedema, the aim of this paper is to verify the hypothesis that VLNT is able to modulate the inflammatory and immune microenvironment of lymphedematous tissue by evaluating any modification of the local inflammatory cell infiltrate. A prospectively database of patients who received VLN transfer for lower extremity lymphedema between January 2018 and December 2020 was reviewed. Nine patients diagnosed with extremities' stage II secondary lymphedema were included, with a mean age of 55.3 (range 39-66 years) years. Gastroepiploic lymph node transfer was performed in all patients and transferred heterotopically. Full thickness 6-mm skin punch biopsies were obtained from all voluntary lymph node transfer patients at identical sites of the lymphedematous limb during the surgical procedure of VLNT (T0) and 1 year later (T1). Immunohistochemistry was performed using antibodies against the following markers: anti-CD3; anti-CD4; anti-CD8; anti-CD68. Data at T0 were compared to those at T1. Post-operative course was uneventful in all cases experiencing a significant reduction (almost a third) in terms of cellulitis episodes: The median duration of follow-up for patients was 28.3 months (range 12-40). The analysis of the density of the inflammatory cells as a whole revealed a significant reduction at T1 compared to T0. Specifically, CD3 expression levels turned from 16.36 ± 3.421 (cells/mm2 ) pre-operatively to 7.6 ± 1.511 (cells/mm2 ) post-operatively (p < .0001). CD4+ cells turned from 7.270 ± 3.421 (cells/mm2 ) at T0 to 4.815 ± 1.511 cells/mm2 at T1 (p = .0173). CD8 expression values decreased from 4.360 ± 3.421 (cells/mm2 ) to 2.753 ± 1.451 (cell/mm2 ) at T1 (p = .0003). Monocyte/macrophage marker CD68 varied from 8.208 ± 2.314 (cells/mm2 ) at T0 to 7.600 ± 1876 (cells/mm2 ) at T1 (p = .0003). VLNT decreases skin and subcutaneous tissues' infiltration of inflammatory cells, providing one explanation for the positive control of lymph node transfer procedure over infectious and immune-mediated processes.

Impact of lymphedema in the management of venous leg ulcers.

Lymphedema (LED) in patients with venous leg ulcers (VLU) [VLU+LED] can impair ulcer healing and predispose to cellulitis. There is little data, however, demonstrating how lymphatic dysfunction may impact the clinical course, treatment, and healthcare expenditures for VLU+LED versus VLU-LED patients. To determine how lymphatic dysfunction might influence treatment and expenditures among VLU patients in a large deidentified healthcare claims database. A retrospective cohort design and data from the IBM MarketScan Database (April 2013 to March 2019) were employed. Study population comprised VLU patients, and was stratified into two subgroups: VLU+LED (index date = date of first LED diagnosis) and VLU-LED (index dates randomly assigned to match distribution of index dates for VLU+LED). Within each subgroup, patients with <1year of healthcare claims information before and after their index dates were excluded. Demographics, comorbidities, procedures/treatments, as well as all-cause post-index medical resource utilization and expenditures ($/patient/year) of the two groups were compared. Stabilized inverse probability treatment weights (IPTWs) were employed to adjust for differences between groups in baseline characteristics. A total of 5466 VLU patients were identified (VLU+LED: N = 299; VLU-LED: N = 5167). Overall ambulatory encounters (AMB ENC) and their components were higher in VLU+LED, which were reflected in increased expenditures for this group (Table 1). Treatment with endovenous ablation (EVA) or stenting for venous hypertension as well as for specific measures for LED were higher in the 1-year post-index period for VLU+LED. The use of LED specific therapy was low for both groups, but a greater percentage of VLU+LED patients received therapy, which was predominantly manual lymphatic drainage (17.4%) rather than pneumatic compression (10.7%). The clinical presence of LED in patients with VLU is a marker for a more complex disease process with more episodes of cellulitis and expenditures, but a surprisingly low specific treatment for LED.

Self-care treatment for lymphoedema of lymphatic filariasis using integrative medicine.

Lymphatic filariasis (LF) is a neglected tropical disease presenting mainly as lymphoedema (elephantiasis). At present, LF is not effectively treated. Integrative medicine (IM) treatment for lymphoedema uses a combination of Indian traditional medicine, Ayurveda, alongside yoga exercises, compression therapy, antibiotics and antifungal treatments, providing a useful combination where resources are limited and different practices are in use. To assess the effectiveness of the IM in the existing clinical practice of lower-limb lymphoedema management and to determine whether the treatment outcomes align with the World Health Organization (WHO) global goal of LF management. Institutional data from electronic medical records of all 1698 patients with LF between 2010 and 2019 were retrospectively analysed using pre- and post-treatment comparisons and the National Institute for Health and Care Excellence guidelines for clinical audit. The primary treatment outcomes evaluated were limb volume, bacterial entry points (BEEPs), episodes of cellulitis, and health-related quality of life (HRQoL). Secondary outcomes included the influence of the patient's sex, duration of illness, education and employment status on volume reduction. Multiple regression analysis, t-test, χ2-test, analysis of variance, Mann-Whitney U-test and the Kruskal-Wallis test were used to assess the association between IM and patients' treatment outcomes. Limb volume reduced by 24.5% [95% confidence interval (CI) 22.47-26.61; n = 1660] following an intensive supervised care period (mean 14.84 days, n = 1660). Limb volume further reduced by 1.42% (95% CI 0.76-2.07; n = 1259) at the first follow-up visit (mean 81.45 days), and by 2.3% between the first and second follow-up visits (mean 231.32 days) (95% CI 1.26-3.34; n = 796). BEEPs were reduced upon follow-up; excoriations (78.4%) and intertrigo (26.7%) were reduced at discharge and further improvements was achieved at the follow-up visits. In total, 4% of patients exhibited new BEEPs at the first follow-up [eczema (3.9%), folliculitis (6.5%), excoriations (11.9%) and intertrigo (15.4%); 4 of 7 BEEPs were recorded]. HRQoL, measured using the disease-specific Lymphatic Filariasis Specific Quality of Life Questionnaire, showed an average score of 73.9 on admission, which increased by 17.8 at the first follow-up and 18.6 at the second follow-up. No patients developed new cellulitis episodes at the first follow-up, and only five patients (5.3%) developed new episodes of cellulitis at the second follow-up. IM for lower-limb lymphoedema successfully reduces limb volume and episodes of cellulitis, and also reduces BEEPs, leading to improved HRQoL. IM aligns with the LF treatment goals of the WHO and is a low-cost, predominantly self-care management protocol. IM has the potential to change care models and improve the lives of patients with lymphoedema.

Complex decongestive therapy in lymphedema: report from an Interdisciplinary Center

Lymphedema is a chronic and worsening disease due to an abnormal accumulation of liquids, with a high protein content in the interstitial space. The disease is characterized by an insufficient flow of lymphatic fluid, which manifests as edema, inflammation, and fibrosis, all the way up to the stiffening of the affected tissues. Because it's a chronic and increasing disease, the treatment is highly complex. The literature shows that the treatment must be multidisciplinary and it is necessary to combine multiple techniques, such as manual lymphatic drainage, mechanical lymphatic drainage, elasto-compressive bandages and other complementary techniques up to surgical treatment in the most advanced forms which are not responsive to physical therapy. Furthermore, the disease is characterized by episodes of cellulitis, that may lead to infectious complications because the lymphatic function becomes insufficient. A condition of local immunodeficiency is created due to the crucial role that the lymphatic system covers with immune defenses, therefore creates a fertile ground for infections caused by small skin wounds, insect bites, animal scratches, nail fungus, blood draws. Therefore, particular attention is paid to skin folds and interdigital spaces for which hygiene is necessary using neutral detergents, drying by dabbing, and applying emollient creams for skin hydration. Unfortunately, such practices of prevention and care are often underestimated. We provide education of the patient on self-care, such as the self-bandage and the correct application of the elasto-compressed stoking. For wrapping the bandage, it is advisable to wear a glove or a special sock. The multilayer bandages are used in the first decongestant phase while over time the elastic stocking is the best aid for the management of lymphedema. Our clinic is a referral center for diagnosis, treatment and surgical therapy, where patients come for surgical evaluation. Since 2016 we have systematically collected clinical data and volume evaluation of more than 600 cases affected by lymphedema and lipoedema of all stages. They have been treated with complex decongestive therapy for 4 hours a day, 15 consecutive days, subsequently a maintenance of once a week for 3 months, then once a month for 6 months. Of more than 600 patients treated, only 150 were submitted to surgery (lymphatic venous anastomosis, fasciotomy or liposuction, chylothorax and chyloperitoneal shunt, reconstructive plastic of external genitalia). Complex decongestive interdisciplinary therapy, when properly performed can stabilize the lymphedema patient situation, reducing the stage and ensuring a good quality of life.

Impact and outcomes after lymphaticovenous anastomosis for 150 cases of lymphoedema followed up over 24 months

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. 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. 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). 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.

The Agonist-Antagonist Myoneural Interface in a Transtibial Amputation.

The agonist-antagonist myoneural interface (AMI) technique at the time of transtibial amputation involves the use of agonist-antagonist muscle pairs to restore natural contraction-stretch relationships and to improve proprioceptive feedback when utilizing a prosthetic limb1. Utilizing the standard incision for a long posterior myofasciocutaneous flap, the lateral and medial aspects of the limb are dissected, identifying and preserving the superficial peroneal and saphenous nerve, respectively. The tendons of the tibialis anterior and peroneus longus are transected distally to allow adequate length for the AMI constructs. After ligation of the anterior tibial vessels, the deep peroneal nerve is identified and tagged to create a regenerative peripheral nerve interface (RPNI). The tibia and fibula are cut approximately 15 cm from the medial joint line, facilitating dissection of the deep posterior compartment and ligation of the peroneal and posterior tibial vessels. The tendons of the lateral gastrocnemius and tibialis posterior are transected distally, and the amputation is completed. The extensor retinaculum is harvested from the residual limb along with multiple 2 × 3-cm free muscle grafts, which will be used for the RPNI constructs. The retinaculum is secured to the tibia with suture anchors, and AMI pairs of the lateral gastrocnemius and tibialis anterior as well as the tibialis posterior and peroneus longus are constructed. Separate RPNIs of the major lower-extremity nerves are performed, and the wound is closed in a standard layered fashion. An isometric myodesis of the gastrocnemius without coaptation of agonist-antagonist muscle pairs can be performed at the time of transtibial amputation. The AMI technique restores natural agonist-antagonist relationships at the time of transtibial amputation to increase proprioceptive feedback and improve prosthetic control. These outcomes contrast with those of a traditional isometric myodesis, which prevents proprioceptive communication from the residual limb musculature to the central nervous system. Additionally, the AMI technique allows for concentric and eccentric muscular contractions, which may contribute to the maintenance of limb volume and aid with prosthetic fitting, as opposed to the typical limb atrophy observed following standard transtibial amputation1,2. With the development and availability of more advanced prostheses, the AMI technique offers more precise control and increases the functionality of these innovative devices. Early clinical outcomes of the AMI technique at the time of transtibial amputation have been promising. In a case series of the first 3 patients who underwent the procedure, complications were minor and consisted of 2 episodes of cellulitis and 1 case of delayed wound healing1. Muscle activation measured through electromyography demonstrated an improved ability to limit unintended muscular co-contraction with attempted movement of the phantom limb, as compared with patients who underwent a standard transtibial amputation1. Additionally, residual limb volume was maintained postoperatively without the need for substantial prosthetic modifications. The tendons of the tibialis anterior, peroneus longus, tibialis posterior, and lateral gastrocnemius should be transected as distal as possible to allow adequate length for creation of the AMI constructs.Approximately 2 × 3-cm free muscle grafts are harvested from the amputated extremity for RPNI3.Smooth tendon-gliding through the synovial tunnels should be confirmed before closure. If necessary, muscle debulking can improve gliding and decrease the size of the residual limb.Harvesting the extensor retinaculum for synovial tunnels has been our preferred method, although we acknowledge that other grafts options such as the tarsal tunnel are available1. RPNI = regenerative peripheral nerve interfaceAMI = agonist-antagonist myoneural interfaceEMG = electromyographic.

Modeling the potential health impact of prospective Strep A vaccines

The World Health Organization published the preferred product characteristics for a Group A Streptococcus (Strep A) vaccine in 2018. Based on these parameters for the age of vaccination, vaccine efficacy, duration of protection from vaccine-derived immunity, and vaccination coverage, we developed a static cohort model to estimate the projected health impact of Strep A vaccination at the global, regional, and national levels and by country-income category. We used the model to analyse six strategic scenarios. Based on Strep A vaccine introduction between 2022 and 2034 for the primary scenario, we estimated vaccination at birth for 30 vaccinated cohorts could avert 2.5 billion episodes of pharyngitis, 354 million episodes of impetigo, 1.4 million episodes of invasive disease, 24 million episodes of cellulitis, and 6 million cases of rheumatic heart disease globally. Vaccination impact in terms of burden averted per fully vaccinated individual is highest in North America for cellulitis and in Sub-Saharan Africa for rheumatic heart disease.

Abstract #1406144: Safety and Efficacy of SGLT2 Inhibitors Use in Patient with Diabetes After Renal Transplant

The sodium glucose cotransporter2 inhibitors (SGLT2i) are preferred anti-glycemic agents for patients with diabetes mellitus (DM) and chronic kidney disease (CKD). These agents have been shown to slow the progression of kidney disease. There is limited experience of SGLT2i in renal transplantation (RT). Concerns have been that the glycosuria induced osmotic diuresis might cause a decrease in renal perfusion and there might be a possible increased risk of urinary tract infections (UTI). We therefore performed a retrospective review of data of patients with DM and RT treated with SGLT2i compared to those without SGLT2i. The primary outcome was the change in eGFR or serum creatinine at 1-year. Secondary outcomes were documentations of serious adverse events (SAE). Data were retrieved from the electronic medical record of a Midwestern academic medical center using the program Epic and the sub-program Slicer/ Dicer. The search algorithm inclusion criteria were: “Diabetes Mellitus” “kidney transplant”, and “medicine: sodium glucose transport inhibitor”, which resulted in an inclusion of 44 patients in the “SGLT2i group”. A comparator group of patients with DM and RT who matched the above screening criteria (except for SGLT2i use), was then retrieved. We then devised a propensity score by performing a multivariate regression analysis with the covariates of age, type of transplant, duration of transplantation, and baseline eGFR. Data from 44 patients on SGLT2i were closely matched (by standardized effects size) for age, estimated GFR, duration and source of transplant with 70 control patients with DM and RT who were not on SGLT2i. Weight changed in SGLT2i group from baseline at 3, 6 and 12months (by -4.1 ± 3.3 kg, -5.1 ± 5.0 kg and -5.2 ± 6.5 kg) and did not change in controls (p [ANOVA, drug] = 0.009). There was no significant difference at 3, 6 or 12 months in changes in: A1c, systolic or diastolic blood pressure, hematocrit, hemoglobin, total cholesterol, LDL cholesterol, HDL cholesterol, or serum triglycerides. There were no documented significant increases in SAE in those on SGLT2i compared with controls in hospitalizations for acute kidney injury, episodes of acute transplant rejections, amputations, cellulitis, diabetic ketoacidosis, or outpatient treatment for urinary tract infections, or genital mycotic infections. Use of SGLT2i in patients with diabetes and renal transplant showed beneficial effect in reducing weight without a higher risk of SAE. Longer follow up may be necessary to define the impact on eGFR.

D30. Immediate Lymphatic Reconstruction (ILR) with Vascularized Lymph Node Transplant (VLNT)

PURPOSE: Patients undergoing exanteration of axillary/groin lymph nodes and radiation are at risk not only for lymphedema but painful contracture and limited range of motion (ROM). Traditional immediate-lymphatic-reconstruction (ILR) addresses the lymphatic defect but not the soft tissue one. The purpose of this study was to evaluate the safety and efficacy of ILR with a vascularized-omentum-lymphatic-transplant (VOLT) to reduce the risk of both contracture and lymphedema development in patients with extensive disease. METHODS: Patients with an overwhelming risk of developing severe lymphedema and contracture were offered VOLT at the time of axillary/groin dissection at a tertiary-cancer-center between 2016 to 2021. Demographic data, volume-measurements, Quality-of-Life scores, and cellulitis episodes were recorded. RESULTS: A total of eight patients underwent ILR with VOLT at the time of axillary (n=4)/groin (n=4) dissection. No complications were observed (0%). The mean follow-up time was 30.7±12 months. Three patients (37.5%) developed lymphedema. One patient (12.5%) experienced one episode of cellulitis. Limited ROM during abduction was reported by 3 patients (37.5%). The mean Lymphedema-Life-Impact-Scale (LLIS) scores after surgery reflected minimal Quality-of-Life impairment globally (7.6±14.4%), physically (2.6±4.6%), psychologically (1.2±2.8%) and functionally (1.3±2.3%). CONCLUSION: This is the first study to report ILR with VOLT. VOLT is a safe and reliable option for immediate-reconstruction of the highest-risk patient group who are almost certain to develop not only lymphedema but severe contracture and functional disability. While larger studies are required to better determine indications and outcomes, it is preferable to replace soft-tissue prior to radiation to mitigate pain and contracture.

Patient With Genital Lymphedema, Pain, and Rash

A 47-year-old man presented to the emergency department (ED) with 3 days of worsening scrotal pain, genital edema, erythema and yellow penile discharge, after completing 2 weeks of doxycycline. He was in an open marriage with a male partner and denied new sexual partners. In the ED he was afebrile and normotensive without tachycardia. His physical exam revealed tender genital lymphedema without crepitus or fluctuance (Figure 1A, 1B). White blood cell count (WBC) was 8.8 × 109/L, Lactate 1.9 mmol/L, and Creatinine 1.22 mg/dL. CT scan revealed no subcutaneous air nor fluid collection. Physical exam evolved with the development of an umbilicated rash with pustules on hospital day #5 (Figure 1C). Tests for HIV, Hepatitis C, HSV-1, HSV-2, Neisseria gonorrhea and Chlamydia trachomatis were negative. His RPR and treponemal antibody were both positive. A)FilariasisB)Monkeypox + SyphilisC)Lymphogranuloma VenereumD)Molluscum Contagiosum + Secondary Syphilis What is the most likely diagnosis? B) Monkeypox + Syphilis In the 2022 United States Monkeypox (MPX) outbreak, infected individuals most often present with a prodrome of fever, lethargy, myalgia, and headache and with subsequent onset of a cutaneous lesions in 95% of cases, most frequently in the anogenital region (73%).1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Transmission occurs through direct and prolonged contact with skin lesions, fomites, and also large respiratory droplets.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Concomitant sexually transmitted infections (STI) have been seen in up to 29% of cases.1Thornhill JP Barkati S Walmsley S et al.Monkeypox Virus Infection in Humans across 16 Countries.N Engl J Med. April-June 2022; (Published online): 2022Google Scholar Furthermore, secondary bacterial infections involving MPX lesions have also been reported.2Ortiz-Martinez Y Rodriguez-Morales Alfonso J Franco-Paredes C Chastain DB Gharamti AA Vargas Barahona L Henao-Martinez AF Monkeypox - a description of the clinical progression of skin lesions: a case report from Colorado, USA.Ther Adv Infect Dis. 2022; 920499361221117726Google Scholar Primary infectious genital lymphedema is most commonly caused by Wuchereria bancrofti, causing Lymphatic Filariasis, which is rare in the U.S.3Pastor C Granick MS. Scrotal lymphedema.Eplasty. 2011; 11 (ic15)https://www.ncbi.nlm.nih.gov/pubmed/22184510Google Scholar Genital lymphedema may also be idiopathic or secondary to prior episodes of Streptococcus cellulitis.4Bjornsdottir S Gottfredsson M Thorisdottir AS et al.Risk Factors for Acute Cellulitis of the Lower Limb: A Prospective Case-Control Study.Clin Infect Dis. 2005; 41: 1416-1422https://doi.org/10.1086/497127Crossref PubMed Scopus (143) Google Scholar Additional considerations include secondary syphilis and Lymphogranuloma Venereum (LV), caused by Chlamydia trachomatis. Secondary syphilis presents with lymphadenopathy and systemic systems, but the presence of extensive perianal pain and proctitis is unusual and more suggestive of MPX.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar The patient described was diagnosed with syphilis by positive RPR and treponemal antibody tests, but this diagnosis alone did not explain his extensive pain. LV is usually characterized by proctitis, proctocolitis, and palpable inguinal and femoral lymph nodes.6Basgoz N Brown CM Smole SC et al.Case 24-2022: A 31-Year-Old Man with Perianal and Penile Ulcers, Rectal Pain, and Rash.N Engl J Med. 2022; 387: 547-556https://doi.org/10.1056/NEJMcpc2201244Crossref PubMed Scopus (26) Google Scholar LV usually presents with a primary asymptomatic genital or anal lesion, but disseminated and persistent skin lesions have not been described and are more consistent with MPX. Patients presenting with acute scrotal pain and/or edema even without pathognomonic lesions, should prompt STI evaluation and early MPX precautions.7Gomez-Garberi M Sarrio-Sanz P Martinez-Cayuelas L et al.Genitourinary Lesions Due to Monkeypox.Eur Urol. 2022; 9 (Published online September)https://doi.org/10.1016/j.eururo.2022.08.034Abstract Full Text Full Text PDF Scopus (5) Google Scholar In the described case, the diagnosis was confirmed with DNA PCR testing of a swabbed genital lesion for Orthopoxvirus and Monkeypox Virus (West African Clade). On hospital day #6, the patient was started on Tecovirimat 600mg prescribed twice daily for two weeks. On hospital day #10, the scrotal lesions healed without areas of apparent necrosis, and scrotal edema subsided to baseline. 5Vives F García-Perdomo HA Ocampo-Flórez GM. Giant lymphedema of the penis and scrotum: a case report.Autops Case Rep. 2016; 6: 57-61https://doi.org/10.4322/acr.2016.026Crossref PubMed Google Scholar.