Limb Circumference Research Articles

94 Bioimpedance Spectroscopy Is a Valid and Reliable Measure of Edema in Hand Burn Injury

Abstract Introduction The assessment of swelling following burn injury is complicated by the presence of wounds and dressings, particularly as the patient cohort experience significant pain, impaired movement, and may require medications that result in modified behavior. Further, traditional measures of volume, such as water displacement volumetry (WDV) or circumferential limb measures may pose increased infection risk and pain due to contact with open wounds. Clinically, edema is most often assessed by noting loss of skin creases, palpation of areas of visible swelling, and loss of function, as there remains a lack of sensitive objective measures for edema in patients with hand burn injury. Bioimpedance spectroscopy (BIS) is a measure of body composition that has been demonstrated by our group to be reliable for measuring whole body and limb edema during resuscitation, and to be sensitive to local edema changes within healing wounds. The aim of this study was to determine the reliability and validity of BIS as a measure of edema following hand burn injury. Methods One hundred patients presenting with hand burn injury were recruited to this trial. Repeated volume measures of the hand were recorded using a novel application of BIS, and repeated using WDV. The results were analysed using multi-level mixed effects regressions. The use of BIS electrodes on the dorsum of the middle finger at the DIP and MCPJ levels, and dorsum of the wrist and forearm have been previously described for measuring lymphedema. Results Paired repeated measures were obtained for 195 hands. Alternate electrode positions on the palm of the middle finger and hand, and volar wrist and forearm, and a combination of palmar hand / dorsal forearm were assessed. There was no evidence of a significant difference between these electrode configurations and the previously described dorsal hand / forearm configuration (position x distance interaction, p=0.608–0.802). Dorsal hand / volar forearm configuration was significantly different (position x distance interaction, p=0.006) from the standard electrode position described. Comparison with WDV demonstrated a strong correlation (r=0.79; limits of agreement 198-460mL; bias 329mL). Reliability of BIS was determined by ICC: 0.9978–0.9999 (CI 0.9967–0.9999). Conclusions Compared to WDV, BIS is a valid and reliable measure of edema following acute hand burn injury. This study also confirmed the interchangeability of multiple BIS electrode positions. Applicability of Research to Practice BIS offers a real time measure of fluid (change) within the extracellular space, and therefore edema in patients with hand burn injury, while minimizing the risk of infection and increased pain in burns patients. The interchangeability of electrode positions provides clinicians with a number of flexible options to accommodate locations of hand burn wounds, thus allowing between patient comparisons.

Lymphaticovenous Anastomosis for Lower Extremity Lymphedema: A Systematic Review.

Background Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces resulting from impairment in the lymphatic circulation that can impair quality of life and cause considerable morbidity. Lower extremity lymphedema (LEL) has an overall incidence rate of 20%. Conservative therapies are the first step in treatment of LEL; however, they do not provide a cure because they fail to address the underlying physiologic dysfunction of the lymphatic system. Among several surgical alternatives, lymphaticovenous anastomosis (LVA) has gained popularity due to its improved outcomes and less invasive approach. This study aims to review the published literature on LVA for LEL treatment and to analyze the surgical outcomes. Methods PubMed database was used to perform a comprehensive literature review of all articles describing LVA for treatment of LEL from Novemeber 1985 to June 2019. Search terms included “lymphovenous” OR “lymphaticovenous” AND “bypass” OR “anastomosis” OR “shunt” AND “lower extremity lymphedema.” Results A total of 95 articles were identified in the initial query, out of which 58 individual articles were deemed eligible. The studies included in this review describe notable variations in surgical techniques, number of anastomoses, and supplementary interventions. All, except one study, reported positive outcomes based on limb circumference and volume changes or subjective clinical improvement. The largest reduction rate in limb circumference and volume was 63.8%. Conclusion LVA demonstrated a considerable reduction in limb volume and improvement in subjective findings of lymphedema in the majority of patients. The maintained effectiveness of this treatment modality in long-term follow-up suggests great efficacy of LVA in LEL treatment.

Volume control of the lower limb with graduated compression during different muscle pump activation conditions and the relation to limb circumference variation

BackgroundThe literature supports the use of graduated compression stockings (GCS) for leg edema. Nevertheless, there is a paucity of data on the GCS effect on limb edema related to sitting, standing, and walking. Data of different limb shapes and their impact on GCS-exerted pressure are lacking. This investigation provides evidence-based information on the effect of GCS on edema reduction and the impact of limb circumference gradients on GCS pressure. MethodsThirty healthy individuals (15 men and 15 women; mean age, 32 ± 5 years) were included. All the participants underwent lower limb volume (Kuhnke formula) measurement, before and after sitting for 30 minutes, wearing below-ankle noncompressive socks. The same assessment was repeated 7 days later, in the same participants, but with wearing of below-knee 16 to 20 mm Hg GCS. At 7-day intervals, 1 week with below-ankle noncompressive socks and 1 week with below-knee 16 to 20 mm Hg GCS, all the participants repeated the same protocol including standing and walking. Ten participants underwent bioimpedance assessment (Biody Xpert II; eBIODY, La Ciotat, France) before and after sitting, standing, and walking. In the same group, B and B1 interface pressure values were measured. ResultsData collection was completed in all 60 limbs. Sitting or walking without GCS led to no significant volume changes, whereas volume was decreased by the use of GCS (−4.8% [P < .00001] and −4.4% [P < .00001], respectively). Standing up without GCS led to an increase in volume (2.7%; P < .0001), whereas limb volume was decreased (4.6%; P < .0001) by use of GCS. Bioimpedance showed extracellular water reduction only while walking with GCS (from 40.55% ± 1.66% to 40.45% ± 1.71%; P < .017). Mean interface pressure was 19 ± 5 mm Hg (B) and 16 ± 5 mm Hg (B1). The interface pressure variation from B to B1 was not homogeneous among participants (mean percentage variation of −13% ± 25%, ranging from −54% to 16%). A negative linear trend between pressure variation and circumference percentage increase was found; the subanalysis excluding the two outliers showed a strong negative linear correlation (Pearson coefficient r = −0.96). ConclusionsGCS led to a significant limb volume reduction irrespective of limb position and muscle pump function. However, extracellular fluid is mobilized only during muscle contraction while walking with GCS. Interestingly, different lower limb circumference variations influence the interface pressure gradient, indicating the importance of proper fitting of both B and B1 during prescription. These data provide a foundation to future investigations dealing with GCS effect on fluid mobilization and with limb geometry impact on compression performance.

MELILOTUS, RUTIN AND BROMELAIN IN PRIMARY AND SECONDARY LYMPHEDEMA

As reported in the literature, benzopyrones (alpha and gamma) have important effects on the microcirculation through various mechanisms. Coumarins are an alpha-benzopyrone as derivatives of Melilotus Officinalis, while bioflavonoids are a gamma-benzopyrone and include Rutin. Alpha-benzopyrones have two fundamental pharmacological effects: they have pro-lymphokinetic action by activating contractility of lymphangions; and the activation of macrophages to provide a proteolytic effect. Gamma-benzopyrones, such as Rutin, have an important anti-exuding and membrane stabilizing effect. Bromelain is known for its anti-inflammatory effect. The present study enrolled 52 patients with primary and/or secondary lymphedema in clinical stages I or II (according to the ISL classification) with 31 cases involving the lower limbs and 21 cases involving the upper limbs. All subjects were given for six months a natural compound consisting of 100 mg of natural Melilotus, that contains 20 grams of Coumarin, 300 mg of Rutin and 100 mg of Bromelain. The following parameters were studied at zero time (T0), after three months (T1), and after six months of treatment (T2): pitting, Stemmer's sign, measurement of limb circumferences, measurement of superficial tissue thickness in the affected limbs using ultrasound, and blood tests to evaluate hepatic function (ALT, AST, GGT, total and fractional bilirubin). At the end of the treatment (T2), the following results were observed: disappearance of pitting in 72% of the cases; unchanged Stemmer's sign; average decrease in limb circumferences of 4.2 cm; and average reduction of the superficial thickness of 29%. There was no variation in the liver function parameters examined. The combination of natural compounds (Melilotus, Rutin, and Bromelain) has been shown to be a valuable aid in the clinical control of both primary and secondary lymphedema of clinical stages I and II as well as in control of inflammatory phenomena related to chronic stasis. There were no side effects and no alteration of liver function parameters found.

Balloon-assisted catheter-directed thrombolysis: A novel approach for acute deep vein thrombosis in the lower extremities

BackgroundDeep vein thrombosis (DVT) is a common cardiovascular emergency that may have life-threatening complications, including pulmonary embolism (PE) and post-thrombotic syndrome (PTS). Conventional anticoagulant medication does not completely dissolve the clots and does not decrease the risk of DVT complications. Invasive catheter-directed thrombolysis (CDT) is an approach that has been reported to reduce the reoccurrence of PTS during acute DVT. We compared balloon-assisted CDT with routine CDT in the treatment of acute DVT and evaluated the clinical efficacy and safety of balloon-assisted CDT. MethodsThis retrospective cohort study included 94 patients diagnosed with a first episode of DVT in the lower extremities and treated from September 2008 to February 2018. The patients underwent routine CDT (group A, n ​= ​50) or balloon-assisted CDT (group B, n ​= ​44) based on their enrollment date. We obtained the circumference difference between the limbs, the degree of clot lysis, and the lysis rate as parameters for evaluating the two approaches. The PE incidence and bleeding amount were recorded. We also compared the total urokinase dose, treatment duration, and retrieval rate of optional filters. ResultsSwelling was significantly alleviated in both groups, as indicated by a reduction in the limb circumference. Patients who underwent balloon-assisted CDT exhibited significantly lower thrombus scores compared with the routine group (S ​= ​1403.50, Z ​= ​−5.7702, P ​< ​0.0001). Additionally, the duration of balloon-assisted CDT was significantly shorter (6 vs. 10 days [S ​= ​1039.0, Z ​= ​−8.0358, P ​< ​0.0001]). The mean urokinase usage per patient was decreased in the balloon-assisted group (P ​< ​0.0001). Bleeding occurred in both groups, with no statistical significance. The filter retrieval rate in the balloon-assisted group was significantly higher than that in the routine CDT group (Χ2 ​= ​4.829, P ​= ​0.028). ConclusionsBalloon-assisted CDT is an effective, cost-efficient, and safe method for the treatment of acute DVT. It exhibited advantages over routine CDT, including less lysis medication, decreased procedure duration, and higher patency rates. Inferior vena cava filtration is mandatory in balloon-assisted CDT. After thrombus removal, the risk of symptomatic PE did not increase in this approach.

Validation of the oscillometric blood pressure monitor Vet20 SunTech in anesthetized healthy cats

ObjectiveTo evaluate a veterinary-specific oscillometric noninvasive blood pressure (NIBP) system according to the guidelines of the American College of Veterinary Internal Medicine (ACVIM) Consensus Statement. Study designProspective clinical study. AnimalsA total of 33 client-owned cats (20 females and 13 males). MethodsCats were premedicated with methadone (0.3 mg kg−1) and alfaxalone (2 mg kg−1) intramuscularly. After 15 minutes anesthesia was induced with isoflurane (3%) in 100% oxygen by facemask while breathing spontaneously. A 22 gauge catheter was placed in the median caudal artery and systolic (SAP), diastolic (DAP) and mean (MAP) arterial pressures were measured. NIBP measurements were collected by placing the cuff (40% of limb circumference) on the right or left antebrachium. The agreement between the two methods was evaluated with the Bland–Altman methods, and the oscillometric NIBP device was evaluated using the ACVIM guidelines for validation of devices. ResultsData from 30 of the 33 cats were analyzed. Five paired measurements were taken from each cat, totaling 150 paired measurements. Mean bias (limits of agreements) for SAP, DAP and MAP were 2.7 (−22.7 to 28.1), 0.9 (−22.3 to 24.2) and 1.3 (−20.4 to 23.0). The oscillometric NIBP passed all validation criteria, except correlation which was <0.9 for SAP, DAP and MAP. Conclusions and clinical relevanceThe Vet20 did not meet all validation criteria by the ACVIM. However, all criteria except correlation were met.

Preoperative Assessment of Upper Extremity Secondary Lymphedema.

Introduction: The purpose of this study was to evaluate the most commonly used preoperative assessment tools for patients undergoing surgical treatment for secondary upper extremity lymphedema. Methods: This was a prospective cohort study performed at a tertiary cancer center specializing in the treatment of secondary lymphedema. Lymphedema evaluation included limb volume measurements, bio-impedance, indocyanine green lymphography, lymphoscintigraphy, magnetic resonance angiography, lymphedema life impact scale (LLIS) and upper limb lymphedema 27 (ULL-27) questionnaires. Results: 118 patients were evaluated. Limb circumference underestimated lymphedema compared to limb volume. Bioimpedance (L-Dex) scores highly correlated with limb volume excess (r2 = 0.714, p < 0.001). L-Dex scores were highly sensitive and had a high positive predictive value for diagnosing lymphedema in patients with a volume excess of 10% or more. ICG was highly sensitive in identifying lymphedema. Lymphoscintigraphy had an overall low sensitivity and specificity for the diagnosis of lymphedema. MRA was highly sensitive in diagnosing lymphedema and adipose hypertrophy as well as useful in identifying axillary vein obstruction and occult metastasis. Patients with minimal limb volume difference still demonstrated significantly impaired quality of life. Conclusion: Preoperative assessment of lymphedema is complex and requires multimodal assessment. MRA, L-Dex, ICG, and PROMs are all valuable components of preoperative assessment.

BIOIMPEDANCE SPECTROSCOPY IS NOT ASSOCIATED WITH A CLINICAL DIAGNOSIS OF BREAST CANCER-RELATED LYMPHEDEMA

The objective of this study was to evaluate the accuracy of bioimpedance spectroscopy measurements (L-Dex) in the diagnosis of breast cancer-related lymphedema. A retrospective review of a prospectively maintained database was performed of all patients that underwent surgical treatment for breast cancer at a tertiary medical center. Patients who had preoperative and postoperative evaluation for possible lymphedema by limb circumference measurements and bioimpedance were eligible for inclusion in the study. No significant demographic differences were found between the group of patients clinically diagnosed with lymphedema (N=134) and those without a clinical diagnosis of lymphedema (N=261). The ability of bioimpedance to diagnose lymphedema based on the manufacturer's criteria demonstrated low sensitivity, which was 7.5% when lymphedema was defined as an absolute L-Dex value greater than 10, and 24.6% when defined as a relative change of >10 between preoperative and postoperative measurements. This corresponded with a positive predictive value of 61-71% and a negative predictive value of 67-70%. We are unable to recommend the use of bioimpedance as a screening tool or for measurement of breast cancer-related lymphedema.

Dancing: More than a therapy for patients with venous insufficiency.

ObjectiveThis study aims to figure out the effects of dance therapy on patients with chronic venous insufficiency disease.MethodsForty subjects with chronic venous insufficiency were recruited to either the control group or the dance therapy group. As the severity of chronic venous insufficiency was defined with the Venous Clinical Severity Scores (VCSS), patients in control group received only medical treatment. Twenty patients with chronic venous insufficiency in dance therapy group received three times a week, for five weeks, totally 15 sessions of dance therapy in addition to medical treatment.ResultsThere was no significant difference in pre- and post-treatment results of Rivermead Index, VCSS parameters constipation complaint, assistive breath muscle activity, lower limb circumference, strength and range of motion between groups ( p &gt; 0.05). The remarkable result of this study was obtaining that the post-treatment quality of life scale’s bodily pain score was significantly higher in the dance therapy group than the control group ( p &lt; 0.05).ConclusionsIt was concluded that dance therapy has positive effects on quality of life. There were no barriers to chronic venous insufficiency patients in this form of gentle exercise, showing that it is to meliorate the cardiovascular, physical and psychological benefits of an activity that is enhancing of the self-esteem in addition to the quality of life. Treatment of chronic venous insufficiency should consist of methods that support the patient mentally, physically and psychologically, in addition to the medical treatment. Dance therapy might be a potential exercise intervention for improvements in chronic venous insufficiency patients, so clinicians focusing on them could recommend this form of gentle exercise in addition to the medical treatment.

The Therapeutic Effects of Goreisan, a Traditional Japanese Herbal Medicine, on Lower-Limb Lymphedema after Lymphadenectomy in Gynecologic Malignancies: A Case Series Study.

Background Lower-limb lymphedema (LLL) is a chronic and progressive complication of gynecologic cancer treatment, including pelvic lymphadenectomy. This study aims to investigate the therapeutic effect of goreisan, a traditional Japanese medicine, which has been used for hydrostatic modulation on patients with LLL. Methods Patients diagnosed with LLL in our hospital in 2018 were included and principally treated with complex decongestive therapy (CDT), including elastic clothing and lymph drainage. The patients who received a combination therapy of CDT and goreisan (CDT-G group) were prescribed goreisan extract granules, with a dose of 7.5 g per os daily in three doses. Patients who were not prescribed goreisan received CDT alone (CDT group). The severity of lymphedema was evaluated by the estimated limb volume calculated by limb circumferences and the ratio of extracellular water (ECW) to total body water (TBW). Results Nineteen women with LLL after pelvic lymphadenectomy were included in the study. The number of patients in the CDT and CDT-G groups was 8 and 11, respectively. There were no statistically significant differences between the CDT and CDT-G groups in terms of patient characteristics and severity of LLL before treatment. Reduction in ECW/TBW in the CDT-G group (in the whole body and the affected lower limb) after the intervention was significantly more remarkable than that in the CDT group. Conclusions Goreisan-based Japanese herbal therapy may be effective in patients with LLL after retroperitoneal lymphadenectomy.

Water Treadmill Therapy After Reconstruction of the Anterior Cruciate Ligament ACL – Case Report

Introduction: The knee joint is one of the most commonly injured joints, especially among physically active persons. In turn, the anterior cruciate ligament (ACL) is the knee ligament which is most frequently torn. Water treadmill therapy is one of the forms of rehabilitation available for patients after ACL reconstruction. Materials and Method: The case of a 38-year-old woman is presented who during parachute jumping sustained injury to the knee joint on landing. Using the magnetic resonance imaging (MRI) a tear of the ACL was diagnosed. Physiotherapeutic examination was performed: palpation and visual observation of both knee joints: assessment of position of the patella and the axes of the lower limbs, assessment of joint temperature, patella ballottement sign, and tenderness. In order to objectively monitor the progress of therapy measurements were taken of the circumference of the lower limbs, and pain complains assessed according to the VAS scale. Eight weeks after reconstruction of the anterior cruciate ligament, the patient underwent 30 treadmill therapy treatments. Results: Quadriceps muscle mass gain and reduction of the knee joint swelling were observed. Full range of knee joint motion was confirmed, and lack of pain in the medial compartment of the knee joint. Conclusions: Water treadmill therapy is an effective supplementation of the process of patient rehabilitation after reconstruction of the anterior cruciate ligament.

Electronic Moxibustion for Breast Cancer-Related Lymphedema: A Pilot Clinical Trial

This is a preliminary study to investigate the feasibility of electronic moxibustion in breast cancer patients with upper limb lymphedema. As current treatment options for lymphedema are unsatisfactory and time consuming, there have been attempts to manage symptoms using integrative treatments. Electronic moxibustion was developed to compensate for the shortcomings of conventional moxibustion and is widely used in clinical practice. However, there have been no studies on using electronic moxibustion in breast cancer-related lymphedema. To investigate the feasibility of electronic moxibustion in treating breast cancer-related lymphedema, this study included subjects who completed primary cancer treatment at least 6 months ago and had more than 10 mm difference in arm circumference of upper limbs. All subjects were assigned to the treatment group. Subjects were treated with 16 sessions (30 minutes/session) of electronic moxibustion for 8 weeks followed by 4 weeks of follow-up. For outcome measures, upper limb circumferences, shoulder range of motion, bioimpedance analysis, and quality of life questionnaire were assessed. All 10 subjects completed the study. The effective index showed 38.21% reduction after treatment (P = .0098) and 29.35% (P = .0039) after 4 weeks of follow-up compared to the baseline. The reduction of lymphedema was most prominent at 10 cm above the elbow crease, where the mean reduction of circumference difference was 7.5 mm (P = .0430) and continued to improve after treatment (mean reduction of 8.3 mm, P = .0156). There was significant improvement in shoulder range of motion only in flexion and internal rotation at week 9. There were 7 adverse events, and most were irrelevant to the treatment. Only 1 participant had a mild burn on the acupuncture point. Here, we demonstrate for the first time that electronic moxibustion treatment is a feasible treatment for breast cancer-related lymphedema. Electronic moxibustion may reduce differences in upper limb circumference and improve shoulder range of motion. A future comparative clinical trial is needed to confirm the clinical efficacy of this treatment.

Effects of mobilized peripheral blood stem cells on treatment of primary lower extremity lymphedema

ObjectiveLymphedema is a chronic debilitating disease characterized by the accumulation of fluid in the extremities as a result of lymphatic system impairment. Current treatments fail to restore the functionality and structural integrity of the lymphatic vessels lost in this condition. In this study, autologous mobilized peripheral blood stem cell transplantation was used and its potential efficacy and safety were evaluated in treating this condition. MethodsTen patients with primary lymphedema in the lower extremity received granulocyte-colony stimulating factor subcutaneously for 4 days, to stimulate stem cell mobilization, after which 200 to 250 mL of blood was drawn from each patient and used to collect stem cells. Mobilized stem cells were counted by flow cytometry with International Society of Hematotherapy and Graft Engineering method. In two sessions, 3 weeks apart, these stem cells were injected subcutaneously in the affected limb at approximately 80 points, along the lymphatic vessels. Each patient was followed for 6 months, during which changes in the limb volume and circumference were measured. Lymphangiogenesis was evaluated by biopsy, the lymphoscintigraphic transport index was calculated using Lymphoscintigraphy, and quality of life was surveyed. ResultsIn this study, patients received on average 9.5 ± 6.8 × 108 mononuclear cells (which divided into 2 × 106 CD34+ cells for each session) in two sessions. The volume of the lower limbs decreased in 60% of patients. One patient showed a slight increase in the volume of lower limbs and three showed no change. The average limb volume was 4469.41 ± 1760.71 cm3, which on average differed from the average initial limb volume by 232.88 ± 392.53 cm3. Quality of life was reported as slightly increased in 60% of patients. The lymphoscintigraphic transport index suggested improvement in 60% of the patients. Likewise, tissue samples showed a 60% increase in lymphatic vessels. ConclusionsSubcutaneous injection of autologous hematopoietic stem cells harvested from peripheral blood into patients with primary lower limb lymphedema is feasible, potentially effective, and without serious adverse effects. However, a larger scale study with more patients is needed to validate our results. Last, to increase the effectiveness of this treatment, the optimal dose of cells injected and the requirement for additional growth factors need further study.

Lymphoedema rates in pedicled anterolateral thigh flaps for coverage of irradiated groin defects.

Limb salvage surgery in conjunction with adjuvant radiotherapy is the preferred treatment for soft tissue sarcoma. This study aims to determine if ipsilateral pedicled anterolateral thigh (ALT) flap reconstruction of groin defects post soft tissue sarcoma resection results in acceptable rates of lymphoedema, while also providing good soft tissue cover and minimal donor site morbidity. A retrospective chart audit was conducted with ethics approval, obtaining a case series of 16 patients operated on at a single institution by the senior surgeon. Patients who underwent ipsilateral pedicled ALT flap coverage of irradiated groin defects following soft tissue sarcoma resection were included. Comparative six-point limb circumference measurements were utilized to diagnose lymphoedema, with a difference of 10% when compared to the non-operative side being deemed significant. Lymphoedema was noted in three patients (18.8%) with an average follow-up period of 40.9 (range 8-59) months. Previously published lymphoedema rates in sarcoma limb salvage surgery of 15.5-30% are comparable to the rates obtained in this cohort. Lymphoedema rates do not appear to be higher in patients undergoing ipsilateral pedicled ALT flap reconstruction, thus making it a useful soft tissue coverage technique in this cohort.

Evaluation of Simplified Lymphatic Microsurgical Preventing Healing Approach (S-LYMPHA) for the Prevention of Breast Cancer-Related Clinical Lymphedema After Axillary Lymph Node Dissection.

To assess the efficiency of Simplified Lymphatic Microsurgical Preventing Healing Approach (S-LYMPHA) in preventing lymphedema (LE) in a prospective cohort of patients. LE is a serious complication of axillary lymph node dissection (ALND) with an incidence rate of 25%. LYMPHA has been proposed as an effective adjunct to ALND for the prevention of LE. This procedure, however, requires microsurgical techniques and significant coordination between services. All patients, undergoing ALND with or without S-LYMPHA between January 2014 and December 2016 were included in the study. During follow-up visits, tape-measuring limb circumference method was used to detect LE. The incidence of LE was compared between ALND with and without S-LYMPHA. A total of 380 patients were included in the analysis. Median follow-up time was 15 (1-32) months. Patients, who underwent S-LYMPHA, had a significantly lower rate of LE both in univariate and multivariate analysis [3% vs 19%; P = 0.001; odds ratio 0.12 (0.03-0.5)]. Excising more than 22 lymph nodes and a co-diagnosis of diabetes mellitus were also correlated with higher clinical LE rates on univariate analysis, but only excising more than 22 lymph nodes remained to be significant on multivariate analysis. S-LYMPHA is a simple method, which decreases incidence of LE dramatically. It should be considered as an adjunct procedure to ALND for all patients during initial surgery.

Effect of Nutritional Intervention Programs on Nutritional Status and Readmission Rate in Malnourished Older Adults with Pneumonia: A Randomized Control Trial.

Pneumonia leads to changes in body composition and weakness due to the malnourished condition. In addition, patient family caregivers always have a lack of nutritional information, and they do not know how to manage patients’ nutritional intake during hospitalization and after discharge. Most intervention studies aim to provide nutritional support for older patients. However, whether long-term nutritional intervention by dietitians and caregivers from patients’ families exert clinical effects—particularly in malnourished pneumonia—on nutritional status and readmission rate at each interventional phase, from hospitalization to postdischarge, remains unclear. To investigate the effects of an individualized nutritional intervention program (iNIP) on nutritional status and readmission rate in older adults with pneumonia during hospitalization and three and six months after discharge. Eighty-two malnourished older adults with a primary diagnosis of pneumonia participated. Patients were randomly allocated to either a nutrition intervention (NI) group or a standard care (SC) group. Participants in the NI group received an iNIP according to energy and protein intake requirements in addition to dietary advice based on face-to-face interviews with their family caregivers during hospitalization. After discharge, phone calls were adopted for prescribing iNIPs. Anthropometry (i.e., body mass index, limb circumference, and subcutaneous fat thickness), blood parameters (i.e., albumin and total lymphocyte count), hospital stay, Mini-Nutritional Assessment-Short Form (MNA-SF) score, target daily calorie intake, total calorie intake adherence rate, and three-major-nutrient intakes were assessed during hospitalization and three and six months after discharge. Both groups received regular follow-up through phone calls. Furthermore, the rate of readmission resulting from pneumonia was recorded after discharge. During hospital stay, the NI group showed significant increases in daily calorie intake, total calorie intake adherence rate, and protein intake compared with the SC group (p < 0.05); however, no significant difference was found in anthropometry, blood biochemical values, MNA-SF scores, and hospital stay. At three and six months after discharge, the NI group showed significantly higher daily calorie intake and MNA-SF scores (8.2 vs. 6.5 scores at three months; 9.3 vs. 7.6 scores at six months) than did the SC group (p < 0.05). After adjusting for sex, the readmission rate for pneumonia significantly decreased by 77% in the NI group compared with that in the SC group (p = 0.03, OR: 0.228, 95% CI: 0.06–0.87). A six-month iNIP under dietitian and patient family nutritional support for malnourished older adults with pneumonia can significantly improve their nutritional status and reduce the readmission rate.

Effects of cuff size and position on the agreement between arterial blood pressure measured by Doppler ultrasound and through a dorsal pedal artery catheter in anesthetized cats

ObjectiveTo compare the effects of cuff size/position on the agreement between arterial blood pressure measured by Doppler ultrasound (ABPDoppler) and dorsal pedal artery catheter measurements of systolic (SAPinvasive) and mean arterial pressure (MAPinvasive) in anesthetized cats. Study designProspective study. AnimalsA total of eight cats (3.0–3.8 kg) for neutering. MethodsDuring isoflurane anesthesia, before surgery, changes in end-tidal isoflurane concentrations and/or administration of dopamine were performed to achieve SAPinvasive within 60–150 mmHg. Cuff sizes 1, 2 and 3 (bladder width: 20, 25 and 35 mm, respectively) were placed on distal third of the antebrachium, above the tarsus and below the tarsus for ABPDoppler measurements. Agreement between ABPDoppler and SAPinvasive or between ABPDoppler and MAPinvasive was compared with reference standards for noninvasive blood pressure devices used in humans and small animals. ResultsMean bias and precision (±standard deviation) between ABPDoppler and SAPinvasive met veterinary standards (≤10 ± 15 mmHg), but not human standards (≤5 ± 8 mmHg), with cuffs 1 and 2 placed on the thoracic limb (7.4 ± 13.9 and –5.8 ± 9.5 mmHg, respectively), and with cuff 2 placed proximal to the tarsus (7.2 ± 12.4 mmHg). Cuff width-to-limb circumference ratios resulting in acceptable agreement between ABPDoppler and SAPinvasive were 0.31 ± 0.04 (cuff 1) and 0.42 ± 0.05 (cuff 2) on the thoracic limb, and 0.43 ± 0.05 (cuff 2) above the tarsus. ABPDoppler showed no acceptable agreement with MAPinvasive by any reference standard. Conclusions and clinical relevanceThe agreement between ABPDoppler and SAPinvasive can be optimized by placing the occlusive cuff on the distal third of the antebrachium and above the tarsus. In these locations, cuff width should approach 40% of limb circumference to provide clinically acceptable estimations of SAPinvasive. Doppler ultrasound cannot be used to estimate MAPinvasive in cats.

Complications of Level I and II Axillary Dissection in the Treatment of Carcinoma of the Breast

Background: The role of axillary dissection as an effective means of controlling regionalnodal disease, has long been recognized. It is associated with significant complicationsand might be more selectively applied only to patients harboring micrometastases to thesentinel nodes.&#x0D; Objective: To assess the complications of level I and II axillary lymph node dissection inthe treatment of stage I and II breast cancer, with mastectomy.&#x0D; Methods: One hundred patients having total mastectomy with axillary dissection, wereevaluated for more than 1 year after surgery for arm swelling as well as non-edemacomplications. All patients had measurements of circumference of upper limb at 4 siteson both the operated and non operated sides.&#x0D; Results: No patient had an axillary recurrence, difference in circumference of upperlimb at the midbiceps level &gt;2 cm - 13% (p &lt;0.001), difference at the antecubitalfossa&gt;12% (p &lt; 0.001), at the mid forearm&gt;2cm - 8% (p &lt; 0.005), and at the wrist 4%(n.s.). Four patients (4%) had mild swelling of the hand. Seventy seven (77%) patientshad numbness or paresthesias of the medial arm and/or axilla after surgery; in 63(82%) of these, the problem had lessened or had resolved on follow-up assessment.Medical therapy with anti-tubercular drugs ranging from 9 to 12 months with follow upmonthly was the mainstay of treatment. Surgical intervention reserved for selectedrefractory cases. Extension of anti-tubercular therapy from 9 to 12 or 18 monthsrequired in fifty-eight(58) patients on the basis of slow clinical response. Completeresolution obtained in 92 patients but residual tiny mass in eight patients confirmed byrepeated FNAC to be fibrotic.&#x0D; Conclusion: Level I and II axillary dissection is associated with various complications.Sentinel lymphadenectomy may be proposed as an alternative to elective axillarydissection.&#x0D; Journal of Surgical Sciences (2017) Vol. 21 (1) :24-28

Comparative assessment of the clinical efficacy of first-generation phlebotonics in the complex treatment of patients with chronic venous diseases of the lower limbs

Target. Comparative assessment of the clinical efficacy of Aescusan I generation phlebotonics application in the complex treatment of patients with CVD.Material and methods.Analysis of treatment of 380 patients who applied for a phlebological appointment at the polyclinic department of SamSMU Clinics for the period from September 2017 to March 2019 was conducted. Group I (n = 104) included patients with even outpatient card numbers who were prescribed Troxevasin as a first-generation phlebotonic according to the scheme recommended by manufacturers Group II (n = 276) included patients with odd outpatient card numbers who were prescribed Aescusan (an extract of horse chestnut seeds Aesculus hippocastanum, active ingredient of which is aescin) as phlebotonics of the first generation according to the scheme recommended by the manufacturers. All patients were examined by a phlebologist before and after 1 course of treatment. Clinical efficacy of the therapy was assessed by the severity of the pain syndrome, feeling of heaviness, swelling and seizures using visual analogue scale (VAS). In addition, the effectiveness of conservative therapy was assessed through interviews and questionnaires. For a comparative assessment of the severity of edema syndrome, the lower limb circumference was measured at ankle level using a graduated tape.Results. No side effects were detected during clinical observation of the use of drugs. After the course of treatment, most of the observations showed positive dynamics. Changes in clinical symptoms (pain, seizures, heavy legs) in Group I were statistically unreliable (p&gt;0.05). In the second group there was a decrease of pain syndrome intensity by 73,2%, a decrease of convulsions - by 63,5%, a decreaseof heaviness feeling – by 73,7%. In the course of the survey, 272 patients (98.5%) of Group II evaluated the treatment results as good, 4 patients (1.5%) did not notice any treatment results.In the course of repeated examination after the treatment 96,5% of doctors noted the result in Group II as good, 3,5% - as satisfactory. Conclusion. Thus, the results of complex treatment of patients with CVD showed that the use of 1st generation phlebotonics should be considered not only as pathogenetically justified, but also effective from the clinical point of view. Application of Aescusan drug leads to statistically significant reduction of clinical symptoms (subjective and objective) of lower limbs CVD.

Efficacy of Ultrasound and Shear Wave Elastography for the Diagnosis of Breast Cancer-Related Lymphedema.

To assess the feasibility of ultrasound and shear wave elastography (SWE) in the diagnosis of breast cancer-related lymphedema. Forty-one patients with a history of unilateral breast surgery and axillary dissection or sentinel lymph node excision were included in this prospective study. The patients were classified as having normal findings, latent lymphedema, and clinical lymphedema on the basis of a physical examination, lymphedema index scores, and limb circumference measurements. The thickness and stiffness of the cutaneous and subcutaneous tissue of the forearm and arm were measured by ultrasound and SWE. The thickness and stiffness of the cutaneous and subcutaneous tissue of the affected limb and contralateral limbs of the normal, latent lymphedema, and clinical lymphedema groups were compared. The mean age ± SD of the 41 patients was 55.42 ± 10.12 years. There were 15 patients with normal findings, 10 with latent lymphedema, and 16 with clinical lymphedema. In the latent lymphedema group, the thickness measurements of the cutaneous tissue of the affected forearm and the cutaneous and subcutaneous tissue of the affected arm were significantly greater than those of the contralateral forearm and arm (P = .034; P = .022; and P = .002, respectively), and the stiffness measurements of the cutaneous and subcutaneous tissue of the affected forearm were significantly greater than those of the contralateral forearm (P = .011; and P = .002). In the clinical lymphedema group, the thickness and stiffness measurements of the cutaneous and subcutaneous tissue of the affected forearm and arm were significantly greater than those of the contralateral limb (P < .001-P = .032). Ultrasound and SWE are effective for diagnosing breast cancer-related lymphedema even at a latent stage.