Hot of the Press June 2021

We have collated some great articles and material published over the last month. Click on the links below to read the  abstract or download the full paper.

Prevalence and Risk Factors

Cellulitis risk factors for patients with primary or secondary lymphedema - click for abstract

Cellulitis risk factors for patients with primary or secondary lymphedema

Stéphane Vignes, Florence Poizeau, Alain Dupuy. J Vasc Surg Venous Lymphat Disord. 2021 May 3

BACKGROUND: Limb lymphedema is a chronic disease with primary and secondary forms, the latter essentially after cancer treatment.

OBJECTIVES: To analyze retrospectively cellulitis frequency and its associated risk factors in patients with primary or secondary limb lymphedema.

METHODS: Information from all 1,991 patients referred to a specialized lymphedema center, from January to June 2018, was collected: previous cellulitis episode(s), clinical and lymphedema characteristics.

RESULTS: Among the 1,846 patients whose information could be analyzed, 695 (37.6%) developed one or more cellulitis episodes and 23.3% had recurrent cellulitis. Cellulitis occurred in 39.5%, 30.5% or 38.6% (P = .02) of the patients with secondary upper limb, secondary lower limb or primary lower limb lymphedema, respectively; lymphedema had been present 106.5, 97 or 243.1 months. Lymphedema-onset-to-first-consultation (in our specialized center) interval, age at lymphedema onset and radiotherapy were independently associated with cellulitis but not axillary lymph-node excision, chemotherapy or lymphedema involvement. Lymphedema-onset-to-first-consultation interval and lymph-node excision were associated with cellulitis, while body mass index (BMI) or age at lymphedema onset for secondary lower limb lymphedema were not. For primary lower limb lymphedema, male sex, BMI and age at lymphedema onset were associated with cellulitis.

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

Assessment

Body Fluid Trend and Prevalence of Lymphedema After Gynecological Cancer Surgery - click for abstract

Body Fluid Trend and Prevalence of Lymphedema After Gynecological Cancer Surgery

Soo Kyung Bok, Dong Joon Cho, Heon Jong Yoo, So Young Ahn. Lymphat Res Biol. 2021 May 10.
This study aimed at understanding the trend in extracellular fluid (ECF) change and estimating the efficacy of the early complex decongestive therapy (CDT) program in terms of prevalence of lower limb lymphedema, as well as at identifying the quality of life (QoL) associated with response to CDT after gynecological cancer therapy. Methods and Results: Thirty-one patients undergoing gynecological cancer treatment were enrolled and randomly assigned to the CDT and control groups. In the CDT group, CDT was started within 2 weeks after surgery for 30 minutes a day, for 2 weeks (5 days per week). The patients’ QoL was assessed through the European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire; version 3. Inbody S10® (Biospace, Seoul, South Korea) was used to calculate the ECF. The assessment was performed at pre- and post-surgery and at 3, 6, and 12 months after surgery. Statistically significant differences, in favor of the CDT group, were encountered at the 3-month follow-up visit, especially with respect to the QoL score. Regarding the prevalence of lymphedema, no significant difference was observed between groups. The mean value of the impedance ratio was low in the CDT group during the entire 12 month follow-up. Conclusions: The results of the present study show that early CDT had a positive effect on the prevalence of lymphedema and body composition. Long-term follow-up studies with a larger sample size are needed to warrant the time-group effect of early rehabilitation

Self-reported symptoms of arm lymphedema and health-related quality of life among female breast cancer survivors - click for abstract

Self-reported symptoms of arm lymphedema and health-related quality of life among female breast cancer survivors

Kayo Togawa, Huiyan Ma, Ashley Wilder Smith, Marian L Neuhouser, Stephanie M George, Kathy B Baumgartner, Anne McTiernan, Richard Baumgartner, Rachel M Ballard, Leslie Bernstein. Sci Rep. 2021 May 21;11(1):10701.
We examined cross-sectional associations between arm lymphedema symptoms and health-related quality of life (HRQoL) in the Health, Eating, Activity and Lifestyle (HEAL) Study. 499 women diagnosed with localized or regional breast cancer at ages 35-64 years completed a survey, on average 40 months after diagnosis, querying presence of lymphedema, nine lymphedema-related symptoms, e.g., tension, burning pain, mobility loss, and warmth/redness, and HRQoL. Analysis of covariance models were used to assess HRQoL scores in relation to presence of lymphedema and lymphedema-related symptoms. Lymphedema was self-reported by 137 women, of whom 98 were experiencing lymphedema at the time of the assessment. The most common symptoms were heaviness (52%), numbness (47%), and tightness (45%). Perceived physical health was worse for women reporting past or current lymphedema than those reporting no lymphedema (P-value < 0.0001). No difference was observed for perceived mental health (P-value = 0.31). Perceived physical health, stress, and lymphedema-specific HRQoL scores worsened as number of symptoms increased (P-values ≤ 0.01). Women reporting tension in the arm had lower physical health (P-value = 0.01), and those experiencing burning pain, tension, heaviness, or warmth/redness in the arm had lower lymphedema-specific HRQoL (P-values < 0.05). Treatment targeting specific lymphedema-related symptoms in addition to size/volume reduction may improve some aspects of HRQoL among affected women

Development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM) - click for abstract

Development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM)

Marie Gabe-Walters, Melanie Thomas. Br J Nurs. 2021 May 27;30(10):592-598
To ensure lymphoedema patients in Wales receive the right care, at the right time, by the right person, patient-reported outcome measures (PROMs) were routinely completed within the All-Wales lymphoedema assessment documentation. This evaluation describes the development of the Lymphoedema Patient Reported Outcome Measure (LYMPROM), which is a tool developed by Lymphoedema Network Wales clinicians and key stakeholders. The tool was explored for face, form and content validity during 3 months in 2019; 128 anonymised completions of LYMPROM were reviewed to establish feasibility, acceptability and internal validity using Cronbach’s alpha. LYMPROM was feasible and acceptability was high. Face and content validity were reported (i-CVI [item content validity index] range=0.43 – 1; s-CVI/Ave=0.94) and internal consistency was excellent (0.958). LYMPROM was easily integrated within lymphoedema services in Wales, promoting patient-led care and supporting value-based health care. Further evaluations of reliability and validity of LYMPROM are proceeding along with digital integration.

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The effect of limb position on the reliability of leg circumference measurements in patients diagnosed with lower limb lymphoedema. - click for abstract

The effect of limb position on the reliability of leg circumference measurements in patients diagnosed with lower limb lymphoedema.

R. Scheer1,2 & E. Crofton1,3 & N. Andrews1,4. Supportive Care in Cancer (2021) 29:3183–3189

Objective To establish the intrarater reliability of lower limb circumference measures in a sample of individuals who are diagnosed with lower limb lymphoedema and to evaluate if change in limb position has an effect on the reliability of circumferential measures.

Method A sample of forty-one adults diagnosed with a lower limb lymphoedema were recruited. Participants had their affected leg measured three times by a qualified therapist during a standard outpatient appointment: twice in a lying position and once in sitting with knee flexed at 90°. To examine the intrarater reliability, interclass correlation coefficients (ICC) with 95% confident intervals were calculated.

Results Excellent intrarater reliability was established at each measurement point and for the sum of circumferential measures when the limb remeasured in the same position by the same therapist. Changing the position of the limb resulted in lower intrarater reliability values at 10 and 30 cm from the base of the foot.

Conclusions The current study provides evidence for the intrarater reliability of lower limb circumference measures and highlights the need for consistency when remeasuring and monitoring the limb of those diagnosed with lower limb lymphoedema. Implications for cancer survivors Lymphoedema is a significant problem for breast cancer survivors but also provides lifetime risk to all survivors of lymph node surgery for solid tumours. The monitoring and surveillance of leg circumference measures of people diagnosed with lower limb lymphoedema has been a valuable instrument when reviewing progress of this chronic condition.

Management Strategies

The education needs of health professionals conservatively managing genital oedema: UK survey findings - click for abstract

The education needs of health professionals conservatively managing genital oedema: UK survey findings

Rhian Noble-Jones, Melanie J Thomas, Marie Gabe-Walters.Br J Nurs. 2021 May 13;30(9):S18-S26
BACKGROUND: Adults and children report genital oedema but prevalence is unknown. Pre-registration nurse training rarely includes genital oedema and postgraduate training opportunities are rare.
AIM: To identify the education needs of health professionals regarding management of genital oedema.
METHOD: An electronic survey was cascaded to health professionals through relevant professional groups and social media.
FINDINGS: Of 149 UK respondents, most manage patients with genital oedema but only 2% felt current training was sufficient. Of 138 responding regarding supplemental training, only a half had completed genital oedema specific education, usually of 1-4 hours’ duration. Confidence in knowledge was up to 22.5% higher in those with genital oedema education, even accounting for years of experience. The most common top three individual needs were compression, contemporary surgical and medical management and patient assessment. Educational resources are needed and both offline and online formats were suggested; collaborative events with urology/pelvic health are essential.
CONCLUSION: Health professionals working in lymphoedema care have (unmet) specific education needs regarding genital oedema management. The desire for both offline and online resources reflects the necessity of accessing learning at a distance and on an ‘as needed’ basis.

Exercise Only Works If You Do It! The Holy Grail of Adherence - click for abstract

Exercise Only Works If You Do It! The Holy Grail of Adherence

Beverley Kok, Margaret McNeely, Makayla Watt, Puneeta Tandon. Am J Gastroenterol. 2021 Apr;116(4):673-674
Exercise interventions in patients with cirrhosis have been shown to improve muscle mass and strength, aerobic capacity, fatigue, and quality of life. There are gaps, however, including limited data on patients with decompensated cirrhosis and home-based routines. This editorial comments on the randomized controlled trial by Lai et al. investigating a home-based exercise intervention in patients with cirrhosis and its impact on physical frailty. Although the trial yielded negative results, the lessons learned should help refine and propel future work. .

Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes - click for abstract

Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes

Philip S Brazio, Dung H Nguyen. Ann Plast Surg. 2021 May 1.
INTRODUCTION: Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema.
METHODS: We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone.
RESULTS: Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence.
CONCLUSION: Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures

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Cost-utility and cost-effectiveness of a guided self-help head and neck exercise program for patients treated with total laryngectomy: Results of a multi-center randomized controlled trial - click for abstract

Cost-utility and cost-effectiveness of a guided self-help head and neck exercise program for patients treated with total laryngectomy: Results of a multi-center randomized controlled trial

Femke Jansen a,*, Veerle M.H. Coup´e b, Simone E.J. Eerenstein a, Ingrid C. Cnossen a, Cornelia F. van Uden-Kraan c, Remco de Bree d, Patricia Doornaert e, Gyorgy ¨ B. Halmosf, Jos´e A.U. Hardillo g, Gerben van Hinte h, Jimmie Honingsi, C. Ren´e Leemans a, Irma M. Verdonck-de Leeuw a,c. Oral Oncology. Volume 117, June 2021, 105306

Highlights •In Tune without Cords is likely to be effective, but possibly at higher expenses.•The probability to be cost-effective is 57–64% at a threshold of 20,000 €/QALY.•The probability to be cost-effective is 65–70% at a threshold of 30,000 €/QALY.
Materials and methods Patients within 5 years after TL were included in this randomized controlled trial. Patients in the intervention group (n = 46) received access to the self-help exercise program with flexibility, range-of-motion and lymphedema exercises, and a self-care education program. Patients in the control group (n = 46) received access to the self-care education program only. Healthcare utilization (iMCQ), productivity losses (iPCQ), health status (EQ-5D-3L, EORTC QLU-C10D) and swallowing problems (SwalQol) were measured at baseline, 3- and 6-months follow-up. Hospital costs were extracted from medical files. Mean total costs and effects (quality-adjusted life-years (QALYs) or SwalQol score) were compared with regression analyses using bias-corrected accelerated bootstrapping.
Results Mean total costs were non-significantly lower (-€685) and QALYs were significantly higher (+0.06) in the intervention compared to the control group. The probability that the intervention is less costly and more effective was 73%. Sensitivity analyses with adjustment for baseline costs and EQ-5D scores showed non-significantly higher costs (+€119 to +€364) and QALYs (+0.02 to +0.03). A sensitivity analysis using the QLU-C10D to calculate QALYs showed higher costs (+€741) and lower QALYs (-0.01) and an analysis that used the SwalQol showed higher costs (+€232) and higher effects (improvement of 6 points on a 0–100 scale).
Conclusion ITwC is likely to be effective, but possibly at higher expenses

Limitations to self-management of adjustable compression wraps in the elderly: results of a prospective cohort study - click for abstract

Limitations to self-management of adjustable compression wraps in the elderly: results of a prospective cohort study

Florence Balet1, Jean-Patrick Benigni2, Jean-François Uhl3, Maxime Chahim4, Pascal Filori5 Int Angiol. 2021 Jun;40(3):261-266.

Background: Adjustable compression wraps are used for treating lymphedema and chronic venous insufficiency. These diseases often affect elderly patients with associated pathologies or other limiting factors. These can prevent the self-application of the device by patients on themselves. A better understanding of these factors or the associated pathology in the elderly is important before prescribing or not prescribing a wrap.

Methods: The objective of this prospective cohort study was to determine the main factors that prevent the self-application of the device (Circaid Juxtalite, Medi Italia S.r.l., Bologna, Italy) to the lower limb in the elderly. A private nurse selected the first 30 retired subjects over 65 years of age seen at home for routine nursing care. After a demonstration, she asked them to put on the wrap to reach a pressure of 40 mmHg in the calf (point B1). She recorded the pressures as the subjects applied the wrap twice in a row. The next day, the subject repeated the application of the wrap twice. We considered that an average pressure of more than 30 mmHg is recommended to treat venous edema or ulceration.

Results: Thirty percent of the subjects put on the wrap by themselves with an average pressure of at least 30 mmHg. Age is not a limiting factor. Obesity, gripping difficulties, cognitive impairment and low social status seem to be factors limiting the daily self-management of an adjustable compression wrap in the elderly.

Conclusions: The self-management of adjustable compression wraps in the elderly person encounters obstacles that need to be known. The investigation has revealed that obesity, gripping difficulties, cognitive impairment and low social status are limiting factors. Age was not shown to be a limiting obstacle.