Title: Tissue Dielectric Constant Measures in Women With and Without Clinical Trunk Lymphedema Following Breast Cancer Surgery: A 78-Week Longitudinal Study
Authors: Koehler LA; Mayrovitz HN.
Publication: Physical Therapy 2020 Vol 100(8) p1384-1392.
Objective: Following breast cancer surgery with lymph node removal, women are at risk of developing lymphedema in the upper extremity or trunk. Currently, trunk lymphedema diagnosis relies on a clinical assessment because no quantifiable standard method exists. Tissue dielectric constant (TDC) values are quantifiable measures of localized skin tissue water and may be able to detect trunk lymphedema. The goal of this study was to (1) compare parameters derived from TDC measurements with those derived from clinically accepted criteria for trunk lymphedema in women following breast cancer surgery and (2) explore the potential utility of TDC to detect trunk lymphedema early in its progression.
Methods: This prospective longitudinal study, a secondary analysis from a larger study, observed women with and without clinically determined truncal lymphedema following breast cancer surgery. TDC was measured on the lateral trunk wall at post-surgery weeks 2, 4, 12, and 78 in women who had surgical breast cancer treatment with lymph node removal. Clinical assessment for trunk lymphedema was determined at 78 weeks by a lymphedema expert. Comparison of TDC measurements in women with and without clinical trunk lymphedema was analyzed.
Results: Clinical assessment identified trunk lymphedema in 15 out of 32 women at 78 weeks. These women had TDC ratios statistically higher than women without truncal lymphedema.
Conclusion: The overall findings indicate that TDC has the ability to quantify trunk lymphedema and might be valuable in early detection. Impact: TDC may be a beneficial tool in the early detection of breast cancer related trunk lymphedema which could trigger intervention.
Title: Reliability of the MoistureMeterD Compact Device and the Pitting Test to Evaluate Local Tissue Water in Subjects with Breast Cancer-Related Lymphedema.
Authors: De Vrieze T, Gebruers N, Nevelsteen I, De Groef A, Tjalma W, Thomis S, Dams L, Van der Gucht E, Penen F, Devoogdt N.
Publication: Lymphatic Research Biology 2020 Vol 18 (2) p116-128.
Background: Local tissue water in patients with breast cancer-related lymphedema (BCRL) can be assessed by measurement of the tissue dielectric constant using the MoistureMeterD Compact® (MMDC) device, or by performing the pitting test. Although these assessment methods are commonly used in clinical practice, literature shows a lack of research on their clinimetric properties. Therefore, the aim of this study was to investigate reliability of both methods, in assessing the upper limb in BCRL.
Methods and Results: Thirty women with BCRL were enrolled. Local tissue water was evaluated at nine reference points on the upper limb and trunk, using both methods. To determine intra- and inter-rater reliability of the MMDC device (using the absolute percentages of water content [PWC%] and interarm PWC% ratios based on single and multiple measures), intraclass correlation coefficients (ICCs), and standard errors of the measurement were calculated. To determine intra- and inter-rater agreement of the pitting test, Cohen’s kappa coefficients were calculated as well as percentages of agreement. MMDC measurements yielded moderate to very strong intra- (ICC 0.648-0.947) and inter-rater (ICC 0.606-0.941) reliability, depending on the measurement location on the edematous limb. The pitting test showed a very strong intrarater agreement at nearly all defined points, but a weak inter-rater agreement, especially at the medial elbow and the breast.
Conclusion: This study supports the MMDC device and pitting test as being useful tools in the clinical evaluation of BCRL. However, further research into the concurrent validity of both tools is warranted.
Title: Palpation of Increased Skin and Subcutaneous Thickness, Tissue Dielectric Constant, and Water Displacement Method for Diagnosis of Early Mild Arm Lymphedema.
Authors: Karlsson K, Nilsson-Wikmar L, Brogardh C, Johansson K.
Publication: Lymphatic Research Biology 2020 Vol 18(3) p219-225
Background: Early diagnosis of mild lymphedema and treatment are important to prevent its progress. The tissue dielectric constant (TDC), measuring local tissue water in the skin and upper subcutis, has neither been related to the water displacement method (WDM) nor been used to diagnose mild arm lymphedema in patients at risk. Our aims were to evaluate TDC and WDM in combination with palpation, examine the association between TDC and WDM measurements, and compare lymphedema-related factors.
Methods and Results: Seventy-two women treated for breast cancer were diagnosed with mild arm lymphedema using skin palpation in combination with TDC from fixed measurement sites (threshold ratio for upper arm ≥1.45 and forearm ≥1.3) and/or WDM (lymphedema relative volume [LRV]: ≥5% to ≤8%). Results revealed that 32 (45%) women were diagnosed by TDC only, 19 (26%) by WDM only, and 21 (29%) by both TDC and WDM. TDC ratios exceeding the threshold were most frequently identified on the medial site of the arm, proximal and distal to the antecubital fossa. TDC and WDM were negatively associated; LRV (r = −0.545, p < 0.001). The women diagnosed by TDC only were diagnosed earlier after surgery (p = 0.003) and had a lower LRV (1.3%) than those diagnosed by WDM only (6.3%) or both TDC and WDM (6.2%; p < 0.001). Conclusions: TDC and WDM can be used together for early diagnosis of arm lymphedema, but TDC is the most valid method, determining the diagnosis earlier after surgery and at a lower arm volume than WDM.
Title: Factors Affecting Interpreting of Tissue Dielectric Constant (TDC) in Assessing Breast Cancer Treatment Related Lymphedema (BCRL).
Authors: Mayrovitz HN, Arzanova E, Somarriba S, Eisa S.
Publication: Lymphology 2019 Vol 52 p92-102.
Tissue dielectric constant (TDC) measurements are increasingly used as quantitative adjunctive tools to detect and assess lymphedema. Various factors affect measured TDC values that may impact clinical interpretations. Our goal was to investigate possible impacts of: 1) anterior vs. medial arm measures, 2) total body water (TBW%) and arm fat percentages (AF%), 3) measurement depth, and 4) skin firmness. In 40 healthy women (24.5±2.5 years), TDC was measured bilaterally on anterior forearm to 0.5, 1.5, 2.5, and 5.0 mm depths using a multiprobe device and on anterior and medial aspects using a compact device. TBW% and AF% were measured at 50KHz and skin firmness measured by skin indentation force (SIF). Results showed: 1) No statistically significant difference in TDC values between anterior and medial arm, 2) a moderate direct correlation between TDC and TBW% (r=0.512, p=0.001), 3) an inverse correlation between TDC and AF% (r= -0.494, p<0.001) with correlations greatest at the deepest depth, and 4) a slight but statistically significant inverse correlation between TDC and SIF (r= -0.354, p=0.001). TDC values with compact vs. multiprobe were within 6% of each other with interarm (dominant/nondominant) ratios not significantly different. The findings provide a framework to help interpret TDC values among divergent conditions. [/av_toggle] [/av_toggle_container] [av_promobox button='yes' label='View PDF' link='manually,https://lymphoedemaeducation.com.au/wp-content/uploads/2021/07/12-Factors-affecting-Interpreting-of-Tissue-Dielectric-Constant.pdf' link_target='_blank' color='theme-color' custom_bg='#444444' custom_font='#ffffff' size='large' icon_select='no' icon='ue800' font='entypo-fontello' box_color='' box_custom_font='#ffffff' box_custom_bg='#444444' box_custom_border='#333333' admin_preview_bg=''] Full article available [/av_promobox] [av_hr class='default' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' av-desktop-hide='' av-medium-hide='' av-small-hide='' av-mini-hide=''] [av_textblock size='' font_color='' color='' av-medium-font-size='' av-small-font-size='' av-mini-font-size='' admin_preview_bg=''] Title: Impact of Body Fat and Obesity on Tissue Dielectric Constant (TDC) as a Method to Assess Breast Cancer Treatment Related Lymphedema (BCRL).
Authors: Mayrovitz H.
Publication: Lymphology 2019 Vol 52 p18-24.
Obesity is linked to the risk of breast cancer and treatment-related lymphedema (BCRL). Thus, knowledge of how obesity, or more specifically total body fat percentage (TBF) and body mass index (BMI), affect measurements that are used to detect or track lymphedema is clinically important. Tissue dielectric constant (TDC) is one measure used to help characterize lymphedema features, detect its presence, and assess treatment-related changes. The goal of this research was to determine the extent to which TDC values depend on TBF and BMI. TDC was measured on both forearms (2.5mm depth) in 250 women (18-72 years) along with TBF (impedance, 50KHz). TBF was 12.2%- 54.4% (median=29.3%) and BMI was 14.7Kg/m2-44.3 Kg/m2 (median=22.6 Kg/m2). TDC values and interarm ratios were compared between subgroups that had TBF and BMI values in lower vs. upper quartiles. Subjects in the upper quartile had slightly lower TDC values (1.3 TDC units, p <0.01) that was at most a 5% differential. Contrastingly, TDC interarm ratios were not dependent on TBF or BMI levels. These findings suggest that when tracking lymphedema changes using the TDC method, treatment-related or temporal changes in a woman's TBF or BMI are unlikely to significantly impact TDC values or their interarm ratios. [/av_toggle] [/av_toggle_container] [av_promobox button='yes' label='View PDF' link='manually,https://lymphoedemaeducation.com.au/wp-content/uploads/2021/07/13-Impact-of-Body-Fat-and-Obesity-on-Tissue-Dielectric-Constant.pdf' link_target='_blank' color='theme-color' custom_bg='#444444' custom_font='#ffffff' size='large' icon_select='no' icon='ue800' font='entypo-fontello' box_color='' box_custom_font='#ffffff' box_custom_bg='#444444' box_custom_border='#333333' admin_preview_bg=''] Full article available [/av_promobox] [av_hr class='default' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' av-desktop-hide='' av-medium-hide='' av-small-hide='' av-mini-hide=''] [av_textblock size='' font_color='' color='' av-medium-font-size='' av-small-font-size='' av-mini-font-size='' admin_preview_bg=''] Title: Reference Values for Assessing Localized Hand Lymphedema Using Inter-Hand Tissue Dielectric Constant Ratios
Authors: Mayrovitz HN, Arzanova E, Somarriba S, Eisa S.
Publication: Lymphatic Research and Biology 2018 16(5) Vol 16(5) p442-444
Background: Early detection and tracking of breast cancer treatment-related lymphedema have been helped by quantitative assessment methods and parameters, including bioelectrical impedance spectroscopy and tissue dielectric constant (TDC). Such measurements are evaluated with respect to interarm differences or ratios that (when exceeding specified thresholds) are suggestive of lymphedema. Specific threshold ratios depend on the assessment method and have been reported for arms. However, there is far less information available on thresholds to assess lymphedema that manifests in at-risk hands and essentially nothing known about TDC ratios in healthy hands. Such information is essential to establish reference values from which lymphedema threshold TDC values may be estimated. The specific aim of this research was to determine such interhand TDC ratios applicable to both young and mature women.
Methods and results: A total of 70 women (35 under 30 years of age, YOUNG, and 35 over 50 years of age, MATURE) participated after signing an approved institutional review board informed consent. TDC values of the hand dorsum web were measured bilaterally in triplicate with participants in a supine resting position. Results showed MATURE TDC values to be about 15% less than YOUNG (p < 0.01) on dominant and nondominant hands, but no statistical difference in dominant/nondominant interarm ratios (1.026 ± 0.100). Conclusions: Based on this data set’s overall mean and two standard deviation value, an age-independent interhand TDC threshold ratio of 1.23 emerges as potentially useful for lymphedema detection. This is a good initial start threshold that is usable in future clinical and research assessments.
Title: Role of Handedness on Forearm Skin Tissue Dielectric Constant (TDC) in Relation to Detection of Early-Stage Breast Cancer-Related Lymphedema.
Authors: Mayrovitz HN, Fasen M, Spagna P, Wong J.
Publication: Clinical Physiology and Functional Imaging 2018 Vol 38, p670-675.
Skin tissue dielectric constant (TDC) measurements help assess local skin water to detect incipient early-stage lymphedema subsequent to breast cancer treatment-related lymphedema. However, presurgery measurements are not always obtained and assessments for evolving lymphedema are only made after surgery. Thus, subsequent TDC assessments may be biased in an unknown way dependent on a patient’s handedness in relation to the at-risk arm. We investigated this issue by comparing TDC values in dominant and non-dominant volar forearms of 31 left-handed women and 31 right-handed women (age range 24–84 years). Body fat and water percentages were assessed by bioimpedance at 50 KHz. Results showed that TDC values of dominant versus non-dominant arms did not significantly differ for left-handers or for right-handers. There was also no statistically significant difference in absolute TDC values between left- and right-handers or a statistically significant difference in dominant-to-non-dominant arm ratios between left- and right-handers. For the composite data set (N = 62), TDC values for dominant and non-dominant arms were, respectively, 30·0 ± 4·6 and 29·6 ± 4·2 and the dominant-to-non-dominant arm TDC ratio for combined left- and right-handers was 1·015 ± 0·075. These results suggest that handedness is not a major factor when assessing lymphedema status in women who have previously been treated for breast cancer but for whom pretreatment TDCvalues have not been obtained. Moreover, these results suggest that threshold ratios of incipient subclinical unilateral lymphedema based on interarm TDC ratios apply independent of a patient’s handedness for the site and tissue depths herein measured.
Title: Skin Indentation Firmness and Tissue Dielectric Constant Assessed in Face, Neck, and Arm Skin of Young Healthy Women.
Authors: Mayrovitz HN, Corbitt K, Grammenos A, Abello A, Mammino J.
Publication: Skin research and technology: official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging (ISSI) [Skin Res Technol], ISSN: 1600-0846, 2017 Feb; Vol. 23 (1) p 112-120.
Purpose: Our goal was to test the hypothesis that skin firmness correlates with skin hydration.
Methods: Dermal water was assessed by tissue dielectric constant (TDC) at 0.5 mm (TDC0.5 ) and 2.5 mm (TDC2.5 ) depths on four face sites and two arm sites of 35 women (25.0 ± 1.6 years). Firmness was determined by force (mN) to indent skin to 0.3 mm (F0.3 ) and 1.3 mm (F1.3 ).
Results: F0.3 was similar among face sites (avg = 16.2 ± 7.2 mN) but F1.3 varied (avg = 32.5 ± 4.1 mN). TDC2.5 was similar among face sites (avg = 37.7 ± 4.2) but TDC0.5 varied (avg = 36.2 ± 4.8). F1.3 of arm sites was similar (avg = 60.2 ± 18.6 mN) and both greater than F1.3 of neck (28.3 ± 7.1 mN) and face. Regression analysis showed a near-zero correlation between forces and TDC at all sites.
Conclusion: The near-zero correlation may be due to low skin interstitial hydraulic resistance to mobile water movement in healthy young skin. If true, then conditions in which dermal hydraulic conductance is reduced as in lymphedematous, diabetic, or aged skin are more likely show the hypothesized relationship. Our findings provide normalized reference values and suggest that such persons are an important population to study to test for a possible skin water-indentation force relationship and its utilization for early diagnosis.
Title: Age-Related Differences in Tissue Dielectric Constant Values of Female Forearm Skin Measured Noninvasively At 300 Mhz.
Authors: Mayrovitz HN, Singh A, Akolkar S.
Publication: Skin research and technology: official journal of International Society for Bioengineering and the Skin (ISBS) [and] International Society for Digital Imaging of Skin (ISDIS) [and] International Society for Skin Imaging (ISSI) [Skin Res Technol], ISSN: 1600-0846, 2016 May; Vol. 22 (2) p 189-95.
Background/purpose: We hypothesized that reported age-related shifts in skin water from less-to-more mobile states would result in increased skin tissue dielectric constant (TDC) values as TDC values depend strongly on water content and state. One aim was to test this hypothesis. Further, as skin-to-fat TDC values are used as a tool for edema and lymphedema assessment, a second aim was to establish reference values suitable for young and older women.
Methods: TDC was measured bilaterally on volar forearm skin in young (20-40 years) and older (≥60 years) women. There were four groups with 50, 50, 100, and 50 subjects per age group measured to depths of 0.5, 1.5, 2.5, and 5.0 mm, respectively.
Results: For each age group, TDC values decreased with increasing depth (P < 0.001). TDC values at 0.5 and 1.5 mm were greater for older women (P < 0.001). At 2.5 mm, there was no age-group difference (P = 0.108). At 5.0 mm the direction of the difference reversed with older TDC values less than the younger (P < 0.001). Conclusion: Results are consistent with age-related shifts in water state from less-to-more mobile and explain depth-dependence differences between age groups. Data also give age-related TDC reference values for assessing local edematous or lymphedematous states.
Title: Assessing Localized Skin-to-Fat Water in Arms of Women with Breast Cancer via Tissue Dielectric Constant Measurements in Pre-Surgery Patients.
Authors: Mayrovitz HN, Weingrad DN, Lopez L.
Publication: Ann Surg Oncol. 2015 May;22(5) p1483-9.
Background: Skin-to-fat tissue dielectric constant (TDC) values at 300 MHz largely depend on tissue water and provide a rapid way to assess skin water by touching skin with a probe for approximately 10 s. This method has been used to investigate lymphedema features accompanying breast cancer (BC), but relationships between TDC and nodes removed, or symptoms is unclear. Our goals were: (1) to compare TDC values in BC patients prior to surgery (group A) and in patients who had BC-related surgery (group B) to determine if TDC of group B were related to nodes removed and reported symptoms and (2) to develop tentative lymphedema-detection thresholds.
Methods: Arm volumes and TDC values of at-risk and contralateral forearms and biceps were determined in 103 women awaiting surgery for BC and 104 women who had BC-related surgery 26.3 ± 17.5 months prior to evaluation. Inter-arm ratios (at-risk/contralateral) were determined and patients answered questions about lymphedema-related symptoms.
Results: Inter-arm TDC ratios for group A forearm and biceps were respectively 1.003 ± 0.096 and 1.012 ± 0.143. Group B forearm ratios were significantly greater, and among group B patients who reported at least one symptom there was a significant correlation between TDC ratios and symptom burden and nodes removed.
Conclusions: Inter-arm TDC ratios are significantly related to symptoms and nodes removed. Ratios increase with increasing symptom score and might be used to detect pre-clinical unilateral lymphedema using TDC ratio thresholds of 1.30 for forearm and 1.45 for biceps. Threshold confirmation awaits targeted prospective studies but can serve as guideposts to provide quantitative and easily done tracking assessments during follow-up visits.
Title: Patterns of Temporal Changes in Tissue Dielectric Constant as Indices of Localized Skin Water Changes in Women Treated for Breast Cancer: A Pilot Study.
Authors: Mayrovitz HN, Weingrad DN, Lopez L.
Publication: Lymphatic Research and Biology 2015 Volume 13(1) p20-32.
Background: Our goal was to characterize temporal patterns of skin Tissue Dielectric Constant (TDC) as a foundation for possible TDC use to detect and quantify lymphedema. Although limb volumes and bioimpedance analysis (BIA) are used for this purpose, potential TDC-method advantages are that it can be done in about 10 seconds at any body site to depths from 0.5 to 5.0 mm below the epidermis.
Methods and results: TDC at forearm, biceps, axilla, and lateral thorax, and BIA values and arm volumes were measured in 80 women with breast cancer prior to surgery and in decreasing numbers at 3, 6-, 12-, 18-, and 24-months post-surgery. Results show that TDC values, reflecting water content in the measurement volume, vary by site and depth but that at-risk/contralateral side ratio (A/C) is relatively independent of site and depth and is the preferred TDC parameter to detect tissue water changes over time in unilateral conditions. Among sites measured, lateral thorax, followed by forearm, appears most useful for TDC measurements with axilla least useful. Pre-surgery TDC inter-side values and A/C ratios showed no significant inter-side differences, suggesting that breast cancer presence per se did not alter tissue water status in this patient population. Sequential changes in TDC A/C ratios detected a greater number of patients who had inter-arm ratio increases exceeding 10% than were detected using BIA ratios. This may indicate a greater sensitivity to localized tissue water changes with the TDC-method.
Conclusions: TDC is a technically viable and potentially useful method to track skin water changes in persons treated for breast cancer.
Title: Experimental and Analytical Comparisons of Tissue Dielectric Constant (TDC) and Bioimpedance Spectroscopy (BIS) in Assessment of Early Arm Lymphedema in Breast Cancer Patients after Axillary Surgery and Radiotherapy.
Authors: Lahtinen T, Seppala J, Tuomas Viren T, Johansson K.
Publication: Lymphatic Research and Biology 2015 Volume 13(3) p176-185.
Background: Early diagnosis of breast cancer treatment-related lymphedema (BCRL) is of great importance for longstanding treatment results. Tissue dielectric constant (TDC) and bioimpedance spectroscopy (BIS) both have a potential for early diagnosis but have not been compared.
Methods and results: One hundred women, treated for breast cancer with breast surgery, axillary dissection, and radiotherapy, were examined within one year after breast cancer treatment, as part of the follow-up procedure. Affected/at-risk and contralateral arms were measured with the TDC technique specific to localized skin water content and the BIS technique assessing arm extracellular fluid (ECF). Thirty-eight patients were clinically diagnosed for lymphedema (38.0%). The sensitivity and specificity for the TDC method were 65.8% and 83.9%, and for BIS method 42.1% and 93.5%, (p < 0.001 and NS), respectively. Of all lymphedema, 18.4% were detected only by TDC and 2.6% by BIS. Affected arm to contralateral arm TDC ratios for upper arm and forearm, 1.56 ± 0.49 and 1.28 ± 0.33, demonstrating the localized feature of the TDC measurements were significantly greater than the BIS arm ratio 1.12 ± 0.12 (both p < 0.001). Conclusions: Discrepancies between TDC and BIS techniques in assessing lymphedema are related to different measurement techniques and assessed tissue water components. Independently of selected technique-specific threshold limit, the TDC technique was more sensitive than the BIS technique in the early assessment of BCRL and demonstrated that nearly 20% of early lymphedema are only superficially localized. The results further supported the complementary role of TDC and arm volume measurements as a highly diagnostic method for early lymphedema.
Title: Tissue Dielectric Constant (TDC) Measurements as a Means of Characterizing Localized Tissue Water in Arms of Women With and Without Breast Cancer Treatment Related Lymphedema.
Authors: Mayrovitz HN, Weingrad DN, Davey S.
Publication: Lymphology 2014 Vol 47 p142-150.
Quantitative measurements to detect lymphedema early in persons at-risk for breast cancer (BC) treatment-related lymphedema (BCRL) can aid clinical evaluations. Since BCRL may be initially manifest in skin and subcutis, the earliest changes might best be detected via local tissue water (LTW)measurements that are specifically sensitive to such changes. Tissue dielectric constant (TDC) measurements, which are sensitive to skin-to-fat tissue water, may be useful for this purpose. TDC differences between lymphedema to us and non-lymphedema to us tissue has not been fully characterized. Thus, we measured TDC values (2.5 mm depth) in forearms of three groups of women (N=80/group): 1) healthy with no BC (NOBC), 2) with BC but prior to surgery, and 3) with unilateral lymphedema (LE). TDC values for all arms except LE affected arms were not significantly different ranging between 24.8 ± 3.3 to 26.8 ±4.9 and were significantly less (p<0.001) as compared to 42.9 ± 8.2 for LE affected arms. Arm TDC ratios, dominant/non-dominant or NOBC, were 1.001 ± 0.050 and at-risk/contralateral for BC were 0.998 ± 0.082 with both significantly less (p<0.001) than LE group affected/control arm ratios (1.663 ±0.321). These results show that BC per se does not significantly change arm LTW and that the presence of BCRL does not significantly change LTW of non-affected arms. Further, based on 3 standard deviations of measured arm ratios, our data demonstrates that an at-risk arm/contralateral arm TDC ratio of 1.2and above could be a possible threshold to detect pre-clinical lymphedema. Further prospective measurement trial are needed to confirm this value. [/av_toggle] [/av_toggle_container] [av_promobox button='yes' label='View PDF' link='manually,https://lymphoedemaeducation.com.au/wp-content/uploads/2021/07/17-characterizing-localized-tissue-water-in-arms-of-women-bcl.pdf' link_target='_blank' color='theme-color' custom_bg='#444444' custom_font='#ffffff' size='large' icon_select='no' icon='ue800' font='entypo-fontello' box_color='' box_custom_font='#ffffff' box_custom_bg='#444444' box_custom_border='#333333' admin_preview_bg=''] Full article available [/av_promobox] [av_hr class='invisible' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello' admin_preview_bg=''] [/av_one_full][av_one_full first min_height='' vertical_alignment='' space='' custom_margin='' margin='0px' padding='0px' border='' border_color='' radius='0px' background_color='' src='' background_position='top left' background_repeat='no-repeat' animation='' mobile_breaking='' mobile_display=''] [av_hr class='invisible' height='50' shadow='no-shadow' position='center' custom_border='av-border-thin' custom_width='50px' custom_border_color='' custom_margin_top='30px' custom_margin_bottom='30px' icon_select='yes' custom_icon_color='' icon='ue808' font='entypo-fontello' admin_preview_bg=''] [/av_one_full]