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Torgbenu E, Luckett T, Buhagiar M, Phillips JL. Practice points for lymphoedema care in low- and middle- income countries developed by nominal group technique. BMC Health Serv Res 2023; 23:740. [PMID: 37422616 DOI: 10.1186/s12913-023-09786-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 07/05/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Lymphoedema is a common, distressing, and debilitating condition affecting more than 200 million people globally. There is a small body of evidence to guide lymphoedema care which underpins several lymphoedema clinical practice guidelines developed for high-income countries (HIC). Some of these recommendations are unlikely to be feasible in low-resource settings. AIM To develop practice points for healthcare workers that optimise lymphoedema care in low- and middle-income countries (LMIC). METHODS A nominal group technique (NGT) was undertaken to gain consensus on which content from HIC guidelines was important and feasible to include in practice points for LMIC, and other important advice or recommendations. Participants included experts, clinicians, and volunteers involved in lymphoedema care in LMIC. The NGT followed five key stages: silent 'ideas' generation, round-robin rationale, clarification, refinement and verification. The first, fourth and fifth stages were completed via email, and the second and third during a video meeting in order to generate a series of consensus based prevention, assessment, diagnosis, and management of lymphoedema in LMIC practice points. RESULTS Of sixteen participants invited, ten members completed stage 1 of the NGT (ideas generation), of whom six contributed to stages 2 (round-robin) and 3 (clarification). All those who completed stage 1 also completed stages 4 (refinement) and 5 (verification). Practice points unanimously agreed on included Complex Decongestive Therapy (CDT) and good skin care, with management to be determined by lymphoedema stage. For podoconiosis-endemic areas, the use of socks and shoes was identified as very important in the prevention of non-filarial lymphoedema and other lymphoedema-causing conditions. Participants indicated that diagnosing lymphoedema using the lymphoscintigraphy and Indocyanine green (ICG) fluorescent lymphography was not possible due to unavailability and cost in LMIC. Surgical procedures for lymphoedema management were unanimously eliminated due to the unavailability of technology, limited workforce, and expensive cost in LMIC. CONCLUSION The consensus-based practice points generated by this project provide healthcare workers with guidance on caring for people with lymphoedema in LMIC. Further development of workforce capacity is needed.
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Affiliation(s)
- Eric Torgbenu
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Tim Luckett
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Mark Buhagiar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- Catholic Diocese of Parramatta, Parramatta, NSW, Australia
| | - Jane L Phillips
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
- School of Nursing, Queensland University of Technology, Brisbane, Australia
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Boccardo F, Santori G, Villa G, Accogli S, Dessalvi S. Long-term patency of multiple lymphatic-venous anastomoses in cancer-related lymphedema: A single center observational study. Microsurgery 2022; 42:668-676. [PMID: 35916247 DOI: 10.1002/micr.30944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 04/11/2022] [Accepted: 07/11/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVES Lymphedema is always initially treated by combined decongestive physiotherapy (CDP). Those cases, refractory to CDP, may be managed by surgical therapy. One of the most used microsurgical procedures is represented by the technique of lymphatic-venous anastomosis (LVA). But very few papers report long term results of LVA. The aim of this study is to assess the long-term patency of multiple lymphatic-venous anastomosis (MLVA) for the treatment of secondary lymphedemas. METHODS From January 2014 to December 2014, 101 patients (mean age: 56.94 ± 8.98 years; female/male: 86/15) affected by secondary cancer-related lymphedema (38 lower and 63 upper limbs) were treated by MLVA. All lymphedemas had previously been treated by conservative therapy without sustained results. Many patients (78%) had 1-3 episodes of acute lymphangitis/year. Lymphoscintigraphy, venous duplex-ultrasonography, and abdominal or axillary ultrasound investigation were performed preoperatively. MLVA patency was assessed by the lymphatic transport index (LyTI) and lymphoscintigraphic pattern. RESULTS At 1 year after surgery, excess volume reduction was 75%-90% in the early stage II secondary lymphedemas, and 60%-75% in the late stage II. The decrease in volume maintained stability in the 5-years follow-up period. Two more advanced lower and one upper limb lymphedemas had 45%-60% reduction. LyTI showed a significant decrease between the preoperative mean value (31.7 ± 9.43) and after 18 months from surgery (11.2 ± 1.91) (p < .001). MLVA patency was shown in 98 (97%) patients. No patients had evidence of postoperative lymphangitis. CONCLUSIONS This study demonstrated the long-term patency of MLVA in the treatment of cancer-related lymphedemas.
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Affiliation(s)
- Francesco Boccardo
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Department of Cardio-Thoracic-Vascular and Endovascular Surgery, San Martino Polyclinic Hospital, Genoa, Italy
| | - Gregorio Santori
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giuseppe Villa
- Department of Diagnostics and Radiotherapy - Nuclear Medicine, San Martino Polyclinic Hospital, Genoa, Italy
| | - Susanna Accogli
- Department of Neuro-Science-Rehabilitation Unit, San Martino Polyclinic Hospital, Genoa, Italy
| | - Sara Dessalvi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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Risk Factors for Lower Extremity Lymphedema after Inguinal Lymphadenectomy in Melanoma Patients: A Retrospective Cohort Study. Surg Open Sci 2022; 8:33-39. [PMID: 35280121 PMCID: PMC8914217 DOI: 10.1016/j.sopen.2022.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/26/2022] [Accepted: 02/04/2022] [Indexed: 01/25/2023] Open
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Cellina M, Gibelli D, Martinenghi C, Giardini D, Soresina M, Menozzi A, Oliva G, Carrafiello G. Non-contrast magnetic resonance lymphography (NCMRL) in cancer-related secondary lymphedema: acquisition technique and imaging findings. Radiol Med 2021; 126:1477-1486. [PMID: 34379302 DOI: 10.1007/s11547-021-01410-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
Cancer-related secondary lymphedema (LE) is a widespread issue, which markedly affects patients' quality of life. Its diagnosis is mainly clinical since there is no consensus on the best imaging technique that should be used to assess this pathology. Even if lymphedema treatment has been traditionally conservative and mainly based on compressive bandages and decongestive therapy, new surgical techniques are proving their effectiveness in the management of the disease and made proper assessment and characterization of lymphedema necessary. In this scenario, non-contrast magnetic resonance lymphography (NCMRL) is acquiring an increasing role, as a non-invasive imaging technique, useful for the analysis of LE. NCMRL is an effective tool in diagnosis confirmation, in providing information about the structural changes of the affected limbs, in grading this disorder, and provides a guide for LE management and treatment planning. This article aims to provide an overview of the literature regarding this examination, analyzing the acquisition technique, the interpretation of the imaging findings and their usefulness, the advantages and limits of this technique, to help the radiologist approach this relatively new investigation in cases of cancer-related LE.
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Affiliation(s)
- Michaela Cellina
- Department of Radiology, ASST Fatebenefratelli Sacco, Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milan, Italy.
| | - Daniele Gibelli
- Dipartimento Di Scienze Biomediche Per La Salute, Università Degli Studi Di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Carlo Martinenghi
- Department of Radiology, Ospedale San Raffaele, Via Olgettina 60, 20121, Milan, Italy
| | - Denisa Giardini
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Massimo Soresina
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Andrea Menozzi
- Lymphedema Center, Nursing Home "La Madonnina", Via Quadronno, 29, 20122, Milan, Italy
| | - Giancarlo Oliva
- Department of Radiology, ASST Fatebenefratelli Sacco, Ospedale Fatebenefratelli, Piazza Principessa Clotilde 3, 20121, Milan, Italy
| | - Gianpaolo Carrafiello
- Department of Radiology, Policlinico Di Milano Ospedale Maggiore | Fondazione IRCCS Ca' Granda, Via Francesco Sforza, 35, 20122, Milan, Italy
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Gjorup CA, Dahlstroem K, Hendel HW, Drzewiecki KT, Klausen TW, Hölmich LR. Factors associated with melanoma-related limb lymphoedema. Acta Oncol 2021; 60:779-784. [PMID: 33793386 DOI: 10.1080/0284186x.2021.1905175] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Melanoma-related limb lymphoedema is a well-known late effect following sentinel node biopsy (SNB), and lymph node dissection (LND) in patients treated of melanoma. However, data on associated risk factors are sparse. This study aimed to investigate factors associated with melanoma-related limb lymphoedema. METHODS The present cross-sectional single-center clinical study included patients between 18 and 75 years with American Joint Committee on Cancer Stages I-III melanoma treated with wide local excision (WLE) and unilateral axillary or inguinal SNB and/or completion LND (CLND) or therapeutic LND (TLND). The diagnosis of secondary unilateral limb lymphoedema was based on the history, symptoms, and physical examination and staged according to the International Society of Lymphology (ISL). Data on factors associated with lymphoedema were analysed with binary logistic regression models. RESULTS In total, 642 patients were eligible, of which 435 (68%) patients participated in the study. Among these 431 patients, 109 (25%) had lymphoedema of which 48 (44%), and 61 (56%) were classified with ISL Stages I and II-III, respectively. Multivariate analyses identified primary tumour on the limb (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.17-4.56; p value .017), inguinal surgery (OR, 6.91; 95% CI, 3.49-14.11; p value <.0001), LND (OR, 6.45; 95% CI, 3.18-13.57; p value <.0001), and persistent pain at the site of lymph node surgery as factors associated with lymphoedema (OR, 3.52; 95% CI, 1.54-8.19; p value .003). Multivariable analysis of ISL Stage II-III lymphoedema further identified limb cellulitis to be associated with lymphoedema (OR 5.74; 95% CI, 2.11-15.99; p value .0006). CONCLUSIONS Melanoma-related limb lymphoedema is associated with inguinal surgery, LND, primary tumour on the limb, persistent pain at the site of lymph node surgery, and cellulitis of the limb. This study highlights the importance of increasing awareness, improving prevention, and treatment of melanoma-related limb lymphoedema.
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Affiliation(s)
- Caroline A. Gjorup
- Department of Plastic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Karin Dahlstroem
- Department of Plastic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Helle W. Hendel
- Department of Clinical Physiology and Nuclear Medicine, PET-center, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Krzysztof T. Drzewiecki
- Department of Plastic Surgery, Breast Surgery and Burns Treatment, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tobias W. Klausen
- Department of Hematology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Lisbet R. Hölmich
- Department of Plastic Surgery, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
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Cellina M, Martinenghi C, Panzeri M, Soresina M, Menozzi A, Daniele G, Oliva G. Noncontrast MR Lymphography in Secondary Lower Limb Lymphedema. J Magn Reson Imaging 2020; 53:458-466. [PMID: 32798265 DOI: 10.1002/jmri.27328] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/27/2020] [Accepted: 07/29/2020] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Invasive imaging techniques have been applied for lymphedema (LE) assessment; noncontrast MR lymphography (NCMLR) has potential as an alternative, but its performance is not known in secondary lower limb LE. PURPOSE To assess the role of NCMRL for the classification and characterization of secondary lower limb LE. STUDY TYPE Retrospective. POPULATION Fifty adults with clinically diagnosed secondary LE. FIELD STRENGTH/SEQUENCE 1.5T, 3D T2 -weighted turbo spin-echo, 3D T2 -weighted turbo spin-echo short tau inversion recovery. ASSESSMENT Three radiologists assessed the following characteristics on NCMRL: honeycomb pattern, dermal thickening, muscular abnormalities, distal dilated lymphatics, inguinal lymph node number, appearance of iliac lymphatic trunks. An LE grading based on the MR images was assigned. The relationship between imaging findings and clinical staging was evaluated, as well as between dermal backflow at lymphoscintigraphy and MR staging, and between the limb swelling duration and peripheral lymphatics dilatation. STATISTICAL TESTS Pearson's correlation test and Cramer's V coefficient were computed to measure the strength of association. The Mann-Whitney test was used to compare the limb swelling duration between patients with and without dilated distal vessels. Agreement among raters was assessed through Kendall's W coefficient of correlation. RESULTS Clinical stage and the MR grading were correlated, with Cramer's V coefficient of 1 for reader 1 (P < 0.05), 0.846 for reader 2 (P < 0.05), and 0.912 (P < 0.05) for reader 3; agreement between interraters was very good (W = 0.0.75; P = 0.05). A honeycomb pattern (P < 0.05), dermal thickening (P < 0.001), muscular abnormalities (P < 0.05), iliac lymphatic trunks appearance (P < 0.05), distal dilated vessels (P < 0.05), and lymph nodes number (P < 0.05) were significantly correlated with LE clinical stage. Dermal backflow at lymphoscintigraphy was described in 10 (20%) patients and showed a significant correlation with the MR grading (P < 0.05). DATA CONCLUSION These preliminary results suggest that NCMRL may provide information useful for the staging and management of patients affected by secondary lower limb LE. Level of Evidence 4 Technical Efficacy Stage 2 J. MAGN. RESON. IMAGING 2021;53:458-466.
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Affiliation(s)
| | | | - Marta Panzeri
- Radiology Department, San Raffaele Hospital, Milan, Italy
| | - Massimo Soresina
- Plastic Surgery Department, Fatebenefratelli Hospital, Milan, Italy
| | - Andrea Menozzi
- Plastic Surgery Department, Fatebenefratelli Hospital, Milan, Italy
| | - Gibelli Daniele
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | - Giancarlo Oliva
- Radiology Department, Fatebenefratelli Hospital, Milan, Italy
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Pereira de Godoy JM, de Fatima Guerreiro Godoy M. Functional classification of secondary lymphedema. Ann Med Surg (Lond) 2019; 48:81-82. [PMID: 31737264 PMCID: PMC6849063 DOI: 10.1016/j.amsu.2019.10.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/18/2022] Open
Abstract
The epidemiological classifications of primary lymphedema based on age at emergence and the severity of the edema are fundamental to the transmission of information about this condition. In the secondary type, the lymphatic system is intact at birth but is injured during the course of life, causing a deficiency that leads to lymphedema. However, years of clinical experience and progress in treatment suggest new classifications to assist in the therapeutic planning of each patient. In clinical practice, we have observed inappropriate treatments that can cause more harm than good. Such observations are important and suggest the need for a proper diagnosis that considers all physiopathological processes involved for the establishment of the best form of treatment.
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Affiliation(s)
- Jose Maria Pereira de Godoy
- Cardiology and Cardiovascular Surgery Department of the Medicine School in São José Do Rio Preto (FAMERP), CNPq (National Council for Research and Development), Brazil
| | - Maria de Fatima Guerreiro Godoy
- Occupational Therapist Professor of the Post-Graduate Stricto Sensu in Medicine School in São José Do Rio Preto (FAMERP), Member of Research Group of the Clínica Godoy, Sao Jose Do Rio Preto, Brazil
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López-Montoya LE, Pereira-de Godoy JM, Guerreiro-Godoy MDF. Evolución distinta de linfedema primario etapa II de miembros inferiores. REVISTA DE LA FACULTAD DE MEDICINA 2019. [DOI: 10.15446/revfacmed.v67n3.66099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Un linfedema es el aumento de fluido rico en proteínas y macromoléculas en el espacio intersticial de un segmento corporal con incremento de volumen en el miembro afectado, el cual causa cambios fibroescleróticos progresivos en los tejidos.Objetivo. Informar sobre la evolución clínica y el análisis de la progresión de un paciente de 52 años con linfedema bilateral primario estadio II.Presentación del caso. Paciente masculino de 52 años quien había sufrido por más de 20 años edema linfostático; el sujeto había recibido diversas opiniones y tratamientos inefectivos los últimos 5 años, hasta que llegó a la Clínica Godoy en Sao Jose de Rio Preto, Brasil, en el año 2016, en donde fue sometido a proceso de terapia intensiva según el modelo de tratamiento propuesto por Godoy & Godoy.Conclusión. Se obtuvieron resultados favorables en un periodo muy corto de tiempo; durante el proceso se observaron distintas evoluciones clínicas en cada pierna, aun recibiendo ambas el mismo tratamiento.
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Non-contrast Magnetic Resonance Lymphangiography: an emerging technique for the study of lymphedema. Clin Imaging 2019; 53:126-133. [DOI: 10.1016/j.clinimag.2018.10.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 09/13/2018] [Accepted: 10/04/2018] [Indexed: 02/06/2023]
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Health-related quality of life in melanoma patients: Impact of melanoma-related limb lymphoedema. Eur J Cancer 2017; 85:122-132. [PMID: 28918186 DOI: 10.1016/j.ejca.2017.07.052] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/29/2017] [Accepted: 07/30/2017] [Indexed: 11/22/2022]
Abstract
AIM To explore health-related quality of life (HRQoL) in recurrence-free melanoma patients, with a focus on the association between melanoma-related limb lymphoedema and HRQoL. METHODS HRQoL was evaluated using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the breast cancer module (EORTC QLQ-BR23) subscales body image and future perspective, the Functional Assessment for Cancer Therapy-General subscale social/family well-being and the Hospital Anxiety and Depression Scale. Data were analysed using linear and ordinal logistic regression adjusting for age and gender. RESULTS A total of 431 melanoma patients who had undergone wide local excision and axillary or inguinal sentinel lymph node biopsy (SLNB) and/or complete lymph node dissection (CLND) participated. No patients had had recurrence of the disease or had received adjuvant radiotherapy. The HRQoL scores improved with time after surgery. Melanoma-related limb lymphoedema was present in 109 patients (25%). Patients with lymphoedema had significantly worse HRQoL scores in the EORTC QLQ-C30 subscales global health status/quality of life, role and social functioning, fatigue, pain and financial difficulties, as well as in the QLQ-BR23 body image subscale. No associations were found between the limb affected (upper or lower limb), clinical stage of lymphoedema, duration of lymphoedema or type of surgery (SLNB or CLND) and HRQoL. We found an interaction with age and gender in the associations between lymphoedema and HRQoL: younger patients and women with lymphoedema had worse social functioning and women had significantly more impaired body image. CONCLUSIONS The negative impact of melanoma-related limb lymphoedema on HRQoL emphasises the importance of developing strategies for increasing awareness and improving prevention and treatment of lymphoedema.
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Yamamoto T, Yamamoto N, Yoshimatsu H, Narushima M, Koshima I. Factors Associated with Lower Extremity Dysmorphia Caused by Lower Extremity Lymphoedema. Eur J Vasc Endovasc Surg 2017; 54:69-77. [PMID: 28392114 DOI: 10.1016/j.ejvs.2017.02.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 02/28/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Indocyanine green (ICG) lymphography has been reported to be useful for the early diagnosis of lymphoedema. However, no study has reported the usefulness of ICG lymphography for evaluation of lymphoedema with lower extremity dysmorphia (LED). This study aimed to elucidate independent factors associated with LED in secondary lower extremity lymphoedema (LEL) patients. METHODS This was a retrospective observational study of 268 legs of 134 secondary LEL patients. The medical charts were reviewed to obtain data of clinical demographics and ICG lymphography based severity stage (leg dermal backflow [LDB] stage). LED was defined as a leg with a LEL index of 250 or higher. Logistic regression analysis was used to identify independent factors associated with LED. RESULTS LED was observed in 106 legs (39.6%). Multivariate analysis revealed that independent factors associated with LED were higher LDB stages compared with LDB stage 0 (LDB stage III; OR 17.586; 95% CI 2.055-150.482; p = .009) (LDB stage IV; OR 76.794; 95% CI 8.132-725.199; p < .001) (LDB stage V; OR 47.423; 95% CI 3.704-607.192; p = .003). On the other hand, inverse associations were observed in higher age (65 years or older; OR 0.409; 95% CI 0.190-0.881; p = .022) and higher body mass index (25 kg/m2 or higher; OR 0.408; 95% CI 0.176-0.946; p = .037). CONCLUSIONS Independent factors associated with LED were elucidated. ICG lymphography based severity stage showed the strongest association with LED, and was useful for evaluation of progressed LEL with LED.
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Affiliation(s)
- T Yamamoto
- Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan; Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan.
| | - N Yamamoto
- Department of Plastic Surgery, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - H Yoshimatsu
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan
| | - M Narushima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan
| | - I Koshima
- Department of Plastic and Reconstructive Surgery, The University of Tokyo, Tokyo, Japan
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Wein TH, Hickenbottom SL, Morgenstern LB, Demchuk AM, Grotta JC. Safety of tissue plasminogen activator for acute stroke in menstruating women. Stroke 2002; 33:2506-8. [PMID: 12364745 DOI: 10.1161/01.str.0000030108.47462.4f] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Menses is a theoretical contraindication to intravenous tissue plasminogen activator (tPA) treatment. We sought to establish the safety of intravenous tPA in the treatment of acute ischemic stroke in women who are actively menstruating. SUMMARY OF REPORT We provide a case report and review of the National Institute of Neurological Disorders and Stroke (NINDS) database for women coded as actively menstruating. Nine subjects were coded as actively menstruating in the NINDS trial (4 placebo and 5 in the treatment). One subject in the treatment group who had a 1-year history of dysfunctional uterine bleeding required emergent uterine artery ligation. We also report a case of a woman requiring transfusion after intravenous tPA administration for acute ischemic stroke. CONCLUSIONS Intravenous tPA may be administered relatively safely in women who are menstruating and should be used with caution in women with a history of dysfunctional uterine bleeding. Potential patients should be advised that they might require transfusion for increased menstrual flow.
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Affiliation(s)
- Theodore H Wein
- Stroke Program, Department of Neurology, University of Texas at Houston Medical School, USA.
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Koch AZ, Abubaker J, Barnett VT, Chan LN. Use of thrombolytic therapy to treat heparin-refractory pulmonary embolism in a menstruating patient. Pharmacotherapy 2002; 22:118-22. [PMID: 11794423 DOI: 10.1592/phco.22.1.118.33493] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A 26-year-old woman developed an acute pulmonary embolism at the beginning of her menstrual cycle and was admitted to the hospital. When she failed initial standard treatment with heparin, the only other therapeutic option was a thrombolytic agent such as recombinant tissue plasma activator (rt-PA). Use of these agents, however, carries a large risk of major bleeding complications and brings concern of increased menstrual blood flow and duration. A literature search of the use of thrombolytic agents in menstruating patients found only limited reports. Our patient responded well to rt-PA therapy Her hemoglobin levels remained stable, and she experienced no bleeding complications. Careful monitoring and caution are recommended when administering thrombolytic agents to menstruating patients.
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Affiliation(s)
- Ada Z Koch
- Department of Pharmacy Practice, College of Pharmacy, University of Illinois at Chicago, Illinois 60612, USA
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Karnash SL, Granger CB, White HD, Woodlief LH, Topol EJ, Califf RM. Treating menstruating women with thrombolytic therapy: insights from the global utilization of streptokinase and tissue plasminogen activator for occluded coronary arteries (GUSTO-I) trial. J Am Coll Cardiol 1995; 26:1651-6. [PMID: 7594099 DOI: 10.1016/0735-1097(95)00386-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES The purpose of this study was to examine the clinical implications of administering thrombolytic therapy to menstruating women with acute myocardial infarction. BACKGROUND Although anecdotal case reports have suggested that thrombolytic therapy is safe during menstruation, the risk of increased bleeding in menstruating women receiving such therapy is poorly defined. METHODS We identified menstruating women who received thrombolytic therapy by soliciting information on all North American women enrolled in the GUSTO-I trial and then collected additional information about them with use of a one-page data form. We compared the characteristics and outcomes of these women with other GUSTO-I patient populations, including all North American women below the median age of menopause, all women and all patients. RESULTS The median age of the 12 menstruating women was 46 years; 75% were cigarette smokers. The median hospital stay was 7 days, 2 fewer than the overall stay in GUSTO-I. None of these women died or had a stroke or severe bleeding. Three patients (25%) had moderate bleeding (vaginal in two patients [66%]) that required transfusion compared with 11% of all GUSTO-I patients and all North American premenopausal women (p = 0.13) and 17% of all female GUSTO-I patients (p = 0.47). Because of the small sample size of 12 women, the power was low (0.37) to detect the observed difference in moderate bleeding. The median nadir hematocrit was 33% in the menstruating women compared with 34% in the premenopausal women and all women. The median time from symptom onset to treatment for the 12 women was 3.7 h, which was 0.9 h longer than the overall median in the trial (p = 0.09). CONCLUSIONS Although there was no statistically significant increase in bleeding risk during menstruation, this fact may be a result of low statistical power rather than a lack of effect. Thus, the results suggest that there may be a clinically significant increase in the risk of moderate bleeding. Nevertheless, the GUSTO-I experience is consistent with the concept that the lifesaving benefit of thrombolytic therapy for acute myocardial infarction should generally not be withheld because of active menstruation.
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Affiliation(s)
- S L Karnash
- Department of Medicine, Duke University Medical Center, Durham, North Carolina 27710, USA
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