Tag Archives: lymphedema

NYU docs are using machine learning to stop a stealthy disease before it’s too late

Lymphedema causes unsightly swelling in the arms and legs. But researchers Mei Fu and Yao Wang have an idea for catching early symptoms sooner.

Researchers at NYU’s Tandon School of Engineering have teamed up with those from the university’s Rory Meyers College of Nursing to develop a machine-learning algorithm that could help detect a lymphatic system disease before doctors are able to.

There is no cure for lymphedema, only physical exercises that can keep the symptoms in check.

Early detection of the disease would allow for physical therapy that could theoretically stop the disease’s progress enough to never allow it to develop.

“Machine learning will help us to develop an algorithm to determine a patient’s status or predict if they will have a measurable symptom later on,” explained Mei Fu, an associate professor at NYU’s Rory Meyers College of Nursing, by telephone last week. “Each time the patients enter the data, the algorithm will teach itself. Later on, machine learning will probably help us say which treatment is better for which kind of patients.”

Read more at Technically Brooklyn

Clinician Resources

Here is a round-up of resources that you may find helpful in your practice.

New illustrations for pressure-injury staging

The National Pressure Ulcer Advisory Panel (NPUAP) has released new illustrations of pressure injury stages. You can download the illustrations, which include normal Caucasian and non-Caucasian skin illustrations for reference.

There is no charge for the illustrations as long as they are being used for educational purposes, but donations to support the work of NPUAP are appreciated.

Ostomy self-advocacy resource

Download the most recent version of the ostomy self-advocacy checklist from the United Ostomy Associations of America. This resource for patients with new ostomies details action steps and provides valuable information. The checklist can be customized with the name and contact information for the local ostomy support group.

Lymphedema webinars

Ready to boost your knowledge about lymphedema? Consider watching a free, on-demand webinar from the Lymphatic Education & Research Network’s symposium series.

Sample topics include:

current and emerging surgical approaches in lymphedema

an overview of normal lymphatic anatomy and ultrastructure

genetics and lymphedema.

Delirium resource

Patients with delirium present many challenges for clinicians. You can get help at a special section of the American Nurses Association’s website dedicated to the topic.

The section includes:

statistics about delirium

links to many resources for clinicians and families

delirium primer for nurses.

Clinical Notes, September 2016

Electrical stimulation and pressure ulcer healing in SCI patients

A systematic review of eight clinical trials of 517 patients with spinal cord injury (SCI) and at least one pressure ulcer indicates that electrical stimulation increases the healing rate of pressure ulcers. Wounds with electrodes overlaying the wound bed seem to have faster pressureulcer healing than wounds with electrodes placed on intact skin around the ulcer.

A quantitative, pooled analysis and systematic review of controlled trials on the impact of electrical stimulation settings and placement on pressure ulcer healing rates in persons with spinal cord injuries,” published in Ostomy Wound Managementstates that the overall quality of the studies was “moderate” and that future trials “are warranted.”

Effect of antiseptics on maggot viability

The short-term application of wound antiseptics on wound beds does not impair the viability of maggots, according to a study in International Wound Journal.

Viability of Lucilia sericata maggots after exposure to wound antiseptics” reports that the maggots can survive up to 1 hour of exposure to antiseptics, such as octenidine, povidone-iodine, or polyhexanide.

Global impact of diabetes underestimated

The prevalence of global diabetes has been seriously underestimated by at least 25%, according to a study published in Nature Reviews Endocrinology.

Diabetes mellitus statistics on prevalence and mortality: facts and fallacies” indicates that there may be more than 100 million people with diabetes globally than previously thought.

Axillary evaluation and lymphedema

A retrospective cohort study in Epidemiology reports that women with ductal carcinoma in situ who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit.

Axillary evaluation and lymphedema in women with ductal carcinoma in situ” included 10,504 women.

Topical insulin and pressure ulcers

A randomized, controlled trial to assess the effect of topical insulin versus normal saline in pressure ulcer healing” concludes that topical insulin is safe and effective in reducing the size of pressure ulcers compared to normal saline-soaked gauze.

Participants of the study, published in Ostomy Wound Management, received either normal saline dressing gauze or insulin dressing twice daily for 7 days. The insulin was sprayed over the wound surface with an insulin syringe, allowed to dry for 15 minutes, and then covered with sterile gauze.

Sexual function and ostomy

Sexual function and health-related quality of life in long-term rectal cancer survivors” reports that long-term sexual dysfunction is common in patients who have undergone surgery for rectal cancer, with more problems seen in patients who have a permanent ostomy.

The study, published in the Journal of Sexual Medicine, included 181 patients with an ostomy and 394 patients with anastomosis.

Effect of venous leg ulcers on body image

Many patients with venous leg ulcers have low self-esteem and negative feelings about their bodies, according to a prospective study published in Advances in Skin & Wound Care.

The impact of venous leg ulcers on body image and self-esteem” included 59 participants. The mean score on the Rosenberg Self-esteem Scale was 22.66, indicating low self-esteem.

Lymphedema and lipedema: What every wound care clinician should know

Imagine you have a health condition that affects your life every day. Then imagine being told nothing can be done about it; you’ll just have to live with it. Or worse yet, your physician tells you the problem is “you’re just fat.”

Many people with lymphedema or lipedema have no idea their condition has a name or that many other people suffer from the same thing. Although lymphedema and lipedema can’t be cured, proper management and resources can help patients cope. This article improves your grasp of these conditions, describes how to recognize and manage them, and explains how to support your patients.

To understand lymphedema and lipedema, first you need to understand how the lymphatic system functions. It makes lymph, then moves it from tissues to the bloodstream. It also plays a major role in the immune system, aiding immune defense. In addition, it helps maintain normal fluid balance by promoting fluid movement from the interstitial tissues back to the venous circulation. (See Lymphatic system: Four major functions.)

If the lymphatic system is impaired from a primary (hereditary or congenital) condition or a secondary problem, lymphedema can result. In this chronic, potentially progressive, and incurable condition, protein-rich fluid accumulates in the interstitial tissues.

Lymphedema basics

Lymphedema occurs in four stages.

Stage 0. During this stage (also called the subclinical or latency stage), transport capacity of the lymphatic system decreases but remains sufficient to manage normal lymphatic loads. Signs and symptomsaren’t evident and can be measured only by sensitive instruments, such as bioimpedance spectroscopy and optoelectronic volumetry. Without such instruments to quantify volume changes, diagnosis may rest on subjective complaints.

In this stage, limited functional reserve of the lymphatic system leads to a fragile balance between subnormal transport capacity and lymphatic loads. Added stress on the lymphatic system (as from extended heat or cold exposure, injury, or infection) may cause progression to stage 1.

Providing appropriate patient information and education, especially after surgery, can dramatically reduce the risk that lymphedema will progress to a more serious stage.

Stage 1. Considered the spontaneously reversible stage, stage 1 is marked by softtissue pliability without fibrotic changes. Pitting can be induced easily. In early stage 1, limb swelling may recede over – night. With proper management, the patient can expect the extremity to decrease to a normal size compared to that of the uninvolved limb. Otherwise, lymphedema is likely to progress to stage 2.

Stage 1 lymphedema may be hard to distinguish from edemas from other causes. Clinicians must rely on the patient history and monitor for swelling resolution with conventional management, such as compression and elevation, or note if swelling persists despite these standard interventions.

Stage 2. Sometimes called the spontaneously irreversible stage, stage 2 is identified mainly from tissue proliferation and subsequent fibrosis (called lymphostatic fibrosis). The fluid component can be removed spontaneously, but removal of the increased tissue proliferation (initially irreversible) takes more time. Tissue proliferation stems from long-standing accumulation of protein-rich fluid; over time, the tissue hardens and pitting is hard to induce. In many cases, swelling volume increases, exacerbating the already compromised local immune defense.

Consequently, infections (particularly cellulitis) are common; these, in turn, increase the volume of the affected area. Proper treatment can reduce volume.

With proper care (complete decongestive therapy [CDT]), lymphedema can stabilize during stage 2. But patients with chronic or recurrent infections are likely to progress to stage 3.

Stage 3. Also called lymphostatic elephantiasis, this stage is marked by further fluid volume increases and progression of tissue changes. Lymphostatic fibrosis becomes firmer and other skin alterations may occur, including papillomas, cysts, fistulas, hyperkeratosis, fungal infections, and ulcers. Pitting may be present. Natural skinfolds deepen (especially those of the dorsum of the wrist or ankle) and, in many cases, cellulitis recurs.

If lymphedema management starts during this stage, reduction can still occur. Even in extreme cases, with proper care and patient adherence to treatment, lymphostatic elephantiasis can be reduced so the leg is a normal or near-normal size.

Assessment and diagnosis

A thorough physical examination is the gold standard for diagnosing lymphedema. A complete patient history, body-systems review, inspection, and palpation can help determine if edema is lymphedema.

Clinically, the only test with proven reliability and validity in diagnosing lymphedema is the Stemmer sign. Fibrotic changes associated with lymphedema can lead to thickened skin over the proximal phalanges of the toes or fingers. If you can’t tent or pinch the skin on the involved extremity, lymphedema is present (a positive Stemmer sign). However, a negative finding (soft, pliable tissue) doesn’t rule out  lymphedema because the condition may be in an early stage, before tissue proliferation and fibrosis have set in.

Management

Although incurable, lymphedema can be managed successfully through CDT. This approach involves proper identification of lymphedema, manual lymph drainage, skin and nail care, patient education, compression, and exercise.

CDT has two phases:

Phase I, the intensive phase, continues until the extremity has decongested or reached a plateau. The clinician provides treatments and educates the patient about all aspects of CDT to prepare him or her for phase II. Phase I can last several weeks to several months depending on lymphedema severity.

Phase II, the maintenance phase, begins once the extremity has decongested or plateaued. This phase still focuses on CDT, but now the patient, not the clinician, is responsible for all care. The goal is to reduce limb size while enabling the patient to become self-sufficient in managing lymphedema. Although CDT can bring significant improvements in limb size, skin quality, and function, patients must remember that phase II continues lifelong. Be sure to provide education about ongoing self-management strategies.

Lipedema: The disease they call “fat”

Lipedema is a painful disorder of fat deposition. Pathologic deposition of fatty tissue (usually below the waist) leads to progressive leg enlargement. Like lymphedema, lipedema is incurable but manageable. Unless managed properly, lipedema can reduce mobility, interfere with activities of daily living, and lead to secondary lymphedema. (See Lipedema stages.)

Lipedema commonly is misdiagnosed as lymphedema. However, lymphedema involves protein-rich fluid, whereas lip edema is a genetically mediated fat disorder. Because lipedema resists diet and exercise, it can lead to psychosocial complications. Lipedema occurs almost exclusively in women; typically, onset occurs between puberty and age 30. One unpublished epidemiologic study puts lip edema incidence in females at 11%. Some patients have a combination of lipedema and lymphedema. (See Viewing lipolymphedema.)

Assessment and diagnosis

As with lymphedema, lipedema diagnosis rests on clinical presentation. Lipedema characteristics include bilateral and symmetrical involvement, absence of pitting (because lipedema isn’t a fluid disorder), soft and pliable skin, and filling of the retromalleolar sulcus (called the fat pad sign.)

Key signs and symptoms include:

• feeling of heaviness in the legs (aching dysesthesia)

• easy bruising

• sensitivity to touch (called “painful fat syndrome”)

• orthostatic edema

• oatmeal-like changes to skin texture.

Nearly half of lipedema patients are overweight or obese, but many appear of normal weight from the waist up. Essentially, the upper and lower extremities don’t match. The lower extremities typically show fatty deposits extending from the iliac crest to the ankles, sparing the feet. (See Lipedema patterns.)

Management

Lipedema is best  managed through weight control, as additional weight gain through adipose tissue tends to deposit in the legs. For patients with concomitant lymphedema (lipolymphedema), modified CDT helps reduce and manage lymphatic compromise. To address excess fat deposition, newer “wet” liposuction techniques have proven beneficial. These techniques gently detach adipose cells from the tissue, helping to preserve connective tissue and lymphatic vessels.

Know what to look for

In both lymphedema and lipedema, early identification and proper diagnosis are key. (See Differentiating lymphedema and lipedema.) A thorough history and physical exam will likely lead to an accurate diagnosis, if clinicians know what to look for. Proper diagnosis and treatment can prevent expensive and ineffective interventions, which can negatively affect both the patient’s condition and psychological well being.

Heather Hettrick is an associate professor at Nova Southeastern University, Department of Physical Therapy in Fort Lauderdale, Florida.

Selected references

Fat Disorders Research Society. Lipedema description.

Fife CE, Maus EA, Carter MJ. Lipedema: a frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care. 2010;23(2):81-92

Herbst KL. Rare adipose disorders (RADS) masquerading as obesity. Acta Pharmacol Sin. 2012;33(2):155-72.

Lipedema Project.

National Lymphedema Network. Position papers.

Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. 2012;166(1):161-8.

Zuther J. A closer look at lipedema and the effects on the lymphatic system. December 13, 2012. lymphedemablog.com/2012/12/13/a-closer-look-at-lipedema-and-the-effects-on-the-lymphatic-system/

Zuther J. Stages of lymphedema. October 3, 2012.

Clinical Notes

Management of biofilm recommendations

The Journal of Wound Care has published Recommendations for the management of biofilm: a consensus document,” developed through the Italian Nursing Wound Healing Society.

The panel that created the document identified 10 interventions strongly recommended for clinical practice; however, panel members noted that, “there is a paucity of reliable, well-conducted clinical trials which have produced clear evidence related to the effects of biofilm presence.”

Statins reduce CVD risk in patients with diabetes

Statins reduce the risk of cardiovascular disease (CVD) and death in patients with type 1 diabetes without a history of CVD, according to a study published in Diabetes Care.

Association between use of lipid-lowering therapy and cardiovascular diseases and death in individuals with type 1 diabetes” included more than 24,000 individuals from the Swedish National Diabetes Register who were followed for a mean of 6 years.

International diabetes organizations support bariatric surgery

Metabolic surgery in the treatment algorithm for type 2 diabetes: a joint statement by international diabetes organizations,” published in Diabetes Care, supports including metabolic (bariatric) surgery as a treatment option for people with type 2 diabetes who are obese. The statement notes when metabolic surgery is recommended and when it should be considered.

The 2nd Diabetes Surgery Summit was convened in collaboration with leading diabetes organizations to develop the guidelines. The multidisciplinary group included 48 international clinicians and scholars from leading diabetes associations; 75% were not surgeons. Draft conclusions were presented and opened to public comment. Following comment, they were amended.

Medicare-VHA dual use associated with poorer chronic wound healing

Veterans with chronic wounds who are enrolled in Medicare and access care through Medicare and the Veterans Health Affairs (VHA) experience poorer healing of chronic wounds, according to a study in Wound Repair and Regeneration.

Medicare-VHA dual use is associated with poorer chronic wound healing” was a retrospective study that followed 227 Medicare-enrolled individuals who used the VHA and who had a chronic lower limb wound. Individuals were followed until the wound was healed or up to 1 year.

“Dual use was associated with a significantly lower hazard of wound healing compared to VHA-exclusive use,” the study authors note. The risks of amputation or death were higher for dual users.

Sacral dressing may help prevent ulcers in ICU patients

Prophylactic sacral dressing for pressure ulcer prevention in high-risk patients,” published in the American Journal of Critical Care, reports that the dressing reduced the number of sacral pressure ulcers in three ICUs by 3.4 to 7.6 per 1,000 patient days depending on the unit.

Data were collected for 7 months and compared to 7 months before the dressings were used, and patients were identified as high risk by using an evidencebased tool. The study authors note that heightened awareness by the care team and increased education also are key in preventing pressure ulcers.

Scale has limited ability to predict pressure ulcers

A study that evaluated the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) during acute care and inpatient rehabilitation following spinal cord injury (SCI) found that the scale could predict pressure ulcers occurring within 2 to 3 days after it was administered in acute care, but didn’t predict ulcer development over a longer term within acute or inpatient rehabilitation.

Predictive validity of the Spinal Cord Injury Pressure Ulcer Scale (SCIPUS) in acute care and inpatient rehabilitation in individuals with traumatic spinal cord injury,” published in NeuroRehabilitation, used retrospective analysis to determine the findings.

Braden Q and Glamorgan scales compared in children

The Journal of Tissue Viability has published A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units,” which found that both work  well in these settings.

The study authors note, however, that the Braden Q may be better at predicting risk in general pediatric units. More than 500 pediatric admissions were included in the study.

Axillary reverse mapping may reduce lymphedema

Researchers report that using axillary reverse mapping during surgery to help identify lymph nodes and vessels reduces the risk of lymphedema in patients undergoing sentinel lymph node biopsy and/or axillary node dissection.

A total of 654 patients participated in Does axillary reverse mapping prevent lymphedema after lymphadenectomy?,” published in Annals of Surgery.

Muslims and QOL after ostomy surgery

Muslims who undergo ostomy surgery experience significant reductions in health-related quality of life (QOL) — greater reductions than seen in non-Muslim patients, according to a study in Journal of Wound Care and Ostomy.

Quality of life after ostomy surgery in Muslim patients: a systematic review of the literature and suggestions for clinical practice” notes that factors associated with the difference include “psychological factors, social isolation, underreporting of complications, and sexual dysfunction leading to breakdown of marital relations as well as diminished religious practices.”

Chronic venous insufficiency consensus statement

Circulation has published “Investigation of chronic venous insufficiency: a consensus statement,” which “provides an up-to-date account of the various methods available for the investigation of chronic venous insufficiency of the lower limbs (CVI), with an outline of their history, usefulness, and limitations.”

Clinical Notes—May/June 2016

Moldable skin barrier effective for elderly patients with ostomy

A study in Gastroenterology Nursing reports that compared to a conventional skin barrier, a moldable skin barrier significantly improves self-care satisfaction scores in elderly patients who have a stoma. The moldable skin barrier also caused less irritant dermatitis and the costs for leakage-proof cream were lower.

The application of a moldable skin barrier in the self-care of elderly ostomy patients” included 104 patients ages 65 to 79 who had a colostomy because of colorectal cancer.

Risk factors for severe hypoglycemia in older adults with diabetes identified

Risk factors associated with severe hypoglycemia in older adults with Type 1 diabetes” include glucose variability and greater lack of awareness of hypoglycemia.

Participants in the case-control, multi-center study, published in Diabetes Care, were age 60 or older and had a history of diabetes dating back 20 years or more.

Thermal imaging via smartphone helps detect inflammation

Early detection of inflammation in wounds promotes early treatment, and clinicians may have an additional assessment tool available to them. A recent study published in the Journal of Wound Care concludes the FLIR ONE, a thermography device that connects to a smartphone, can be successfully used to assess subclinical inflammation in patients with pressure ulcers and diabetic foot in clinical settings.

Use of smartphone attached mobile thermography assessing subclinical inflammation: A pilot study” included 16 thermal images from eight patients and found good criterion-related validity and inter-rater reliability when the FLIR ONE results were compared to those from a handheld device. The findings may open the door to more thermal imaging assessment at the bedside.

Role of skin substitutes in treatment of diabetic foot ulcers analyzed

Systematic review and meta-analysis of skin substitutes in the treatment of diabetic foot ulcers,” published in Wound Repair and Regeneration, concludes that skin substitutes “can, in addition to standard care, increase the likelihood of achieving complete ulcer closure compared with standard care alone in the treatment of diabetic foot ulcer.”

The authors caution, however, that long-term effectiveness, including limb salvage and recurrence, is not known, and cost-effectiveness is not clear. The review included 17 randomized clinical trials, with a total of 1,655 patients.

Tap water safe alternative for wound cleaning

“Tap water is a safe alternative to sterile normal saline for wound cleansing in a community setting,” concludes a study in the Journal of Wound, Ostomy and Continence Nursing.

Tap water versus sterile normal saline in wound swabbing: A double-blind randomized controlled trial” studied 22 people with 30 wounds. Half were in the tap water group and half in the sterile normal saline group. Researchers found no differences in the proportion of wound infection and healing between the two groups.

Review of skin grafting in patients with chronic leg ulcers

Autologous split-thickness skin grafting remains the gold standard in terms of safety and efficacy for chronic leg ulcers, according to a review article in International Wound Journal.

Skin grafting for the treatment of chronic leg ulcers—a systematic review in evidencebased medicine” also found that skin grafts are more successful in patients who have chronic venous leg ulcers, compared to other types. The researchers noted that skin tissue engineering is “rapidly expanding” and holds promise for better outcomes when treating patients with long-lasting chronic wounds.

C difficile may be risk factor for pouch failure after reconstruction

Patients with a history of preoperative Clostridium difficile colitis may be at higher risk for pouch failure after ileal pouchanal anastomosis reconstruction following total proctocolectomy for ulcerative colitis, according to a study in Inflammatory Bowel Disease.

The authors of “Clostridium difficile infection in ulcerative colitis: Can alteration of  the gut-associated microbiome contribute to pouch failure?” defined pouch failure as permanent ostomy diversion or pouch excision. Of 417 patients in the study, 28 (6.7%) developed pouch failure.

Lymphedema education lacking

Researchers of a study in the Journal of Cancer Education report that only 19.9% of 180 women with lymphedema after breast cancer surgery reported they had received education or information about the condition postoperatively.

The importance of awareness and education in patients with breast cancer-related lymphedema” also reports that, “The degree and duration of lymphedema were lower in patients who had been informed or educated about lymphedema as compared to the patients who had not been informed or educated, but the difference was not statistically significant.”

Color charts help improve pressure ulcer risk assessment

Use of Munsell color charts to measure skin tone objectively in nursing home residents at risk for pressure ulcer development,” published in the Journal of Advanced Nursingconcludes that the color charts provide a “more objective measurement of skin tone than demographic categories.”

The researchers state that use of the charts can improve pressure ulcer risk assessment when current clinical guidelines are less effective.

Clincal Notes

Value of systematic reviews and meta-analyses in wound care

Systematic reviews and meta-analyses—literature-based recommendations for evaluating strengths, weaknesses, and clinical value,” in Ostomy Wound Management, discusses evidence-based practice and how systematic reviews (SRs) and meta-analyses (MAs) can help improve management of wound care patients.

The authors of the article explain evidence-based practice and provide useful definitions for key terms. They then provide a list of eight questions to use when evaluating SRs and practical tips such as how to search for SR and MA studies. The article finishes with a list of eight inter­ventions supported by the most evidence: hydro­colloidal dressings, honey, biosynthetic dressings, iodine complexes, silver compounds, hydrogels, foam dressings, and negative pressure wound therapy.

Inflammatory markers and diabetic foot osteomyelitis

Procalcitonin (PCT) is higher in patients with osteomyelitis than those without, according to a study of 35 patients with infected foot ulcers published in International Wound Journal.

The authors of “The value of inflammatory markers to diagnose and monitor diabetic foot osteomyelitis” also measured erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-8 (IL-8), and monocyte chemotactic protein-1 (MCP-1) at baseline and after 3 and 6 weeks of standard therapy. They found that CRP, ESR, PCT, and IL-6 levels decreased significantly in patients with

osteomyelitis after starting therapy, while MCP-1 increased. These findings indicate the markers might be helpful in monitoring response to therapy.

Proposed treatment algorithm for patients with sickle cell disease and leg ulcers

The authors of “A treatment algorithm to identify therapeutic approaches for leg ulcers in patients with sickle cell disease,” published in International Wound Journal, note that sickle cell ulcers, a common complication of sickle cell disease, are slow to heal and often recur. The article reviews treatment options and presents a proposed treatment algorithm.

Mechanism of action for maggot therapy

Maggot debridement therapy can promote healing in patients with diabetic foot wounds, according to “Maggot debridement therapy promotes diabetic foot wound healing by up-regulating endothelial cell activity.”

The authors of the study, published in Journal of Diabetes and Its Complications, report that maggot excretions/secretions promote healing by “up-regulating endo­thelial cell activity.” In vitro, maggot excretions/secretions increased human umbilical vein endothelial cell proliferation, improved tube formation, and increased expression of vascular endothelial growth factor receptor 2 in a dose-dependent manner. CD34 and CD68 levels were increased in treated wounds.

People with diabetes and PAD at greater risk for impaired mobility

Diabetes is associated with increased risks of low lean mass and slow gait speed when peripheral artery disease is present,” published in Journal of Diabetes and Its Complications, notes that low lean mass and mobility impairment were not seen in people who had either diabetes or peripheral artery disease (PAD) alone, only when both were present.

The study included 4,769 participants 40 years or older from the National Health and Nutrition Examination Survey 1999–2004.

Systematic review of diabetic foot offloading

Treatment of the diabetic foot by offloading: a systematic review” reports that total contact casts are the “most effective” devices for ulcer healing. However, the authors of the study in Journal of Wound Care note that contact casts “are not without complications and their impact on cost, compliance, and quality of life is not well understood.” The review included 15 studies.

Fleet enema may be sufficient prep for DLI surgery

A fleet enema alone may be sufficient for preoperative bowel prep in patients under­going anterior resections followed by a diverting loop ileostomy (DLI), according to “Colonic transit: what is the impact of a diverting loop ileostomy?”

The study in ANZ Journal of Surgery included 10 patients with a mean age of 57 years who were undergoing low anterior resection or ultra-low anterior resection for treatment of rectal cancer.

CDP with surgery treatment option for lower-extremity lymphedema

The combination of complex decongestive physical therapy (CDP) perioperatively and reduction surgery is an option for some patients with elephantiastic lymphedema of the lower extremity, according to a study in Obesity Surgery.

An integrative therapeutic concept for surgical treatment of severe cases of lymphedema of the lower extremity” included 26 patients who underwent CDP and surgery and 30 patients who received medial thigh lift due to post-bariatric or aesthetic issues.

Clinical Notes

Factors affecting medication adherence in patients with diabetes identified

Factors associated with better adherence to antidiabetic medications taken by patients with diabetes include older age, male sex, higher education, higher income, use of mail-order vs. retail pharmacies, primary care vs. nonendocrinology specialist prescribers, higher daily total pill burden, and lower out-of-pocket costs.

Determinants of adherence to diabetes medications: Findings from a large pharmacy claims database,” published in Diabetes Care, also found that patients who are new to diabetes therapy are less likely to be adherent. The study included more than 200,000 patients who were treated for diabetes with noninsulin medications.

LMW heparin may improve healing of chronic venous ulcers

International Wound Journal has published “Low molecular weight heparin improves healing of chronic venous ulcers especially in the elderly,” a study that included 284 patients.

The healing rate for those receiving low-molecular-weight (LMW) heparin was around 80% at 12 months, compared to around 60% for those who didn’t receive heparin. Older patients received the most benefit and also had the lowest recurrence rate.

Comparison of dressings for pediatric donor skin-graft sites

Compared to foam and hydrofiber, calcium alginate is the optimum dressing for pediatric donor skin-graft sites, according to a study in the Journal of Burn Care & Research.

Management of pediatric skin-graft donor sites: A randomized controlled trial of three wound care products” included 57 children, and the median size of the donor site was 63.50 cm2. The median days for healing for those in the calcium alginate group was 7.5, compared to 8 days for hydrofiber and 9.5 days for foam.

Insulin pump clinical safety appraised

Insulin pump risks and benefits: A clinical appraisal of pump safety standards, adverse event reporting, and research needs,” is a Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group published in Diabetes Care. The article contains several recommendations for reducing adverse effects caused by user error, including:

  • Select appropriate candidates for pump therapy.
  • Provide those beginning pump therapy with appropriate and ongoing education and support.
  • Ensure that healthcare professionals supporting pump users are themselves well trained and supported.

The article also notes that the clinical studies required before marketing an insulin pump are “small and over-reliant on bench testing” and that once a pump is on the market, “insufficient data are made publicly available on its long-term use in a real-world setting.”

Resistance training may improve lymphedema

According to a poster presented at a Florida State University symposium, “Resistance training improves muscular strength and lymphedema in breast cancer survivors,” 33 female participants experienced moderate- to high-intensity resistance therapy over 12 weeks. The researchers found that participants tolerated therapy well and that lymphedema was significantly decreased.

Ability to stop insulin varies with bariatric surgery type

Insulin cessation and diabetes remission after bariatric surgery in adults with insulin-treated type 2 diabetes,” published in Diabetes Care, found that patients who had Roux-en-Y gastric bypass surgery were more likely than those who had laparoscopic adjustable gastric banding to be able to stop insulin after surgery.

Pilot studies find acupuncture reduces lymphedema

Acupuncture research at Memorial Sloan Kettering Cancer Center” reports acupuncture significantly reduces arm circumference in patients with lymphedema.

The article, published in the Journal of Acupuncture and Meridian Studies, discusses two pilot studies that indicate acupuncture is safe for patients who have had breast cancer surgery.

Clinical practice guidelines for ostomy surgery released

Diseases of the Colon & Rectum has published “Clinical practice guidelines for ostomy surgery.” The American Society of Colon and Rectal Surgeons developed the guidelines, which discuss ostomy creation, closure, and complications.

The guidelines state that the “optimal care for patients undergoing ostomy surgery includes preoperative, perioperative, and postoperative care by an ostomy nurse specialist.”
DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

A collaborative approach to wound care and lymphedema therapy: Part 1

PDF-icon

By Erin Fazzari, MPT, CLT, CWS, DWC

Have you seen legs like those shown in the images below in your practice? These images show lymphedema and venous stasis ulcers, illustrating the importance of collaboration between clinicians in two disciplines: lymphedema and wound care.

My experience

Over the last 12 years as a physical therapist specializing in lymphedema therapy and wound care, I’ve had the opportunity to treat many patients with wounds in multiple settings. I’ve also had the opportunity to collaborate with medical professionals in multidisciplinary treatment centers where lymphedema therapists and wound care clinicians act as a team. Through this experience—and through review of the literature—I’ve learned that such a team has improved patient outcomes.

To help the team reap maximal benefits, I’d like to share information related to lymphedema, its management, and how collaboration in multidisciplinary treatment centers can enhance outcomes.

In Part 1 of this two-part series, I discuss pathophysiology related to wounds and lymphedema and begin the discussion of collaboration.

The basics

To understand the role of lymphedema therapy as it relates to wound care, it’s first necessary to take a step back and define both chronic wound and lymphedema. A chronic wound is a wound that doesn’t heal in an orderly set of stages and in the predictable amount of time that most wounds do. Delayed healing may result from a variety of underlying factors, such as poor systemic immune function, malnourishment, chemotherapeutic agents, high bioburden, repetitive mechanical trauma, and cytotoxic agents.

Lymphedema is a condition of localized fluid retention and tissue swelling characterized by high-protein edema caused by a compromised lymphatic system. All exterior regions of the body (for example, face, neck, torso, extremities, and genitals) can be affected. Common causes of lymphedema and accompanying diseases that can contribute to lymphedema include heredity, filariasis, trauma, surgeries, lymph node dissections, radiation therapy, malignancy, obesity, diabetes, chronic heart failure, dependent mobility and, of course, venous disease—the principal culprit of our wound for discussion, the venous stasis ulcer.

The venous stasis ulcer is one major debilitating result of advanced venous disease. Venous ulceration is the most common cause of lower-extremity ulcer, accounting for half of these ulcers and affecting 1% to 2% of the U.S. population, with 3% to 5% of patients older than age 65.

Venous stasis ulcers and lymphedema

So how are the venous ulcer and lymphedema related? The venous and lymphatic systems are closely intertwined. When explaining the systems to patients, I often refer to the lymphatics as the sewer system of the venous system.

Most wound care clinicians are familiar with the pathophysiology that results in venous disease and the cascade of events that leads to a venous ulcer. Many clinicians, however, aren’t as familiar with the role of the lymphatics in this process.

Under optimal circumstances, the venous system is responsible for the removal of 90% of interstitial fluid at the capillary level. The remaining 10% is the responsibility of the lymphatic system. However, the lymphatics have a built-in safety net to manage excess interstitial fluid that occurs when the veins function inefficiently or ineffectively. Venous reflux may be present, but edema in the tissue isn’t yet visible when the lymphatics are able to manage the load. Edema in the lower extremities, as well as other areas of the body, is visible only when both the veins and lymphatics are no longer capable of managing the load.

The lymphatics are also responsible for the removal of large macromolecules from the interstitial space, including proteins that are unable to diffuse back into the venous system at the capillary level. A venous stasis ulcer occurs when the increase in protein concentrations in the tissue results in chronic inflammation and infiltration of white blood cells and fibroblasts. This leads to fibrosis of the edematous tissue, dilation and insufficiency of lymphatic tissue, and damage to endothelial cells, further reducing lymphatic flow and enhancing the destructive process.

The body’s physiologic responses illustrate the close anatomic and physiologic connection between the two systems. Consequently, it should be a priority for us, as clinicians, to address both the lymphatic and venous systems when edema is detectable in the tissue.

Worldwide impact

The anatomy and physiology of these systems have a huge impact on our patient population. Each year in North America, 5 to 7 million chronic wounds occur. Lower-extremity venous stasis ulcer is the most common of these, with an incidence of 2.5 million. In the United States alone, chronic leg wounds account for 2 million lost workdays per year.

When it comes to lymphedema, 1 in 30 people worldwide are estimated to be afflicted with this debilitating disease, not including those suffering from venous disease.

World organizations have begun to recognize the importance of addressing lymphedema and wound care collaboratively. (See World action on lymphedema and wound care.) As noted earlier, anatomy and physiology don’t separate the venous and lymphatic systems, so wound care and lymphedema clinicians need to work collaboratively to help patients.

Common goals

A good place to start collaborating is to understand that the disciplines of lymphedema therapy and wound care have many common goals, including:

  • reducing and stabilizing edema
  • achieving ulcer healing
  • preventing recurrence
  • preventing infection
  • maximizing tissue healing.

Multidisciplinary teams are the wave of the future of health care. Consider how a team approach with lymphedema and wound care professionals would enhance your practice, and watch for Part 2 of this series, which will further address common goals, review the gold standard of management (complex decongestive therapy), and illustrate how collaboration in multidisciplinary treatment centers can enhance patient outcomes.

Selected references

Ditzler K. Collaborating lymphedema and wound care [lecture]. Penn Medicine at Radnor, Radnor, PA; 2014.

Foldi M, Foldi E. Foldi’s Textbook of Lymphology: For Physicians and Lymphedema Therapists. 3rd ed. Munich, Germany: Urban & Fischer, 2012.

Law K. Addressing the Whole, Not Just the Hole: A Collaborative Approach for Patient Success [Lecture]. Penn Medicine at Radnor, Radnor, PA; 2014.

MacDonald J, Asiedu K. WAWLC: World alliance for wound and lymphedema care. Wounds. 2010; 22(3):55-9.

MacDonald J, Geyer, MJ, eds. Wound and lymphoedema management. World Health Organization: 2010 http://whqlibdoc.who.int/publications/2010/9789241599139_eng.pdf

Macdonald JM, Sims N, Mayrovitz HN. Lymphedema, lipedema, and the open wound: the role of compression therapy. Surg Clin North Am. 2003;83(3):639-58.

Norton S. CDT theoretical review course for the certified lymphedema therapist. Norton School of Lymphatic Therapy; 2005.

Pawel D, Franek A, Kolank M. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci. 2013 Dec;11(1):34-43.

Sen CK, Gordillo GM, Roy S, et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009 Nov-Dec;17:763-7.

Erin Fazzari is a physical therapist at Good Shepherd Penn Partners: Penn Therapy and Fitness, in Philadelphia, Pennsylvania.

Clinical Notes

Diabetes carries high economic burden

According to a study published in Diabetes Care, the economic burden associated with diagnosed diabetes (all ages) and undiagnosed diabetes, gestational diabetes, and prediabetes (adults) exceeded $322 billion in 2012, amounting to an economic burden exceeding $1,000 for each American.

The authors of “The economic burden of elevated blood glucose levels in 2012: Diagnosed and undiagnosed diabetes, gestational diabetes mellitus, and prediabetes” note that the $322 billion number, which comprises $244 billion in excess medical costs and $78 billion in decreased productivity, is 48% higher than the $218 billion estimate for 2007.

Review article on lymphedema published

Recent progress in the treatment and prevention of cancer-related lymphedema,” published in CA: A Cancer Journal for Clinicians, reviews recent developments in the diagnosis, treatment, and prevention of cancer-related lymphedema, including breast cancer and other cancer types—melanoma, gynecologic, genitourinary, and head and neck.

The article also discusses the issue of insufficient insurance coverage for the diagnosis and treatment of lymphedema. The authors emphasize the importance of early identification of the condition and early referral.

Preventing breast cancer

Risk determination and prevention of breast cancer,” published in Breast Cancer Research, estimates that half of breast cancers might be prevented in women at high and moderate risk by using chemoprevention (tamoxifen, raloxifene, exemestane, and anastrozole). For all women, lifestyle measures, including weight control, exercise, and moderating alcohol intake, could reduce breast cancer risk by about 30%.

Ostomy can hinder goal attainment in cancer patients

Changes in cancer patients’ personal goals in the first 6 months after diagnosis: The role of illness variables,” in Supportive Care in Cancer, notes that overall, patients reported a “decrease in illness-related hindrance, higher attainability and likelihood of success, a decrease in total number of goals, goals with a shorter temporal range, and more physical and fewer social goals.”

However, patients with more advanced stages of cancer, rectal cancer, or a stoma and receiving additional chemotherapy or radiotherapy reported more difficulty attaining their goals because of their illness. Only patients with a stoma reported “lower attainability, likelihood of success, and more short-term goals.”

Device to prevent parastomal hernia studied

In “A promising new device for the prevention of parastomal hernia,” in Surgical In­novations, researchers from Switzerland report their experience with a new stoma­plasty ring (KORING) that they invented. The ring, which has been used only once, is intended to prevent parastomal hernias.

CDC releases guideline on preventing HIV transmission from those with HIV

The Centers for Disease Control and Prevention (CDC) has released “Recommendations for HIV prevention with adults and adolescents with HIV in the United States, 2014.” The guideline includes recommendations about biomedical, behavioral, and structural interventions that can help reduce the risk of human immunodeficiency virus (HIV) transmission from persons with HIV by reducing their infectiousness and their risk of exposing others to HIV.

Rate of rising healthcare costs slows

The Centers for Medicare & Medicaid Services reports U.S. healthcare spending in 2013 increased 3.6% to $2.9 trillion, or $9,255 per person. “National health spending in 2013: Growth slows, remains in step with the overall economy,” published in Health Affairs, notes that spending slowed by an 0.05 percentage point, compared with 2012. Health care has been 17.4% of the gross national product since 2009.

The slower growth is consistent with slower growth in private health insurance and Medicare spending. Other reasons include slower growth in spending for hospital care, investments in medical structures and equipment, and spending for physician and clinical care.

Low-glycemic index diet doesn’t improve cardiovascular risk factors

Overweight and obese persons who eat a diet that has a low glycemic index of carbohydrate don’t have improvements in insulin sensitivity, lipid levels, or systolic blood pressure, according to a study in JAMA.

Effects of high vs low glycemic index of dietary carbohydrate on cardiovascular disease risk factors and insulin sensitivity” concludes that “using glycemic index to select specific foods may not improve cardiovascular risk factors or insulin resistance.”

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.