Lymphoproliferation- a clue towards an underlying monogenic disorder of immune dysregulation- a retrospective analysis from a single center in India

Background: Lymphoproliferation is the persistent proliferation of lymphoid cells and it's incidence in inborn errors of immunity varies from 0.7 to 18%. Material(s) and Method(s): This is a retrospective analysis of patients referred to the department of Immunology, B. J. Wadia Hospital for Children, Mumbai between March 2017 to December 2022. Inclusion criteria consisted of 3 months duration of significant lymphadenopathy and/or splenomegaly or history of lymphoma. The clinical characteristics, laboratory and molecular findings of the included patients were analyzed. Result(s): A total of 66 patients were included. There was a male preponderance with male:female ratio of 25:8. Median age of onset of lymphoproliferation was 4.75 years(Range 1 year to 60 years). Splenomegaly was seen in 75%. Infections included recurrent pneumonia (14/66), recurrent ear infections(5/66), COVID(4/66), one episode of pneumonia(6/66), herpes zoster(3/66), recurrent subcutaneous abscess (3/66), abdominal koch(3/66), chronic sinusitis(2/66), dermatophytosis(2/66), esophageal candidiasis(2/66), recurrent malaria(1/66), recurrent varicella(1/66), cryptococcal meningitis(1/66), gram negative sepsis(1/66), BCG adenitis(1/66), pseudomonas osteomyelitis(1/66), impetigo (1/66), pseudomonas urinary tract infection (1/66), chicken pox(1/66), herpes keratitis(1/66), dengue(1/66), Other manifestations included Evans plus phenotype(10/66), Evans phenotype(8/66), Autoimmune hemolytic anemia(5/66), bronchiectasis(5/66), Type 1 diabetes(3/66), hyper reactive airway disease(2/66), inflammatory bowel disease(4/66), autoimmune thrombocytopenia(2/66), stroke(3/66), hemophagocytic lymphohistiocytosis(2/66), hypertriglyceridemia(2/66), hypothyroidism(2/66), celiac disease(1/66), Type 2 diabetes(1/66), autoimmune encephalitis(1/66), autoimmune hepatitis(2/66), anti-parietal cell antibody(1/66), arthritis(1/66), autoimmune enteropathy(1/66), systemic lupus erythromatosus(1/66), primary biliary cirrhosis requiring liver transplant(1/66), nephrotic syndrome(1/66), lymphoedema(1/66), hypersplenism(1/66), recurrent oral ulcers(1/66), gout(1/66), dermatitis(1/66), ovarian teratoma(1/66), alopecia areata(1/66). Hodgkin's lymphoma(HL) was the most common malignancy(9/66), followed by non Hodgkin lymphoma(NHL)(6/66), transformation from NHL to HL(1/66), Burkitt to T-cell lymphoma(1/66), HL to DLBCL(1/66), HL to anaplastic T-cell lymphoma(1/66). EBV driven lymphoproliferation was seen in biopsy of21/66. Genetic testing showed mutations in LRBA(11/66), PIK3CD(5/66), CTLA4(3/66), TET2(2/66), IL2RA (1/66), IL12RB1(1/66), BACH2(1/66), PRKCD(1/66), TNFSFR13B(1/66), TNFAIP3(1/66), FAS(2/66), FASL(1/66), Caspase8(1/66), CARD11(1/66), RTEL1(1/66), AICD(1/66), PIK3R1(1/66), IKBKB(1/66). Treatment included IVIG, chemotherapy, rituximab, sirolimus, abatacept, HSCT. Conclusion(s): All children with persistent lymphoproliferation, with or without autoimmunity and/or infections should be worked up for an underlying monogenic disorder of immune dysregulation. Lymphomas presenting at abnormal site and/or age, relapse and EBV driven lymphomas require further evaluation. Presence of monogenic cause helps in providing targeted therapy.Copyright © 2023 Elsevier Inc.

Proceedings of the 6th National Patient Reported Outcome Measures (PROMs) Annual Conference

The proceedings contain 47 papers. The topics discussed include: long COVID rehabilitation services, Cardiff and Vale and Cwm Taf Morgannwg University health boards: social return on investment;the clinical meaning of family reported outcome measure (FROM-16) scores: translational research to support holistic clinical practice;patient-centered outcome measure design: the perspectives and preferences of children and young people with life-limiting or life-threatening conditions;co-creation of a patient reported outcome measure for older people with frailty and acute care needs (PROM-OPAC);PROMs: coming of age in lymphoedema services in Wales;ForMi-person-centered planning and outcomes recording app;true colors online mood monitoring in the bipolar disorder research network (BDRN) research program: challenges, benefits and importance of personalization;patient reported outcome measures for rheumatoid arthritis disease activity: using Rasch measurement theory to achieve more meaningful measurement;developing a roadmap towards national collection of electronic patient-reported outcomes for people with chronic kidney disease in the UK;and measuring bereavement support needs in people bereaved during Covid-19;the adaptation and development of a bereavement support needs scale.

Recognition of Those at Risk of Lymphedema, Benefits of Subclinical Detection, and the Importance of Targeted Treatment and Management

Primary and secondary lymphedemas, irrespective of their cause, remain a significant issue around the world, impacting physical, functional, and psychological well-being, family relationships, and the ability of the affected person to undertake work and household tasks. Often, an accurate, objective differential diagnosis is not (or cannot) be made, sometimes resulting in treatment, which is suboptimal, or which does not achieve expected outcomes due to the impact of a range of comorbidities on lymphatic load or functioning. Diagnosis, Management, and targeted treatment of these comorbidities such as chronic edema, lipedema, and phlebedema will allow improved outcomes for the lymphedemas. To treat and manage lymphedemas well, there is a lifelong cost both to the affected individual, the family, and the health-care system. However, for those with lymphedemas irrespective of its stage, there are significant leverage points for obtaining a good outcome through an accurate differential diagnosis, but it is the group who are at risk of lymphedema where we can have the greatest impact with respect to optimizing their health and well-being. The solution is multifaceted involving three major components: (1) the recognition of those at elevated risk of developing lymphedema and the reduction or management of those risks;(2) the early detection of the subclinical stages of lymphedema;and (3) appropriately targeted and sequenced treatment delivered in a holistic sense within a compassionate caring community environment with appropriate integrated and continuing health professional support. We also need to be aware that high-level technology and equipment is not always needed for an accurate assessment of the lymphedema or its risk, with simple tape measurements and associated volume calculations along with the use of the pitting test and the Stemmer sign being acknowledged as dependable and informative. While the evidence is increasing that lymphovenous or lympho-lymphatic anastomoses, and lymph node transfers are of benefit when created in the earlier stages of lymphedema (and perhaps in those detected as being at a high risk of developing it), complex and invasive treatments are most often not needed when the lymphedema is detected early. In these stages, simple management strategies work well when we employ our knowledge of the importance of weight control, self-management through exercise and activity programs (which can include yoga and tai chi breathing techniques) and skin care, massage with compression provided by bandaging, garments, or wraps, in an environment of integrated professional functioning and advice. In today's COVID environment and when services are not available nearby or what the patient cannot travel, when it is not possible to physically see a therapist or other health professional, telemedicine and its associated information and interactive education programs are of increasing importance. We must together ensure that the information about lymphedema, its risk factors, treatments, and management is made available in clinics and community health facilities, so everyone has access to it and is aware of who to approach for continuous and integrated holistic care.

Breast Cancer-Related Lymphedema and its Relationship to Major Landmark Trials in Surgical Oncology and Radiation Oncology

INTRODUCTION: Many landmark trials have challenged the need for extensive axillary surgery and radiation in breast cancer patients. De-escalation of axillary treatment could potentially result in less breast cancer-related lymphedema (BCRL). Our study aims to define the incidence and trends of BRCL over the last 15 years. METHOD(S): Since 2005, our institution has prospectively screened breast cancer patients for lymphedema during and after treatment with a Perometer. 2,334 women diagnosed with breast cancer with baseline arm volume measurements and at least 2 follow-up measurements were divided into 3 cohorts based on date of surgery (Cohort 1: 2005-2010, Cohort 2:2011-2016, Cohort 3: 2016-2022). The cohorts were selected to coincide with publications of the landmark trials NSABP B-32, ASCOG Z0011, ASCOG Z1071, and EORTC 10981-22023 AMAROS which demonstrated safety in reducing the number of axillary lymph node dissections (ALND). Lymphedema was defined as a relative volume change of 10% or greater from preoperative baseline at least 3 months post-operatively. In cases of bilateral surgery, the weight-adjusted arm volume change equation was utilized. Cohort, age, BMI, axillary surgery type, chemotherapy timing, radiation type, and surgery type were all included in the multivariate analysis. RESULT(S): The overall incidence of BCRL was 12.8%, with a 29.6% incidence for those undergoing ALND and a 6.4% incidence for those undergoing sentinel lymph node biopsy. While the number of ALND performed decreased between cohorts (Figure 1), there was no significant difference in BCRL between assigned cohorts (HR 1.02 (95% CI [0.69, 1.51], p=0.930 for cohort 3 vs cohort 1). On multivariate analysis, significant associations with development of BCRL were identified with older age (HR 1.02;95% CI [1.01, 1.03], p=0.002), higher BMI (HR 1.05;95% CI [1.04, 1.07], p< 0.0001) and ALND (HR increased the risk of (HR 3.67;95% CI [2.62, 5.13], p< .0001). Regional lymph node radiation was not significantly associated with BCRL. CONCLUSION(S): Despite a reduction in the number of ALND performed over time, we did not see a dramatic reduction in the incidence of BCRL. Interestingly, between cohort 2 and cohort 3 there was a stable incidence of ALND which could be related to the COVID pandemic with an increase in more advanced cancers and a decrease in the ability to screen patients for BCRL during that time period.

Telemedicine Justification

Funding: None. Synopsis: Because of COVID-19, re-imbursement restrictions for medical services have been relaxed, both to continue provision of healthcare services and afford physicians a stream of revenue. While telemedicine may have relevance in medical and psychiatric practices, its benefits appear less tangible for vascular surgical patients. Those patients, most of whom have multiple co-morbidities, have a high acuity of illness and assessment absent physical examination has the potential for providing a lower standard of care. Many articles laud telemedicine without determining if telemedicine is non-inferior to customary hand-on care. To determine if telemedicine is equivalent, a retrospective review was performed to ascertain if telemedicine provides equivalent care Methods: A retrospective, single observer, the charts of 100 consecutive patients were reviewed to determine if their condition could have been adequately treated via telemedicine. Data were collected from patient records and each chart was reviewed to determine if physical patient contact was essential to the assessment and treatment strategy. Result(s): Of the 100 patient encounters, 78 patients were determined to require an in-depth interview and physical examination. 40 were new patients and 60 were established patients, seen either for post-surgical follow-up or manifestation of a new problem. There were 55 males and 45 females. Average age was 56.2 years with 59 patients older than 65. Diagnoses and clinical severity were recorded and the determination was made if a face-to-face encounter could have been conducted via telemedicine. Those conditions requiring direct contact included chronic kidney disease, differentiation between vascular and neurogenic symptoms, aneurysm, carotid stenosis, wound complications, and musculoskeletal disorders. (TABLE 1) Conditions that could have been safely managed with telemedicine included venous insufficiency, carotid ultrasound results, lymphedema, and pre-operative patients. Of the 100 patients, only 7 seven patients were candidates for telemedicine. (TABLE 2) Not included in this study were 57 additional patients who underwent ultrasounds/non-invasive studies and whose results were transmitted to the patients by a mid-level. Conclusion(s): A small minority of vascular patients are adequately treated via telemedicine. While Medicare payments for the telephone evaluation and management visits are equivalent to established office/outpatient visits, care must be taken to assure that equivalency exists between telemedicine and face-to-face encounters. Controlled outcome studies with larger populations should be performed to determine if telemedicine and in-person visits provide equal patient benefit. [Formula presented] [Formula presented] Institution: Memorial Healthcare System, Davie, FLCopyright © 2022

Effect of Telerehabilitation Versus In-Clinic Rehabilitation Delivery on Self-Efficacy in Breast Cancer-Related Lymphedema

Background: Individuals with breast cancer-related lymphedema (BCRL) require self-management strategies to reduce risk of infection, exacerbation, and/or progression of lymphedema. The coronavirus pandemic thrust the medical field into the world of telehealth;both patients and providers were forced to reduce in-person treatments and engage in this new platform of rehabilitation delivery. The role of telehealth in promotion of self-management for BCRL is unknown. Purpose(s): This study examines self-efficacy during cancer rehabilitation for in-clinic versus telehealth visits among individuals with BCRL during the pandemic quarantine April to November 2020. Method(s): Forty women who recently completed oncology rehabilitation for BCRL were asked to complete demographics and 2 Likert surveys, including the Exercise Self-Efficacy Scale (ESES) and the Self-Care Self-Efficacy Scale (SCSE), to compare the efficacy of telehealth versus in-person treatment modalities. Result(s): Thirty-two participants completed the survey and indicated that the percentage of telehealth visits was less than face-to-face visits. Despite this, the participants indicated numerous positive moderately strong correlations between self-care self-efficacy and exercise self-efficacy for both types of visits (P <.05). Limitation(s): Self-report surveys by a convenience sample, multifactorial characteristics of rehabilitation treatment across modes, and varying severity of lymphedema may limit study findings. Conclusion(s): Telehealth provided safe and effective care to participants and bolstered confidence in self-care and self-management of BCRL. Data support that telehealth visits can be considered an essential part of comprehensive cancer rehabilitation care. Future research is needed to establish and optimize practice guidelines in both health delivery systems.Copyright © 2023 Lippincott Williams and Wilkins. All rights reserved.

Side effects of COVID-19 vaccinations in patients treated for breast cancer.

Lymph node swelling is a side effect of the mRNA COVID-19 vaccines, a distressing side effect for women treated for breast cancer. The purpose of this study is to present side effects reported by a cohort of patients treated for breast cancer. A survey link was sent to 4945 women who received breast cancer treatment and were prospectively screened for breast cancer-related lymphedema. In total, 621 patients who received an mRNA vaccine and responded to the survey were included in analysis. We assessed the frequency and predictors of side effects. The most frequent side effects reported were injection site soreness, fatigue, generalized muscle soreness, headache, and chills, with median duration ≤ 48 h. Lymph node swelling occurred most often in the axilla ipsilateral to the vaccine. The median duration was 1 week or less after all doses. These data will inform patient education regarding future vaccine doses, including reassurances about which side effects to expect, particularly lymph node swelling which may impact mammograms after vaccination. Type and duration of side effects were similar to that reported by the general population in Phase 3 testing trials of the mRNA vaccines. Clinical Trial Registration NCT04872738 posted May 4, 2021.

Underused Physical Therapy Services in Primary Care Settings: An Overview

The combined effects of longer life, noncommunicable diseases, and injuries increase the need for rehabilitation services. Although physical therapists' unique skill set on movement-related dysfunction allows for broad contributions to health care, physical therapy (PT) remains underutilized. This article situates the problem within the broader primary care context, focusing on PT's ability to mitigate disability and dysfunction in complex syndromes including pelvic floor incontinence, vertigo, cancer, chronic neuromusculoskeletal pain, and long coronavirus disease (ie, lingering effects after acute coronavirus disease infection passes). The path from PT research to clinical implementation remains dependent on factors beyond research evidence. This overview underscores the need to address this evidence to practice gap.

Side Effects of the mRNA COVID-19 Vaccines in Women Treated for Breast Cancer

Background: The introduction of the novel COVID-19 vaccination raised concerns regarding side effects from patients who had undergone breast cancer treatment. Lymph node swelling after the mRNA vaccines (Moderna, Pfizer) is a distressing side effect for women treated for breast cancer as it may indicate cancer progression or recurrence. Patients at risk of breast cancer-related lymphedema (BCRL) are fearful that lymph node swelling from the vaccine could incite or worsen BCRL. Data investigating associated side effects in this population is essential for patient education and future self-advocacy. Purpose(s): The purpose of this study was to elicit side effects associated with the COVID vaccine in women treated for breast cancer. Method(s): 4,945 surveys were sent to women over the age of 18 who had received breast cancer treatment and had been prospectively screened for BCRL with perometry. 621 participants who received an mRNA vaccine and responded to the survey were included in analysis, 469 of whom completed booster dose surveys. Participants were asked about type and duration of side effects after each vaccine dose. Solicited side effects included injection site soreness, swelling, or redness;swelling, numbness, or heaviness of the arm;generalized muscle soreness (GMS);fatigue;headache;joint pain;chills;nausea;vomiting;fever;Bell's palsy;axillary or supraclavicular lymph node swelling;other;or none of the above. We computed frequencies and the median duration of side effects for each dose. To investigate predictors of side effects, we fit multivariable logistic regression models separately for each side effect, with random effects for participants to account for clustered responses. We considered significant predictors those with p < 0.05. Result(s): Of the 621 participants, the median follow-up time between breast surgery and date of first vaccine dose was 69 months. The distribution of the top 5 side effects is presented in Table 1. Of note, the majority of participants who reported lymph node swelling (9.8% dose 1, 12.9% dose 2, 11.3% dose 3) reported it in the axilla ipsilateral to the vaccine (54.1% D1, 61.3% D2, 71.7% D3). Lymph node swelling was also reported in the axilla contralateral to the vaccine (45.9% D1, 45% D2, 24.5% D3), supraclavicular region ipsilateral (29.5% D1, 26.3% D2, 32.1% D3) and contralateral (18% D1, 18.8% D2, 9.4% D3) to the vaccine. Older patients reported each side effect significantly less frequently. Those who had received neoadjuvant chemotherapy reported significantly more GMS and headache than those who did not. Those who had received regional lymph node radiation were less likely to report GMS, as were patients who had sentinel lymph node biopsies (vs. no lymph node surgery). The median duration of side effects for all three doses was 48 hours or less, with the plurality (41.0% D1, 38.7% D2, 44.1% D3) of participants reporting side effects lasting 24 hours or less. While all side effects apart from injection site soreness were significantly more common in the second than the first doses, the duration of side effects only increased for 28.1% of participants. Conclusion(s): Over 86% of women treated for breast cancer may experience at least one side effect after any dose of the COVID-19 vaccine. This data, collected specifically for patients with breast cancer, will help enhance guidelines for structured and universal education regarding additional doses of the vaccine in the future. This will allow patients to better understand COVID vaccine side effect profiles after breast cancer treatment and self-advocate prior to future doses. (Table Presented).

Plasma Cytokines/Chemokines as Predictive Biomarkers for Lymphedema in Breast Cancer Patients.

Breast cancer-related lymphedema (BCRL) occurs in ~ 40% of patients after axillary lymph node dissection (ALND), radiation therapy (RT), or chemotherapy. First-line palliative treatment utilizes compression garments and specialized massage. Reparative microsurgeries have emerged as a second-line treatment, yet both compression and surgical therapy are most effective at early stages of LE development. Identifying patients at the highest risk for BCRL would allow earlier, more effective treatment. Perometric arm volume measurements, near-infrared fluorescent lymphatic imaging (NIRF-LI) data, and blood were collected between 2016 and 2021 for 40 study subjects undergoing treatment for breast cancer. Plasma samples were evaluated using MILLIPLEX human cytokine/chemokine panels at pre-ALND and at 12 months post-RT. A Mann-Whitney t-test showed that G-CSF, GM-CSF, IFN-2α, IL-10, IL-12p40, IL-15, IL-17A, IL-1ß, IL-2, IL-3, IL-6, and MIP-1ß were significantly higher at pre-ALND in those presenting with BCRL at 12 months post-RT. MIP-1ß and IL-6 were significantly higher at pre-ALND in those who developed dermal backflow, but no BCRL, at 12 months post-RT. Plasma IL-15, IL-3, and MIP-1ß were elevated at 12 months after RT in those with clinical BCRL. These findings establish BCRL as a perpetual inflammatory disorder, and suggest the use of plasma cytokine/chemokine levels to predict those at highest risk.

Early Detection of Breast Cancer-Related Lymphedema in COVID-19 Pandemic.

Background: This study aimed at presenting a prospective surveillance model of care delivered at home for women qualified for surgery due to breast cancer under the epidemic-related restrictions. Methods and Results: Women (age ≥18 years, diagnosed with breast cancer, no clinical features of upper limbs lymphedema, and a volume difference between the limbs <5%, not using any prophylactic compression products) will be provided with comprehensive education in the field of self-measurements and lymphedema prevention. The outcome measures include limb volume (circumferential measurements with a tape at 4 cm intervals), simplified protocol of three measurement points combined with the symptoms monitoring (according to the physical section of Lymphedema Quality of Life Inventory [LyQLI]). We propose a new calculation method as the RACI (relative arm circumference increase) in accordance with previous research-RAVI (relative arm volume increase) and the new proposal-the RACD (relative arm circumference difference). According to cylinder formula it can be calculated that 5% increase in limb volume results in ∼2% change in RACI. Regular appointments will be planned at 3, 6, 9, and 12 months after the enrollment. Additional urgent appointments will be arranged after the home or phone "red flags" (an increase circumference by ≥2%, positive pitting test, and any new symptoms) detection. We hypothesize that performing only three measurements combined with the typical symptoms monitoring would be accurate for lymphedema diagnosis based on the RAVI of ≥5%. Moreover, RACI/RACD increments combined with positive symptoms would correlate with RAVI. Conclusions: The new proposal of protocol can be the optimal solution in COVID-19 pandemic.

The Impact of the COVID-19 Pandemic on People With Lymphedema in an Endemic Area for Lymphatic Filariasis in Brazil.

Objectives: To investigate the repercussions of the COVID-19 pandemic on lymphedema patients from an endemic area of lymphatic filariasis. Methods: The study descriptive compared sociodemographic and clinical aspects, risk of falling and quality of life, prior and during the COVID-19 pandemic in 28 lymphedema patients, older than 18 years old and under investigation of filarial infection. For the evaluation of functional mobility, the Time Up and Go test and The Medical Outcome Study Short Form-36 Health for quality of life, was used. Results: An increase in interdigital and dermal lesions, a higher frequency of acute dermatolymphangioadenitis crises and risk of falling, worsening of quality of life in the domains of physical functioning, general health, vitality, and mental health during the pandemic was observed. Conclusion: Our findings of clinical worsening and quality of life of patients during the COVID-19 pandemic indicate the need to reinforce the goal of the Lymphatic Filariasis Program regarding the follow-up of these patients in the actions of the Global Program for the Elimination of Lymphatic Filariasis, due to the discontinuity in the care during the pandemic.

Lower limb lymphedema and cellulitis as a complication of COVID-19 vaccine: A case report.

A 68-year-old man without complications following his first dose of Sinopharm (BBIBP-CorV) COVID-19 vaccine developed left foot and ankle edema, extending to his left leg 3 days after his second dose. Color-Doppler sonography and lymphoscintigraphy showed extensive soft tissue swelling and fat edema in both legs, proposing lymphatic drainage disorder.

Reality of care at a specialized lymphedema clinic in Bavaria-Experiences from the COVID-19 pandemic

The COVID-19 pandemic has created medical and physical therapy shortages for patients with lymphedema disorders. Both in-patient and out-patient treatment of these patients was nearly completely suspended in order to free up capacity for COVID-19 patients. For a considerable number of patients, this led to reduced quality of life and exacerbated symptoms, in some cases with dramatic courses. Performing recompensation therapy in these patients will be a huge challenge. The current increase in the number of COVID-19 cases threatens to cause new restrictions in treatment options for patients with lymphedema at our clinic. Copyright © 2020 Wirtschafts-und Praxisverlag GmbH. All rights reserved.

Measureable changes in patient quality of life or lymphedema after the first COVID-19 lockdown in Austria

The lockdown imposed in the context of the COVID-19 pandemic from mid-March 2020 to late May 2020 in Austria has led to significant cuts in the care of lymphedema patients. The investigation aimed to determine whether these reductions have any short-term effects on the objective and subjective course of the disease.. Copyright © 2020 Wirtschafts-und Praxisverlag GmbH. All rights reserved.

COVID-19: Impact and issues affecting lymphedema management

This article describes the influence of COVID-19 on the development of lymphedema. It summarizes the specific pandemic-related recommendations for patients with lymphedema published by the different medical associations. For example, key phlebological and lymphological societies have published a consensus paper in which they have agreed to a Venous and Lymphatic Triage and Acuity Scale (VELTAS), in which triage urgency for venous and lymphatic disorders is classified into four categories: 1) Medical Emergencies, requiring immediate attendance, 2) Urgent, to be seen as soon as possible, 3) Semi-urgent, to be attended to within 30 to 90 days, and 4) Discretionary/Non-urgent, to be seen within 6 to 12 months. Copyright © 2020 Wirtschafts-und Praxisverlag GmbH. All rights reserved.

Evaluation der Versorgungsituation von Patient*innen mit chronischen Lymphödemen während der COVID-19-Pandemie

Background The COVID-19 pandemic poses a major challenge for patients with chronic disease as well as their care. In particular, multiprofessional and multidisciplinary care of patients with lymphedema as well as prevention of complications and exacerbations appear significantly impaired. The aim of this study was to present the impact of the COVID-19 pandemic on the life satisfaction of lymphedema patients and to provide a patient perspective on healthcare provision. Methods 100 patients of a lymphedema outpatient clinic were interviewed about the use of health services, therapies and their personal situation during the pandemic. The SWLS (Satisfaction with Life Scale) was used to evaluate life satisfaction. Results The SWLS decreased from 24.5 +/- 6.7 SD pre-pandemic to 21.4 +/- 7.4 SD during the pandemic (p < 0.0001;r= -0.58). There was a trend toward fewer physician visits with increased incidence of complications. Lymphedema-typical non-physician health services showed significantly reduced access rates. Telemedical services were well accepted. Conclusion The subjective quality of life of patients with chronic lymphedema decreased significantly and with a strong effect. This underlines that this group is particularly vulnerable to problems concerning health care during a pandemic and therefore require additional care.

Surgical management of unilateral lower limb lymphedema in combination of debulking and physiologic procedures: A case report

Lymphedema has a high incidence and various causes including filariasis in developing countries and as complications following oncological surgery in developed countries. It reduces patients' quality of life, productivity and currently lacks a cure. Current management involves debulking or physiological methods, with debridement being the preferred debulking method and lymph node transfer, the preferred physiological option. Most reports on the management of lymphedema or its associated outcomes have reported the use of either of these modalities with favourable outcomes, albeit some complications. There is however paucity of documented cases where a patient underwent both debulking and physiological treatment in management of chronic lymphedema and our case study reports on the same, with favourable outcome and minimal complications. Our patient, a 30 year old female presented with an 8 year history of slowly progressive right lower limb oedema. Physical examination revealed marked right lower limb swelling that was non- pitting, non-tender, erythematous, with marked thickening of skin, yellowing of the nails and a positive stemmer sign. Lymphoscintigraphy revealed hypoplastic lymphatic channels and faulty valves. Debulking using modified Charles procedure and vascularised lymph node transfer were done within a one month interval. Ten months later, she is doing well with no relapse. © 2022 Author.

Totally Online Initiation of Comprehensive Decongestive Therapy (CDT) for Lymphedema

Background: Lymphedema is estimated to effect between 100 - 300 million people worldwide, India has a higher proportion due to tropical problems like Filariasis and Podoconiosis over and above general causes like cancer, venous disease trauma, old age, obesity etc. Not only do the patients get a disfiguring swelling but they also get repeated infections in the limb called Adeno-Dermato-Lymphangitis Attacks (ADLA). These are mostly gram positive in origin and best managed through Penicillin. CDT (Comprehensive Decongestive Therapy) is considered the worldwide gold standard for management of Lymphoedema. CDT is labor intensive requiring physical interaction with a trained therapist who are expensive as well as hard to find. This is yet to become commonplace in India. It consists of two parts, Initiation Phase done in the hospital, and Maintenance phase, at home. MLD orManual Lymphatic Drainage is a major component of Initiation phase, but lately its relevance has been discounted. We have been managing Lymphedema - largely without MLD at our clinic since 25 years, giving good outcomes. Training on self bandaging has been a major component of our processes. Recently due to COVID some patients from far, could not reach us for care initiation. So we decided to provide counselling and training totally online. A case report is presented. Method(s): We get lymphedema patients come from across India. After diagnosis, we initiate CDT on an ambulatory basis along with long term Penicillin, counselling, training and motivation to continue self care at home. The duration of initiation phase has of late reduced great from the initial 7-10 days, as patients and care givers are taught how to self bandage. Patients are encouraged to make videos for later recall. An Electronic Medical Record system which has a special module for Lymphedema is used for care documentation. Penicillin was prescribed and patient sent appropriate bandage sets. Online training provided not only of self tying of bandage but also how to take measurements. Result(s): A total of 10 Video-Conferencing (VC) sessions were held over 2 weeks with the first two devoted to patient examination and taking measurements. The volume difference from the normal side reduced from 53% to 39% initially, later she became lax and got an ADLA attack after another 2 weeks, Penicillin had not been taken. the same was started and another counselling session done. After another two months the limb was stable at 35% volume difference from original. Limb circuferenence over time Table showing results with calculated volumes marked out Conclusion(s): Totally online CDT provision saves hugely in costs of travel and stay away from home. The occurrence of ADLA showed that patients may not follow online instructions strictly.