Endermologie (with and without compression bandaging)--a new treatment option for secondary arm lymphedema.

Two treatment protocols are presented using the LPG Endermologie system in combination with compression bandaging as a new treatment option for secondary arm lymphedema. Both protocols were applied 4 days a week for 4 weeks but differed in Trial II in time spent clearing the regions of the trunk adjacent to the swollen limb and the addition of a larger treatment head so that a greater area could be covered more quickly. The first protocol involved 24 women and the second involved 10 women. At the end of the treatment period, both protocols demonstrated overall reductions in limb volume (134mls; 18.3% p = 0.000 and 185mls; 28%, p = 0.002), limb fluid (182mls; 28%, p = 0.000 and 216mls; 33%. p = 0.014), truncal fluid (342mls; p = 0.002 and 290mls; p = 0.066), improvements in fibrotic induration in some lymphatic territories, and significant improvements in subject reporting of heaviness, tightness, tissue hardness and limb size. Trial II demonstrated additional benefits in terms of reduction in whole arm volume at 24 hours, improved fluid and arm volume reductions, and a significant improvement in subject reported arm range of movement. The additional time spent clearing the regions adjacent to the swollen limb in the second protocol appears to produce an increase in limb volume and limb fluid loss compared to the original treatment protocol.

A systematic review of common conservative therapies for arm lymphoedema secondary to breast cancer treatment.

Secondary arm lymphoedema is a chronic and distressing condition which affects a significant number of women who undergo breast cancer treatment. A number of health professional and patient instigated conservative therapies have been developed to help with this condition, but their comparative benefits are not clearly known. This systematic review undertook a broad investigation of commonly instigated conservative therapies for secondary arm lymphoedema including; complex physical therapy, manual lymphatic drainage, pneumatic pumps, oral pharmaceuticals, low level laser therapy, compression bandaging and garments, limb exercises and limb elevation. It was found that the more intensive and health professional based therapies, such as complex physical therapy, manual lymphatic drainage, pneumatic pump and laser therapy generally yielded the greater volume reductions, whilst self instigated therapies such as compression garment wear, exercises and limb elevation yielded smaller reductions. All conservative therapies produced improvements in subjective arm symptoms and quality of life issues, where these were measured. Despite the identified benefits, there is still the need for large scale, high level clinical trials in this area.

The effect of gentle arm exercise and deep breathing on secondary arm lymphedema.

The aim of this study was to explore the benefits of gentle arm exercise combined with deep breathing for secondary arm lymphedema. 38 women participated in 10 minutes of standardized arm exercise and deep breathing and were measured every 10 minutes for 1 hour, then 24 hours and 1 week post regime. A smaller cohort of 24 women continued the 10 minute exercise regime morning and evening for 1 month, with measurements being repeated at the end of this time. Directly after performing the regime, there was a reduction in arm volume of 52 mls (5.8%), with the reduction being sustained at 30 minutes (50 mls, 5.3%). Even though participants were told not to further do the exercise, at 24 hours the volume reduction was 46 mls (4.3%) and at 1 week, 33 mls (3.5%). At the one month follow-up, the reduction was 101 mls (9.0%). All reductions were statistically significant. Reported arm heaviness and tightness also statistically significantly decreased directly after the regime with the reduction in tightness being sustained at 24 hours. The reduction in heaviness was sustained at 24 hours, 1 week, and even one month after the program. Perceived limb size was significantly reduced at 1 week and at the 1 month follow-up. There was also a significant improvement in the anterior thorax tonometry reading at the 1 month follow-up.

Mainstreaming palliative care for cancer patients in the acute hospital setting.

Palliative care is now emerging as an integrated part of mainstream health care delivery. The importance of patient choice regarding place of dying means that a substantial proportion of palliative care provision occurs in community settings. In part, this is due to the inappropriateness of the acute hospital setting for the care of dying patients. However, most patients with cancer and other terminal illnesses are diagnosed and treated in acute hospitals. Acute hospitals are also the most common setting where people actually die. Therefore, there remains a need for skilled and compassionate provision for the care of dying patients in the acute hospital setting. This paper presents a case for the provision of palliative care services in teaching hospitals. It further argues that a high level of integration between cancer treatment services and palliative care services is needed to optimize the care of cancer patients.

Provider perspectives on palliative care needs at a major teaching hospital.

Jericho Metropolitan Hospital (JMH) is a major Australian teaching hospital which lacked a designated palliative care service at the time this study was conducted. A questionnaire addressing palliative care service needs, and educational and support needs of staff, was sent to 267 multi-disciplinary oncology staff at JMH. A response rate of 83% was achieved. Staff identified a number of palliative care needs that were being particularly poorly addressed by existing services. These included: spiritual support, cultural needs, grief and bereavement support, pleasant surroundings, adequate privacy and facilities for families. The majority of respondents identified the following issues as critical problems in palliative care provision: lack of a designated palliative care service, lack of palliative care education of staff, unmanageable caseloads and inadequate physical facilities for the provision of care. Only 24% of respondents reported having had any palliative care education, and 92% of respondents expressed a need for further education. The majority of respondents (79%) expressed a need for improved staff support. There was a significant association between perceived need for improved support and professional discipline (chi2 = 31.33, P < 0.002), with medical staff being significantly less likely than other staff groups to report a need for improved support. Overall, the health providers surveyed identified major deficiencies in the provision of palliative care to cancer patients at JMH and in the palliative care education and support for staff caring for terminally ill cancer patients. The findings support the need for a designated palliative care service at JMH to improve the standard of care of dying cancer patients, and the need for improved palliative care education and support for staff.

Treatment of chronic postmastectomy lymphedema with low level laser therapy: a 2.5 year follow-up.

Ten women with unilateral arm lymphedema after axillary clearance (radical mastectomy) and radiotherapy for breast cancer received 16 treatment sessions with Low Level Laser Therapy (LLLT) over 10 weeks and seven patients were followed for 36 months. The effect of LLLT was monitored by arm circumference, plethysmography, tonometry, bioimpedance and a questionnaire dealing with subjective symptoms. After treatment, edema volume (both extracellular and intracellular) was decreased, the tissue (except for the upper arm) progressively softened or approached a normal texture, and the patients reported improvement in aches/pains, tightness, heaviness, cramps, pins/needles, and mobility of the arm. Skin integrity was also improved and the index for risk of infection decreased. Follow-up assessment at 1, 3, 6, and 30-36 months showed varying trends although at 30-36 months most subjective parameters and bioimpedance derived data on ECF and ICF tended to return toward pre-treatment levels. Arm circumference continued to show overall improvement, however, with a volume reduction of the affected arm reaching 29%. Tonometry also showed maintenance of near normal values for the involved forearm and anterior and posterior chest; however, the upper arm showed progressive induration. The data suggest that laser treatment, at least initially, improved most objective and subjective parameters of arm lymphedema.

Extension of the generalized multipole technique to three-dimensional anisotropic scatterers.

New expansions are derived for the simulation of three-dimensional anisotropic scatterers with the generalized multipole technique (GMT). This extension of the GMT makes possible the investigation of subtle phenomena such as the interaction of light with realistic crystals or magneto-optic materials.

Influence of the edge meshes on the accuracy of the coupled-dipole approximation.

We demonstrate that an appropriate discretization scheme can render the convergence of the coupled-dipole approximation (also known as the discrete-dipole approximation) much more regular and improve its accuracy by as much as a factor of 24. This discretization scheme is simple, can be applied to arbitrarily shaped scatterers, and does not require additional computation time.

The effects of radiation on the contractile activity of guinea pig mesenteric lymphatics.

In order to assess the effects of irradiation on lymphatic function, the contraction frequency and maximum and minimum diameters of guinea pig mesenteric collecting lymphatic vessels were measured in vivo 4 hours after 1000 rads of abdominal irradiation. The mean contraction frequency for lymphatics from irradiated guinea pigs (7.6 +/- 0.7) was significantly higher than for normals (non-irradiated) (4.7 +/- 0.7) during an initial control observation period, but there was no difference in maximum or minimum diameter between the two groups during this period. Topical application of 10(-4) M noradrenaline (NA) significantly increased contraction frequency in both groups; lymph vessel diameter significantly decreased after NA in irradiated, but not in normal guinea pigs. Intravenous infusion of calcium dobesilate (200 mg/kg) caused a significant increase in the contraction frequency of lymphatic vessels in both normal (to 9.4 +/- 1.5) and irradiated (to 9.8 +/- 1.2) animals, but diameter was not significantly altered. Thus, lymphatic vessels from irradiated guinea pigs were still responsive to exogenous stimuli 4 hours post-irradiation and were initially pumping more actively than those from normal guinea pigs, presumably in response to radiation-induced edema. They also exhibited a supersensitivity to the vasoconstrictive effects of NA, perhaps due to an alteration of the pacemaker or smooth muscle cells by irradiation.

Treatment of lymphedema of the arms and legs with 5,6-benzo-[alpha]-pyrone.

BACKGROUND: Benzopyrones can reduce the volume of high-protein edema fluid by stimulating proteolysis. These compounds provide a method for removing excess protein and its consequent edema and reduce its clinical sequelae, such as chronic inflammation and secondary infections. METHODS: We conducted a randomized, double-blind, placebo-controlled, crossover trial of 5,6-benzo-[alpha]-pyrone in 31 patients with postmastectomy lymphedema of the arm and 21 patients with lymphedema of the leg of various causes (this agent, also known as 56 BaP, 1,2-benzopyrone, or coumarin, is not an anticoagulant). The patients received 400 mg of the active drug or placebo, each for six months. RESULTS: During the placebo period, lymphedema often worsened, especially in the arms. Measurements of limb volume showed that the active drug reduced the mean amount of edema fluid in the arms from 46 percent above normal to 26 percent above normal (P < 0.001) and the amount in the legs from 25 percent to 17 percent above normal (P < 0.001). The circumference of the arms was reduced from 17 percent to 13 percent above normal, and the circumference of the legs from 11 percent to 7 percent above normal (P < 0.001). The softness of the limb tissue was increased (P < 0.001), and elevated skin temperatures were reduced (P < 0.001). There were fewer attacks of secondary acute inflammation (P = 0.01). Bursting pains and feelings of hardness were decreased, as were feelings of tightness, tension, swelling, and heaviness; limb mobility also improved. The active drug was preferred to the placebo by 93 percent of the patients (P < 0.001). Side effects--mild nausea or diarrhea--occurred in seven patients taking the active drug. None withdrew from the trial, and the side effects disappeared after the first month of therapy. CONCLUSIONS: 5,6-Benzo-[alpha]-pyrone results in slow but safe reduction of lymphedema of the extremities.

Lymphoedema post-mastectomy: is elevation alone an effective treatment?

In an attempt to obtain information about the efficacy of arm elevation on the reduction of lymphoedema following mastectomy, a study on 33 patients was carried out in which both the control, contralateral and lymphoedematous arms were elevated for periods of 1 and 5 h. There were statistically significant (p < 0.05) reductions in the volumes of the control and lymphoedematous arms after 1 and 5 h of elevation. After 1 h of elevation, significantly more fluid was removed from the control arm (2.7%) than the lymphoedematous one (1.3%). At 5 h there was no significant difference in the volume of fluid removed from the control arm (3.3%) compared with the lymphoedematous one (3.1%).

Assessment of the anti-inflammatory action of calcium dobesilate. Effect on macrophages attaching to subcutaneously implanted coverslips in guinea pigs.

Calcium dobesilate (Doxium) has been shown to significantly reduce the attachment of activated and quiescent macrophages to subcutaneously implanted coverslips in guinea pigs. Since the implanted coverslips represent an inflammatory stimulus and macrophages have a dominant role in inflammation it suggests that calcium dobesilate may have a pronounced anti-inflammatory action. It is speculated that calcium dobesilate may do this by reducing the number of circulating monocytes, by blocking the action of macrophage activating factors or more likely by stimulating a more rapid production of host macrophage deactivating factors such as Transforming Growth Factor (TGF) beta 1 and 2.

Macrophage and tissue changes in the developmental phases of secondary lymphoedema and during conservative therapy with benzopyrone.

The normal role that the macrophage plays in tissue homeostasis is presented along with the morphological and functional changes that occur to the macrophage population as the lymphoedema progresses from the latent to the chronic phase and then with the treatment with a representative benzopyrone called coumarin. Underlying the lymphoedema, there is a chronic inflammation. It is this, in association with the accumulating protein and the subsequent alterations it produces in the tissues that attract monocytes and macrophages to the affected area. Despite the fact that macrophages are facultative anaerobes, and that larger numbers than normal accumulate, the tissue conditions result in a depression in their activity levels. Apart from these tissue conditions there is the possible production of deactivating proteins such as transforming growth factor beta 1 and 2. Evidence for this deactivation comes from enzymatic studies in which levels of typical macrophage enzymes are reduced and from morphological work which has shown a reduction in pseudopods and a tendency to accumulate large amounts of lipid in their vacuoles. As a consequence of this deactivation further protein accumulation occurs thereby osmotically attracting fluid. Also there is a tendency for the tissues to become fibrotic as the balance between collagen lysis and deposition shifts towards the latter since it has been shown that macrophages have an important role in collagen lysis. The administration of coumarin stimulates the macrophages resulting to their return to normal or supranormal activity levels within the lymphoedematous tissues. As well as this there is an increase in macrophage numbers. The reasons for stimulation are uncertain, however, alterations in the fine structure of the proteins and complement which make these more attractive for phagocytosis seem the most likely. The end result is an rapid enhanced breakup of the excess interstitial protein and the removal of the osmotically attracted fluid together with a more gradual removal of the deposits of fibrotic tissue by the non-stimulated macrophage. Clinically this manifests itself as a softening of the tissues, a reduction in circumference of the lymphoedematous extremity, a return to normal tissue remodelling processes and a range of subjective improvements for the patient.

The lymphogogue action of calcium dobesilate on the flow of lymph from the thoracic duct of anesthetized and mobile guinea pigs.

Calcium dobesilate increases thoracic duct lymph flow in both anesthetized and mobile guinea pigs. The marked lymphogogue action of this drug may explain in part the improvement in tissue survival with ischemic insult.

A double-blind, cross-over trial of O-(beta-hydroxyethyl)-rutosides (benzo-pyrones) in the treatment of lymphoedema of the arms and legs.

A randomised, double-blind, cross-over trial was performed on 26 patients with postmastectomy lymphoedema of the arm, and 14 with lymphoedema of the leg. For 6 months, patients took 0-(beta-hydroxyethyl)-rutosides (oxerutin; "Paroven", "Venoruton", Zyma) in doses of 3 g/day, or the placebos; then they took the reverse. Measurements (volume, circumferences, tonometry and skin temperature) were made monthly. The active drug reduced the volumes of the limbs (p less than 0.05 to 0.01) and their circumferences (p less than 0.05 to 0.001). It increased the softness of the limbs, as shown by the increases in the tonometry values (p less than 0.01 to 0.001). There was a lowering of the elevated skin temperatures (p less than 0.05 to 0.001). Patients reported increased comfort and freedom of movement, a lessening of their bursting pains, heaviness and tension (p less than 0.05 to 0.01), and an increased mobility of their limbs (p less than 0.0001). Most patients (70%) preferred the active drug (p less than 0.0001). An increase in general well-being was reported by 97% of patients when taking the active drug compared with 4% for placebo (p less than 0.0001).

The effect of coumarin (5,6 benzo-alpha-pyrone) on elicited members of the mononuclear system in dogs with chronic secondary lymphedema.

The effect of coumarin is investigated on the morphological features of members of the mononuclear phagocytic system (MPS) attaching to subcutaneously (s.c.) implanted coverslips in "normal" and chronically lymphedematous tissues. In untreated "normal" tissues there was no attachment suggesting that the presence of lymphedema elsewhere influences MPS activity. Coumarin restored attachment proportions to those found in normal tissues of dogs with no lymphedema. In lymphedema, coumarin significantly increased the proportion of macrophages which were round with less than ten pseudopods (new recruits) and the proportion with distinct pseudopods combined with more than ten vacuoles (active elicited members of the MPS). Coumarin resulted in a significant decline in the proportion of macrophages which were round and with more than ten apparently lipid-containing vacuoles, suggesting a facilitation of their removal to other sites.

The problems of lymphatic microsurgery for lymphedema.

The problems of microsurgery for lymphedema consist of the discrepancy between the excellent technical possibilities, especially of microsurgical lympho-venous shunts and the subsequently insufficient reduction of the lymphedematous tissue fibrosis and sclerosis. Generally, the lymphatic surgeon considers the lymphatic system to be a canalicular system of drainage tubes, of lymph collectors. Bypassing a lymph block through peripheral lympho-venous shunts should therefore solve the problem of lymphstasis, present in each type of lymphedema. In chronic lymphedema however, not only the canalicular lymphatic system, but also the tissues, and integral part of the lymphatic system, are affected. In chronic lymphedema, canalicular repair, for reasons of quantitative lymph drainage, exceptionally only provides a "restitutio ad integrum" of the tissues, altered by lymph stasis.

The influence of a non-specific stimulator of host resistance on the number and morphological characteristics of macrophages attaching to subcutaneously implanted coverslips in the rat.

The influence of a preparation (Esberitox) which is claimed to be a non-specific stimulator of host resistance was examined in macrophages attaching to s.c. implanted coverslips in rats. Not only did this preparation significantly increase macrophage numbers but it also very significantly increased the proportion which were stimulated.

Lymphoedema, macrophages and benzopyrones.

The role of macrophages in lymphoedema is discussed, with particular reference to post mastectomy lymphoedema. In the latter, the normal course of events is detailed using clinical and experimental evidence. Particular importance is placed on the events of the latent phase since it is during this time that important changes are occurring in the functioning of the blood-tissue-lymph system. These changes are not usually demonstrable clinically until the end of the latent phase when lymphoedema becomes manifest. Evidence suggests that the majority of these changes can be linked with changes in the functioning of the members of the mononuclear phagocytic system. Of particular importance is the disruption to the normal tissue remodelling processes as we know in lymphoedema the delicate balance between the deposition and lysis of collagenous fibres is shifted in favour of deposition--thus fibrosis occurs. The basic mechanisms behind such changes are discussed. A group of drugs, called the benzopyrones have been shown both clinically and experimentally to be of benefit in reducing most forms of high protein oedemas including lymphoedema. It is shown that they can do this by stimulating the rather depressed functioning of the members of the mononuclear phagotic system. The exact mechanism of action of these drugs is discussed with particular emphasis on coumarin which is one of the components of Venalot.

Tissue changes in chronic experimental lymphoedema in dogs.

Chronic lymphoedema was experimentally induced in the legs of dogs and studied with the electron microscope, including by quantitation. It was found that some cells (macrophages, fibroblasts and, to a lesser extent, lymphocytes) increased greatly in numbers and relative volumes. Collagen (and fat cells) also greatly increased in relative volume. The lengths of blood vessels and initial lymphatics were much greater in the injured tissue. The numbers of small vesicles and vacuoles rose greatly in both types of vessels. Both also had many open endothelial junctions--although no doubt from different causes. It is probably caused by excessive accumulations of proteins, so chronic lymphoedema is probably a form of chronic inflammation.