Lymphoedema – a challanging situation

I have seen three lymphoedema patients today consecutively (and rather randomly booked) in clinic. It is a pretty challanging case that so far has no proper cure for. 
 My advice consists currently of the following components (ref. uptodate May 2015) – 
 1- The term complete decongestive therapy (CDT, also called complex decongestive therapy, complex decongestive physiotherapy, or decongestive lymphatic therapy) refers to an empirically derived, multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures [14,21,28]. 
 2- CDT generally consists of a two-phase treatment program that can be used in both adults and children [14,21,28]. Success is dependent in part upon the availability of physicians, nurses, and physical therapists that are trained in these techniques. 
 ●The first phase (treatment phase) includes meticulous skin and nail care to prevent infection, therapeutic exercise, a massage-like technique called manual lymph drainage (MLD), and limb compression using repetitively applied, multilayered padding materials and short-stretch bandages. The patients receive daily therapy five days per week, with circumference and volume measurements weekly to see if improvement is continuing or the patient has plateaued [21]. The usual duration of the first stage is two to four weeks. 
 ●The second phase (maintenance phase) is intended to conserve and optimize the benefit attained in the first phase. It consists of compression garments worn during waking hours and, if necessary, self-compression bandaging at night, skin care, continued exercises, and, as necessary, self-MLD. Limb circumference and volume measurements should be monitored every six months or sooner if necessary [21]. 
3- Efficacy of CDT has been suggested in observational studies, which demonstrated a reduction in limb volume with improved pain, cosmesis, and/or function [35-39]. In these studies, the reduction in limb volume ranged from 33 to 68 percent. However, patient compliance is required for long-term success. In one study, at least 90 percent of the lymphedema reduction was maintained in compliant patients at an average follow-up of nine months, while noncompliant patients lost approximately one-third of the initial benefit [35]. The benefit of CDT was shown in a small phase III trial in which 53 patients with lymphedema after breast cancer treatment were randomly assigned to CDT (lymph drainage, multilayer compression bandaging, elevation, remedial exercise, and skin care) versus standard physiotherapy (bandages, elevation, head-neck and shoulder exercises, and skin care) [40]. The group receiving CDT had a significantly greater improvement in edema as measured by circumferential and volumetric measurements.

smoking .. best ever study

Taken from BMJ – how to read a paper.

The world’s most famous cohort study, which won its two original authors a knighthood, was undertaken by Sir Austin Bradford Hill, Sir Richard Doll, and, latterly, Richard Peto. They followed up 40 000 British doctors divided into four cohorts (non-smokers, and light, moderate, and heavy smokers) using both all cause mortality (any death) and cause specific mortality (death from a particular disease) as outcome measures. Publication of their 10 year interim results in 1964, which showed a substantial excess in both lung cancer mortality and all cause mortality in smokers, with a “dose-response” relation (the more you smoke, the worse your chances of getting lung cancer), went a long way to showing that the link between smoking and ill health was causal rather than coincidental.31 The 20 year and 40 year results of this momentous study (which achieved an impressive 94% follow up of those recruited in 1951 and not known to have died) illustrate both the perils of smoking and the strength of evidence that can be obtained from a properly conducted cohort study.32 33