Novel combined surgical treatment for chronic upper extremity lymphedema patients : simultaneous lymph node transfer and liposuction

BACKGROUND: Upper limb lymphedema is a common problem after axillary lymph node dissection. Lymphatic drainage can be improved by microvascular lymph node transfer, whereas liposuction can be used to reduce arm volume and excess of adipose tissue. We present the results of chronic lymphedema patients who have undergone lymph node transfer and liposuction simultaneously in one operation and compare the results to patients who have undergone lymph node transfer without liposuction. METHODS: During May 2007 to February 2015, 20 postmastectomy patients and one Hodgkin’s lymphoma patient presenting with chronic non-pitting lymphedema (age between 37-74 years, average 56.7 years) were operated using the combined technique and 27 postmastectomy patients presenting with early stage lymphedema (age between 31 to 68 years, average age 50.2 years) were operated using only the lymph node transfer. Changes in clinical parameters, arm volume, lymphoscintigraphy and compression garment usage were compared. The study was retrospective observational study. RESULTS: In the combined technique group the average arm volume excess decreased postoperatively 87.7% and in 7/10 patients the edema volume did not increase even without compression. 17/21 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 12/15 patients and the improvement was significantly greater than in the lymph node transfer group. The number of erysipelas infections was decreased in 7/10 patients and the decrease was significantly greater than in the lymph node transfer group. In the lymph node transfer group the average excess volume decreased postoperatively 27.5%. 14/27 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 8/19 patients, the number of erysipelas infections was decreased in 1/3 patients. CONCLUSIONS: Liposuction can safely be performed with lymph node transfer in one operation to achieve optimal results in patients with chronic lymphedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation. The significantly greater reduction in lymphoscintigraphy values and erysipelas infections suggests that the combined technique might be better for late stage lymphedema patients than lymph node transfer alone

Opettajien kokemuksia opetustiloista ja työskentelystä uudessa oppimisympäristössä

Oppimisympäristöjä koskeva keskustelu käy tällä hetkellä vilkkaana ja suomalaiset koulurakennukset ovat vähitellen kokemassa kauan kaivatun uudistuksen. Uudistukset ja muutokset uusiin oppimisympäristöihin herättävät käyttäjissä kuitenkin ajatuksia, joita hyödynnetään tällä hetkellä vielä liian vähän suunnittelu– ja kehitystyössä. Tämän tutkimuksen tarkoituksena oli kartoittaa, millaisia asioita opettajat olivat kokeneet uuteen oppimisympäristöön muuton myötä ja lisätä ymmärrystä siitä, millaisia asioita tulisi ottaa huomioon tulevissa muutoksissa. Oppimisympäristö on käsitteenä haastava määritellä, sillä sille ei ole yksinkertaista ja yhtä määritelmää. Tässä tutkimuksessa käsitteellä viitattiin kuitenkin fyysisiin tiloihin ja paikkoihin, joissa tapahtuu opiskelua ja oppimista. Tarkemmin tutkimuksen tavoitteena oli selvittää, millaisia kokemuksia opettajilla oli uuden oppimisympäristön käytöstä sekä oliko uudessa oppimisympäristössä työskentelystä aiheutunut mitään muutoksia opettajien työhön. Lisäksi haluttiin selvittää millaisia asioita opettajat itse arvostavat opetustiloissa, eli mil-laisen tilan he itse suunnittelisivat, jos heillä olisi siihen mahdollisuus. Työssä tutkittiin erästä uutta länsisuomalaista koulua, joka toteuttaa opetusta niin tilallisesti kuin opetuksellisesti poiketen monesta muusta perinteisestä koulusta. Tutkimusaineisto kerättiin keväällä 2019 kyselylomakkeella sekä haastattelulla. Tutkimukseen osallistui 10 opettajaa, joista neljä ilmoittautui lisäksi haastatteluun. Tutkimuksen tulosten mukaan opettajat olivat kokonaisuudessaan melko tyytyväisiä oppimisympäristön eri osa-alueisiin, kuten opetustiloihin. Kolme arvostetuinta piirrettä hyvässä ja toimivassa oppimisympäristössä olivat muunneltavuus, riittävä tilan tuntu sekä teknologia. Näiden lisäksi haluttiin selvittää, mikäli opettajat kokivat muutoksia päivittäisessä työssään. Suurin osa opettajista koki, että jokapäiväinen työ sekä suunnittelu olivat ainakin jollain tapaa muuttuneet uusien tilojen myötä. Työhön liittyvät muutokset olivat aiheutuneet jonkin opetusmenetelmän tai työtavan muutoksesta sekä yhteistyön lisääntymisestä työyhteisössä. Lisäksi osa opettajista koki, että pelkkiin tilojen käyttöön liittyi itsessään nykyään suunnittelua. Muutosten lisäksi haastatteluissa korostui, miten raskaana osa opettajista oli kokenut ensimmäisen vuoden. Lisäksi haastatteluissa nousi ajatus siitä, miten uusi oppimisympäristö haastoi opettajia olemaan omalla epämukavuusalueellaan ja kehittymään ammatillisesti

Short duration of upper extremity lymphedema correlates with a favorable cytokine response after lymph node transfer surgery

Vascularized lymph node transfer surgery (VLNT) can provide benefit to lymphedema patients. Cytokines mayplaya role in the development oflymphedema and in the regeneration oflymphatic vessels after VLNT. Ourprimary aim was to investigate whether the VLNTpatients have a specific cytokine profile. Our secondary aim was to see whether the preoperative lymphedema or severity affects the postoperative cytokine response. Wound exudate was gathered from 18 patients undergoing VLNT on the first and sixth postoperative day (POD). The concentrations of IL-10, TNF-alpha, TGF-beta 1 and VEGF-C were analyzed using enzyme-inked immune-sorbent assays. A general score was generated to assess the benefit ofthe surgery. The changes in cytokine concentrations (1(st) POD-6th POD) were correlated with the pre- andpostoperative lymphedema related factors. A shorter duration oflymphedema preoperatively correlated with an increase in the concentration of IL-10 and TNF-beta during the first six PODs (IL-10: r=0.495, p=0.051; TNF-alpha: p=0.006) and a decrease in the concentration of 7VF-111 (r= p=0.020). The increase ofthe concentration of TNF-alpha during the first six PODs also correlated with a greater total general score (r=0.775, p=0.005) and hence indicated a better response to the surgery. The patients with a shorter duration oflymphedema preoperatively had a more favorable cytokine response during the first six PODs after VLNT

Combined Surgical Treatment for Chronic Upper Extremity Lymphedema Patients Simultaneous Lymph Node Transfer and Liposuction

Background Upper limb lymphedema is a common problem after axillary lymph node dissection. Lymphatic drainage can be improved by microvascular lymph node transfer, whereas liposuction can be used to reduce arm volume and excess of adipose tissue. We present the results of chronic lymphedema patients who have undergone lymph node transfer and liposuction simultaneously in 1 operation and compare the results with patients who have undergone lymph node transfer without liposuction. Methods During May 2007 to February 2015, 20 postmastectomy patients and 1 Hodgkin's lymphoma patient presenting with chronic nonpitting lymphedema (age between 37 and 74 years, average 56.7 years) were operated using the combined technique and 27 postmastectomy patients presenting with early-stage lymphedema (age between 31 and 68 years, average age 50.2 years) were operated using only the lymph node transfer. Compression therapy was started immediately after the operation and the patients used compression 24 h/d at least 6 months postoperatively. Changes in clinical parameters (number of erysipelas infections, pain), arm volume, transport indexes calculated form lymphoscintigraphy images, and daily usage of compression garments were compared preoperatively and postoperatively and between groups (combined technique vs lymph node transfer). The study was a retrospective observational study. Results In the combined technique group, the average arm volume excess decreased postoperatively 87.7%, and in 7 of 10 patients, the edema volume did not increase even without compression. Seventeen of 21 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 12 of 15 patients and the improvement was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.01). The number of erysipelas infections was decreased in 7 of 10 patients and the decrease was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.02). In the lymph node transfer group, the average excess volume decreased postoperatively 27.5%. Fourteen of 27 patients were able to reduce the use of compression garments. Lymphoscintigraphy results were improved in 8 of 19 patients, and the number of erysipelas infections was decreased in 1 of 3 patients. Conclusions Liposuction can safely be performed with lymph node transfer in 1 operation to achieve optimal results in patients with chronic lymphedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation. The significantly greater reduction in lymphoscintigraphy values and erysipelas infections suggests that the combined technique might be better for late-stage lymphedema patients than lymph node transfer alone

Low TGF-β1 in Wound Exudate Predicts Surgical Site Infection After Axillary Lymph Node Dissection

PurposeSurgical site infection (SSI) after axillary lymph node dissection (ALND) for breast cancer increases morbidity and delays the onset of adjuvant treatment. Only a few studies have investigated the feasibility of wound exudate analysis in SSI prediction. This study assessed changes in cytokine levels in postsurgical wound exudate after ALND and examined their predictive value for the early diagnosis of SSI.MethodsAn observational prospective pilot study was conducted in 47 patients with breast cancer undergoing ALND. Wound exudate samples were collected on the first and sixth postoperative days (POD). Interleukin (IL)-1α, IL-1β, IL-4, IL-10, IL-13, tumor necrosis factor alpha (TNF-α), transforming growth factor beta1 (TGF-β1) and vascular endothelial growth factor (VEGF) C and D levels were measured by immunoassay. Patients were followed to detect SSI.ResultsSSI was diagnosed in 8/47 (17.0%) patients. Four SSI patients were hospitalized and treated with intravenous antibiotics. The concentration of TGF-β1 in wound exudate was significantly lower on POD#1 in the SSI group compared to the no SSI group (p=0.008). The receiving operator characteristics (ROC) curve for TGF-β1 showed an area under curve of 0.773 (p=0.0149) indicating good diagnostic potential. On POD#6, the concentration of TGF-β1 remained significantly lower (p=0.043) and the concentrations of IL-10 (p=0.000) and IL-1β (0.004) significantly higher in the SSI group compared to the no SSI group.ConclusionTo our knowledge, this is the first study suggesting a predictive role of wound exudate TGF-β1 levels for SSI. Our results suggest that the risk for SSI can be detected already on POD#1 and that the assessment of TGF-β1 levels in the wound exudate after ALND can provide a usefull method for the early detection of SSI. The key findings of this pilot study warrant verification in a larger patient population.</p

Phase 1 Lymfactin® Study: 24-month Efficacy and Safety Results of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema

BACKGROUNDLymphedema is a common problem after breast cancer treatment. Lymfactin® is a prolymphangiogenic growth factor vector inducing the expression of human vascular endothelial growth factor C (VEGF-C). It promotes growth and repair of lymphatic vessels.METHODSLymfactin® was combined with microvascular lymph node transfer surgery (VLNT) to study the safety and efficacy of the treatment in breast cancer-related upper limb lymphedema (BCRL) patients. This is a continuation study with a 3 year efficacy and 5 year safety follow-up.RESULTSFifteen patients were recruited in the study between June 2016 and February 2018. Three patients received a lower dose (1 × 1010 viral particles (vp)), and 12 patients received a higher dose (1 × 1011 vp) of Lymfactin®, respectively. In the higher dose group, the reduction of excess arm volume was on average 46% after the 12 month follow-up, and the transport index was improved in 7/12 patients. At baseline, removal of the compression garment for 7 days resulted in significant arm swelling (105.7±161.0 ml, p=0.0253). However, at 12 months, there was less and not significant swelling after removal of the garment (84.4±143.0 ml, p=0.0682). Lymphedema Quality of Life Inventory (LQOLI or LyQLI) questionnaire showed significant and sustained improvement of quality of life.CONCLUSIONSDuring 24 months' of follow-up, the results indicate that Lymfactin® is well tolerated. The most promising findings were a 46% reduction in excess arm volume and a nonsignificant volume increase after garment removal at 12 months, suggesting that there is potential for the reduction of lymphedema.</p

Varaston simulointiohjelman työohjeen luominen opetuskäyttöön

Tämän opinnäytetyön tarkoituksena oli luoda C-WIS varaston suunnittelu- ja simulointiohjelmistolle selkeät ja helppokulkuiset työohjeet opetuskäyttöön alkuperäisten työohjeiden ollessa sen verran puutteelliset ja vaikeaselkoiset. Päätavoitteena työssä oli pienentää Sisälogistiikan suunnittelu –opintojaksolle opettajan työmäärää sekä ennen kaikkea parantaa opiskelijoiden oppimistuloksia parannetuilla työohjeilla. Teoriaosuuden tavoitteena oli toimia alustuksena työn empiiriselle osuudelle. Teoriaosuus koostui yleisimmistä varastointiin liittyvistä asioista, varastoinnin suunnitteluun ja optimointiin liittyvistä asioista, simuloinnin tärkeydestä varaston suunnittelussa sekä yleisestä tiedosta C-WIS varaston suunnittelu- ja simulointiohjelmistosta. Teoriaosuus kerättiin luotettavia kirjallisuus- ja internetlähteitä käyttäen. Tieto työohjetta varten kerättiin kvalitatiivisella haastattelumenetelmällä sekä omalla empiirisellä tutkimisella. Työohjetta varten haastateltiin noin viittäkymmentä C-WIS käyttäjää. Haastatteluissa saatiin tarvittavat tiedot alkuperäisen työohjeen parannustarpeista, joita hyödyntäen laadittiin täysin uusi työohje C-WIS varaston suunnittelu- ja simulointiohjelmistolle. Raportin loppuun sisällytettiin valmiit työohjeet liitteeksi, joka on tämän työn tulos.The purpose of this thesis was to create clear and easy instructions for C-WIS program of warehouse optimizing and simulating because the original instructions were incomplete and challenging to use. Main target of this thesis was to decrease the teachers amount of work for “Sisälogistiikan suunnittelu” –course. With these enhanced instructions we especially tried to improve the learning results of students. The goal of the theoretical part was to act as platform for the empirical part. The theoretical part consisted of the most general matters of warehousing, planning and optimizing of warehousing, the importance of simulation for warehouse planning and essentials about C-WIS program. Only reliable literature and internet sources were used. The data for this instruction gathered using a method of qualitative interview and own empirical experience. Around 50 users of C-WIS were interviewed for making of this instruction. The data for improve the original instruction was gained with the interviews. Utilizing this data the new instruction for C-WIS program was created. Completed instructions which are the results of this thesis were included as an appendix

The importance of personal branding for ice hockey players

The personal branding of athletes has become a very relevant and important topic because a strong personal brand can be the key to a successful career even after the actual career in sport has ended. Personal branding is an ongoing effort to show the world your best authentic self. It is your reputation, and the way people will remember you. The purpose of this study was to identify the importance of personal branding for ice hockey players. The study focuses on the key factors in an ice hockey player’s and athlete’s personal brand and brand building such as sponsorships and social media. In addition to literature review, this study utilizes qualitative research methodology. The qualitative research data consisted of four semi-structured interviews in which four different people are interviewed, each with the necessary information and experience on the topic under study

Long-term Results of Microvascular Lymph Node Transfer : Correlation of Preoperative Factors and Operation Outcome

Background: Our objective was to analyze whether a correlation could be observed between preoperative factors and microvascular lymph node transfer outcome after long-term follow-up. Methods: We included 67 patients in this retrospective case series. The incidence of cellulitis, the difference of arm circumference, the use of the compression garments both preoperatively and postoperatively, and subjective symptoms, such as pain, were analyzed. Volumetry and lymphoscintigraphy results were also analyzed in a subgroup of patients. We correlated preoperative factors with postoperative results. Results: After 70 +/- 17 months of follow-up, 42% of the patients were able to discontinue the use of compression garments. The subjective pain symptoms were reduced in 75% of the patients. The incidence of cellulitis was reduced from preoperative 0.20 +/- 0.55/y to postoperative 0.02 +/- 0.08/y. As a novel finding, the patients with preoperative cellulitis were more likely to continue the use of the compression garments. Conclusions: The surgery is beneficial to most studied lymphedema patients, although it is not the cure for all patients. The incidence of cellulitis was reduced, and further, the presence of preoperative cellulitis seems to affect the outcome of the operation.Peer reviewe

Phase 1 Lymfactin (R) Study : 24-month Efficacy and Safety Results of Combined Adenoviral VEGF-C and Lymph Node Transfer Treatment for Upper Extremity Lymphedema

BACKGROUND: Lymphedema is a common problem after breast cancer treatment. Lymfactin (R) is a prolymphangiogenic growth factor vector inducing the expression of human vascular endothelial growth factor C (VEGF-C). It promotes growth and repair of lymphatic vessels.METHODS: Lymfactin (R) was combined with microvascular lymph node transfer surgery (VLNT) to study the safety and efficacy of the treatment in breast cancer-related upper limb lymphedema (BCRL) patients. This is a continuation study with a 3 year efficacy and 5 year safety follow-up.RESULTS: Fifteen patients were recruited in the study between June 2016 and February 2018. Three patients received a lower dose (1 x 10 10 viral particles (vp)), and 12 patients received a higher dose (1 x 10 11 vp) of Lymfactin (R), respectively. In the higher dose group, the reduction of excess arm volume was on average 46% after the 12 month follow-up, and the transport index was improved in 7/12 patients. At baseline, removal of the compression garment for 7 days resulted in significant arm swelling (105.7 +/- 161.0 ml, p = 0.0253). However, at 12 months, there was less and not significant swelling after removal of the garment (84.4 +/- 143.0 ml, p = 0.0682). Lymphedema Quality of Life Inventory (LQOLI or LyQLI) questionnaire showed significant and sustained improvement of quality of life.CONCLUSIONS: During 24 months' of follow-up, the results indicate that Lymfactin (R) is well tol-erated. The most promising findings were a 46% reduction in excess arm volume and a nonsignif-icant volume increase after garment removal at 12 months, suggesting that there is potential for the reduction of lymphedema.(c) 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Pub-lished by Elsevier Ltd. This is an open access article under the CC BY license ( http://creativecommons.org/licenses/by/4.0/ )Peer reviewe