Neil B. Piller

Treatment of Postmastectomy Lymphedema with Low-Level Laser Therapy A Double Blind, Placebo-Controlled Trial

The current study describes the results of a double blind, placebo‐controlled, randomized, single crossover trial of the treatment of patients with postmastectomy lymphedema (PML) with low‐level laser therapy (LLLT).

Identification of patients with noncancer diseases for palliative care services

OBJECTIVE To identify criteria for measuring the eligibility of patients with end-stage noncancer diseases for palliative care services in Australian residential aged care facilities. METHODS No validated set if guidelines were available so five instruments were used: an adaptation of the American National Hospice Association Guidelines; a recent adaptation of the Karnofsky Performance Scale; the Modified Barthel Index; the Abbey Pain Score for assessment of people who are nonverbal and a Verbal Descriptor Scale, also for pain measurement. In addition, nutritional status and the presence of other problematic symptoms and their severity were also sought. RESULTS The adapted American National Hospice Association Guidelines provided an initial indicative framework and the other instruments were useful in providing confirmatory data for service eligibility and delivery.

Reliability of bioimpedance spectroscopy and tonometry after breast conserving cancer treatment.

BACKGROUND Measuring the female breast, especially after breast cancer treatment, is problematic due to breast size, texture, and patient positioning. However, being able to accurately measure changes in the breast is important, as it may help in the earlier diagnosis and treatment of early breast edema and later lymphedema. METHODS 14 women who had undergone breast conserving surgery for breast cancer (> 12 months ago) were recruited to assess the between subject reproducibility of tonometry and bioimpedance spectroscopy (BIS). With the participant supine, two repeat measurements of the resistance of the tissues to compression (tonometry) and fluid levels (BIS) of the treated and normal breast were taken for each of the four quadrants of the breast. RESULTS The between subject reproducibility for both measurement techniques was high, with covariance ranging from 1.29% to 3.25% for tonometry and 0.20-0.86% for BIS. CONCLUSIONS The reliability of these two measurement techniques provides an opportunity for researchers and clinicians to easily quantify breast tissue and fluid changes which in turn may lead to the earlier diagnosis and targeted treatment of breast edema and lymphedema.

Yoga management of breast cancer-related lymphoedema: a randomised controlled pilot-trial.

BackgroundSecondary arm lymphoedema continues to affect at least 20% of women after treatment for breast cancer requiring lifelong professional treatment and self-management. The holistic practice of yoga may offer benefits as an adjunct self-management option. The aim of this small pilot trial was to gain preliminary data to determine the effect of yoga on women with stage one breast cancer-related lymphoedema (BCRL). This paper reports the results for the primary and secondary outcomes.MethodsParticipants were randomised, after baseline testing, to receive either an 8-week yoga intervention (n = 15), consisting of a weekly 90-minute teacher-led class and a 40-minute daily session delivered by DVD, or to a usual care wait-listed control group (n = 13). Primary outcome measures were: arm volume of lymphoedema measured by circumference and extra-cellular fluid measured by bioimpedance spectroscopy. Secondary outcome measures were: tissue induration measured by tonometry; levels of sensations, pain, fatigue, and their limiting effects all measured by a visual analogue scale (VAS) and quality of life based on the Lymphoedema Quality of Life Tool (LYMQOL). Measurements were conducted at baseline, week 8 (post-intervention) and week 12 (four weeks after cessation of the intervention).ResultsAt week 8, the intervention group had a greater decrease in tissue induration of the affected upper arm compared to the control group (p = 0.050), as well as a greater reduction in the symptom sub-scale for QOL (p = 0.038). There was no difference in arm volume of lymphoedema or extra-cellular fluid between groups at week 8; however, at week 12, arm volume increased more for the intervention group than the control group (p = 0.032).ConclusionsAn 8-week yoga intervention reduced tissue induration of the affected upper arm and decreased the QOL sub-scale of symptoms. Arm volume of lymphoedema and extra-cellular fluid did not increase. These benefits did not last on cessation of the intervention when arm volume of lymphoedema increased. Further research trials with a longer duration, higher levels of lymphoedema and larger numbers are warranted before definitive conclusions can be made.

The effect of yoga on women with secondary arm lymphoedema from breast cancer treatment

BackgroundWomen who develop secondary arm lymphoedema subsequent to treatment associated with breast cancer require life-long management for a range of symptoms including arm swelling, heaviness, tightness in the arm and sometimes the chest, upper body impairment and changes to a range of parameters relating to quality of life. While exercise under controlled conditions has had positive outcomes, the impact of yoga has not been investigated. The aim of this study is to determine the effectiveness of yoga in the physical and psycho-social domains, in the hope that women can be offered another safe, holistic modality to help control many, if not all, of the effects of secondary arm lymphoedema.Methods and designA randomised controlled pilot trial will be conducted in Hobart and Launceston with a total of 40 women receiving either yoga intervention or current best practice care. Intervention will consist of eight weeks of a weekly teacher-led yoga class with a home-based daily yoga practice delivered by DVD. Primary outcome measures will be the effects of yoga on lymphoedema and its associated symptoms and quality of life. Secondary outcome measures will be range of motion of the arm and thoracic spine, shoulder strength, and weekly and daily physical activity. Primary and secondary outcomes will be measured at baseline, weeks four, eight and a four week follow up at week twelve. Range of motion of the spine, in a self-nominated group, will be measured at baseline, weeks eight and twelve. A further outcome will be the women’s perceptions of the yoga collected by interview at week eight.DiscussionThe results of this trial will provide information on the safety and effectiveness of yoga for women with secondary arm lymphoedema from breast cancer treatment. It will also inform methodology for future, larger trials.Trial registrationACTRN12611000202965

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 (2 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.

Phlebolymphoedema/chronic venous lymphatic insufficiency: an introduction to strategies for detection, differentiation and treatment.

In order to better understand phlebolymphoedemas and the impact of a dysfunctional venous system and an overloaded lymphatic system on them, it is necessary first to understand the major anatomical features of the lymphatic system. To gain better patient outcomes, the range of treatments focusing on areas other than the venous system, and to be aware of their strengths and limitations, it is important to know and understand the basics of the physiology of the lymphatic system and the pathological changes that chronic venous insufficiency may cause. It is important to be aware that the deep and superficial lymphatic systems (but particularly the superficial) are divided into a series of drainage areas called lymphatic territories, which are separated from each other by boundaries called watersheds. Often, anatomoses (which can be closed or open) cross these boundaries and between major lymph collectors within each territory. Each lymphatic territory is drained by a greater or lesser number of larger lymph vessels called lymph collectors. Usually, these drain directly to lymph nodes where up to an estimated 30% of the lymph fluid is re-absorbed. Due to proximity relationships between the lymphatic and venous systems, there are frequent lymphovenous anastomoses, which at varying times may be open but which seem to often require external intervention to maintain their patency. The lymphatic system normally is concerned with four major roles: (1) maintenance of tissue fluid and physiological homeostasis, though its role in absorption and removal of fluids and their contents; (2) body defense (those patients with a poorly functioning lymphatic system are more susceptible to infection); (3) absorbance of long-chain fats from the mesenteric area; and (4) overall control of the immune response, although the breadth of these roles is not always recognized. There are many occasions when the lymphatic system is structurally and functionally normal and can manage a large additional load of fluids and their contents as might occur when there is a compromised venous system; however, continuing excessive loads above the maximum transport capacity of an otherwise normal lymphatic system can lead to its failure to remove them. This is termed a ‘dynamic insufficiency’. Other than chronic venous insufficiency, the main reasons are right ventricular failure, inflammation and kidney disease. If, in addition, the lymphatic system has some form of structural impairment such as that which occurs when the lymphatic system is malformed (congenital forms of lymphoedema), or following surgery, radiotherapy, inflammation or trauma, then the transport capacity can be significantly reduced. A similar situation of reduced transport Correspondence: N Piller PhD, Flinders Medical Centre, Department of Surgery, School of Medicine. Email: neil.piller@flinders.edu.au

Aerobic exercise and the post myocardial infarction patient: a review of the literature

Meta analyses of randomized controlled tests of cardiac rehabilitation after myocardial infarction demonstrate that regular exercise reduces the risk of overall mortality and cardiovascular mortality. In patients with established coronary artery disease, exercise is associated with improved activity tolerance, modification of risk factors, and improvement in quality of life. Randomized controlled tests demonstrate that whereas older patients after coronary events are substantially less fit than younger patients, they obtain a similar relative improvement of aerobic capacity with a graded conditioning program. However, older adults are enrolled in such programs at a lower rate than other age groups. Despite similar clinical profiles to men, women are less likely to participate in exercise rehabilitation. In this article we discuss the principles of program development, guidelines for monitoring of patients, and facilitation of exercise programs in the Australian context.

CYP2A6 polymorphisms: is there a role for pharmacogenomics in preventing coumarin-induced hepatotoxicity in lymphedema patients?

Lymphedema is a chronic progressive and significantly disabling disease that affects over 150 million people worldwide. Coumarin is an effective pharmacological treatment, but is banned in some countries due to incidences of hepatotoxicity in rats and mice, and the rare finding of similar hepatotoxicity in humans. Cytochrome P450 (CYP)2A6 is the major enzyme involved in metabolizing coumarin to 7-hydroxycoumarin. A reduction in CYP2A6 activity will lead to shunting of coumarin into other metabolic pathways. In particular, coumarin is metabolized by CYP3A4 to form 3-hydroxycoumarin, the major metabolite in mice and rats. It has been shown that an increase in the 3-hydroxycoumarin ratio is associated with an increased production of the significant cytotoxic product o-hydroxyphenylacetylacetaldehyde (o-HPA), suggesting that a shunting of coumarin metabolism away from 7-hydroxylation is the cause of the toxicity. Hence, poor CYP2A6 metabolizers are more likely to metabolize coumarin via the cytotoxic pathway. Identifying these patients, and not treating them with coumarin, may reduce the incidence of toxicity associated with this drug. The technology to do so exists, but more information is required regarding the mechanism of coumarin toxicity.

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.