Objective: The aim of this study was to identify the comprehensive risk factors for lymphedema, thereby enabling a more informed multidisciplinary treatment decision-making. Summary Background Data: Lymphedema is a serious long-term complication in breast cancer patients post-surgery; however, the influence of multimodal therapy on its occurrence remains unclear. Methods: We retrospectively collected treatment-related data from 5549 breast cancer patients who underwent surgery between 2007 and 2015 at our institution. Individual radiotherapy plans were reviewed for regional nodal irradiation (RNI) field design and fractionation type. We identified lymphedema risk factors and used them to construct nomograms to predict individual risk of lymphedema. Nomograms were validated internally using 100 bootstrap samples and externally using 2 separate datasets of 1877 Asian and 191 Western patients. Results: Six hundred thirty-nine patients developed lymphedema during a median follow-up of 60 months. The 3-year lymphedema incidence was 10.5%; this rate increased with larger irradiation volumes (no RNI vs RNI excluding axilla I–II vs RNI including axilla I–II: 5.7% vs 16.8% vs 24.1%) and when using conventional fractionation instead of hypofractionation (13.5% vs 6.8%). On multivariate analysis, higher body mass index, larger number of dissected nodes, taxane-based regimen, total mastectomy, larger irradiation field, and conventional fractionation were strongly associated with lymphedema (all P < 0.001). Nomograms constructed based on these variables showed good calibration and discrimination internally (concordance index: 0.774) and externally (0.832 for Asian and 0.820 for Western patients). Conclusions: Trimodality breast cancer treatment factors interact to promote lymphedema. Lymphedema risk can be decreased by deintensifying node dissection, chemotherapy regimen, and field and dose of radiotherapy. Deescalation strategies on a multidisciplinary basis might minimize lymphedema risk.

Choi JH, et al. Ann Rehabil Med. 2014 Aug;38(4):485-493. http://dx.doi.org/10.5535/arm.2014.38.4.485

Kim DS, et al. Yonsei Med J. 2011 Nov;52(6):977-981. http://dx.doi.org/10.3349/ymj.2011.52.6.977

Objective. The purpose of this study was to investigate the feasibility of using real‐time high‐resolution sonography to guide an injection needle into the intra‐articular space within the knee. Methods. Eighty‐nine patients with radiographically confirmed knee osteoarthritis (Kellgren‐Lawrence grade 2 or 3) without an effusion were included. After sonographically guided or blind injection of hyaluronic acid (HA) and contrast dye through a medial patellar portal (MPP) into the knee joint, a radiographic image was made to ascertain whether the injected material had reached the intra‐articular space. Result. Sonographically guided injections of HA into the knee joint had a significantly greater accuracy rate (95.6%) than blind injections (77.3%; P = .01). Conclusions. Intra‐articular injections via an MPP using sonographic guidance may raise the accuracy rate in knee joint injections.

Objective: The aim of this study was to assess whether the effects of a motorized aquatic treadmill exercise program improve the isometric strength of the knee muscles, cardiorespiratory fitness, arterial stiffness, motor function, balance, functional outcomes, and quality of life in subacute stroke patients. Design: Thirty-two patients were randomly assigned to 4-wk training sessions of either aquatic therapy (n = 19) or land-based aerobic exercise (n = 18). Isometric strength was measured using an isokinetic dynamometer. Cardiopulmonary fitness was evaluated using a symptom-limited exercise tolerance test and by measuring brachial ankle pulse wave velocity. Moreover, motor function (Fugl-Meyer Assessment [FMA] and FMA-lower limb [FMA-LL]), balance (Berg Balance Scale [BBS]), Activities of daily living (Korean version of the Modified Barthel Index [K-MBI]), and quality of life (EQ-5D index) were examined. Results: There were no intergroup differences between demographic and clinical characteristics at baseline (P > 0.05). The results shows significant improvements in peak oxygen consumption (P = 0.02), maximal isometric strength of the bilateral knee extensors (P < 0.01) and paretic knee flexors (P = 0.01), FMA (P = 0.03), FMA-LL (P = 0.01), BBS (P = 0.01), K-MBI (P < 0.01), and EQ-5D index (P = 0.04) after treatment in the aquatic therapy group. However, only significant improvements in maximal isometric strength in the knee extensors (P = 0.03) and flexors (P = 0.04) were found within the aquatic therapy group and control group. Conclusions: Water-based aerobic exercise performed on a motorized aquatic treadmill had beneficial effect on isometric muscle strength in the lower limb. To Claim CME Credits: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives: Upon completion of this article, the reader should be able to: (1) Articulate the rationale for including walking on an aquatic treadmill in the rehabilitation of subacute stroke patients; (2) Describe the beneficial effects of a motorized aquatic treadmill exercise program in the rehabilitation of subacute stroke patients; and (3) Determine the appropriate indications for incorporating a motorized aquatic treadmill exercise program in the rehabilitation of subacute stroke patients. Level: Advanced Accreditation: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.