Secondary scrotal lymphedema: A novel microsurgical approach
Sylvain Mukenge, M.D. 1 *, Carlo Pulitanò, M.D. 1, Renzo Colombo, M.D. 2, Daniela Negrini, B.D. 3, Gianfranco Ferla, M.D. 1
1Department of Surgery, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy2Department of Urology, Scientific Institute San Raffaele, Vita-Salute San Raffaele University, Milan, Italy3Department of Experimental and Clinical Biomedical Sciences, University of Insubria, Varese, Italy
email: Sylvain Mukenge (mukenge.mvunde@hsr.it)
*Correspondence to Sylvain Mukenge, Department of Surgery, Scientific Instistute H San Raffaele, Via Olgettina 60, 20132 Milan, Italy
setDOI("ADOI=10.1002/micr.20426")
Abstract
Secondary scrotal lymphedema is an infrequent complication of radical cystectomy assiociated with pelvic lymphadenectomy. We report a case of secondary lymphedema of male genitalia presenting more than 4 years after a radical cystectomy with extended pelvic lymphadenectomy for adenocarcinoma of the bladder. Microsurgical lymphovenous anastomoses are usually performed using only the scrotal lymphatics excluding the testicular lymphatics drainage. We have experimented a new microsurgical technique based on lymphovenous anastomosis between the collectors of the spermatic funiculus and the veins of the pampiniform plexus, allowing the testicular lymphatic drainage.
Wiley InterScience
Friday, November 30, 2007
Thursday, November 22, 2007
Infectious Disease Doctor for Lymphedema
I am a firm believer in the concept of a “team” approach to the management and treatment of lymphedema and its associated complications.
The team approach is a group of medical providers working together for the well being and health of the lymphedema patient.
In my situation, my team consists of
Primary Care Doctor
Oncologist
Pulmonary Doctor
Infectious Diease Doctor
Why Do I Need an Infectious Disease Doctor?
Until I acquired lymphoma, the most pressing complication that I experienced with my leg lymphedema was recurrent and severe cellulitiis. It was apparent long ago that we desperately needed a way to control it (try to prevent) and if it did occur to promptly and successfully treat the infection.
The result is that I have been under the care of an ID doctor now for over twenty years.
Because of our susceptibility to infections and because our lymphedema arm or leg is immunocompromised, it is essential that any lymphedema patient with recurrent infections enlist the aide of an “ID” doctor. They are specially trained in infections and are far more qualified to treat them then any other type of doctor.
My ID doc, Dr. Elliott Raizes has been a life saver and a God send in my own battle with lymphedema. Not only does he has that “old fashioned” and rapidly disappearing concern for his patients, but his knowledge of bacterial infections is unbelievable.
How Do I Find an Infectious Disease Doctor?
The easiest way is to simply ask or if need be insist on a referral to one in your area from your PCP. They may already know of a good doctor within your community.
You can also find participating ID doctors in your insurance plan through their “Find a Doctor” service or you can locate one through the internet.
Infectious Disease Specialists are like medical detectives. They examine difficult cases, looking for clues to identify the culprit and solve the problem.
Your ID Physician Has 9-10 Years of Specialized Education & Training
4 years of medical school
3 years training as a doctor of internal medicine
2-3 years specialized training in infectious diseases
Most ID specialists who treat patients also are board certified. They have passed a difficult certification examination by the American Board of Internal Medicine in both internal medicine and infectious diseases.
Reducing Risk of Infectious Disease
One of the best strategies for preventing infectious diseases is immunization. Make sure you and your children receive all recommended vaccinations.
Ask your doctor for advice about other things you and your family can do to prevent infectious diseases.
When You Need an ID Specialist
Many common infections can be treated by your personal physician. Your doctor might refer you to an ID specialist in cases where an infection is difficult to diagnose, is accompanied by a high fever, or does not respond to treatment. ID specialists also see healthy people who plan to travel to foreign countries or locations where infection risk is higher. In these cases, ID specialists can help determine whether special immunizations or other preventive measures are necessary to protect travelers from disease.
ID specialists review your medical data, including X-rays and laboratory reports such as blood work and culture data. They also may perform a physical exam to help determine the cause of the problem.
ID specialists often order laboratory tests to examine samples of blood or other body f luids or cultures from wounds. A blood serum analysis can help the ID specialist detect antibodies that indicate what type of infection you have. These advanced tests can further explain the results of earlier tests, helping to pinpoint the problem.
Treatments consist of medicines—usually antibiotics—to help battle the infection and prevent it from returning. These medicines may be given to you orally (in the form of pills or liquids) or administered directly into your veins, via an IV tube. Many ID specialists have IV antibiotic therapy available in their offices, which decreases the likelihood that you will need to be hospitalized.
What Information Should You Give Your ID Specialist?
All medical records related to your condition
X-rays, laboratory reports and immunization records. Often your personal physician will forward this information to the specialist before your scheduled appointment.
A list of all medications you take
This list should include over-the-counter and prescription medications
A list of any allergies you have.
Let the ID specialist know if you are taking birth control pills.
Some antibiotics may interfere with the effectiveness of oral contraceptives.
How Does My ID Specialist Work With Other Medical Professionals?
The ID specialist works with your personal physician to determine which diagnostic tests are appropriate. If treatment is necessary, your doctor and the ID specialist will work together to develop a treatment plan best suited to your needs. Often you will be asked to return to the ID specialist for a follow-up visit. This allows the specialist to check on your progress, confirm that the infection is gone and help prevent it from coming back. If you acquire an infection while in the hospital, the ID specialist will work with other hospital physicians to help direct your care.
The specialist also might provide follow-up care after you go home.
If your ID specialist is also your personal physician, he or she will coordinate your care, referring you to other specialists when necessary.
ID Specialists Are Experts in the Diagnosis and Treatment of Illnesses Caused by Microorganisms.
ID specialists see patients to determine whether their symptoms are due to an infection.
Patients often see ID specialists due to a fever.
Some ID specialists serve as primary care physicians, for example, for people with HIV/AIDS, treating most illnesses and coordinating their patients’ overall care.
In all of these cases, the specialized training and diagnostic tools of the ID specialist can help determine the cause of your infection and the best approach to treatment.
Where Can I Get More Information About the Prevention and Treatment of Infectious Diseases?
Your doctor is your best source of information. In addition, the Infectious Diseases Society of America (IDSA), a professional organization of nearly 8,000 ID physicians, scientists, and other infectious diseases experts, can help point you in the direction of resources and additional information.
Infectious Disease Internal Medicine Subspecialty
An infectious disease (ID) specialist is a doctor of internal medicine (or, in some cases, pediatrics) who is qualified as an expert in the diagnosis and treatment of infectious diseases. After seven or more years of medical school and postgraduate training, ID specialists complete two to three years of additional training in infectious diseases.
ID specialists have expertise in infections of the sinuses, heart, brain, lungs, urinary tract, bowel, bones and pelvic organs. Their extensive training focuses on all kinds of infections, including those caused by bacteria, viruses, fungi and parasites. Many ID physicians specialize in treating patients with infections due to human immunodeficiency virus (HIV), the cause of AIDS.
Along with their specialized knowledge comes a particular insight into the use of antibiotics and their potential adverse effects. ID specialists also have additional training in immunology (how the body fights infection), epidemiology (how infections spread) and infection control.
What an infectious disease specialist does
The role of an infectious disease specialist is to review a patient's medical data, including records, X-rays and laboratory reports. They may perform a physical examination, depending on the type of problem. They also counsel healthy people who plan to travel to countries where there is an increased risk of infection.
Laboratory studies are often necessary and may include blood studies and cultures of wounds or body fluids. They may order blood serum studies for antibodies indicating the presence of unusual or uncommon diseases. These studies may help explain the results of studies that a general internist may already have done.
Work in the infectious disease specialty is limited to diagnosis and medical treatment. Infectious diseases specialists do not perform surgery.
When you need an infectious disease specialist
Not everyone who has an infectious disease needs an infectious disease specialist. Your general internist can take care of most infections, but sometimes specialized expertise is needed to either diagnose or manage specific infectious diseases.
When a fever raises the suspicion that you may have an infection, when an infection is potentially serious, or when problems occur with treatment, it may be necessary to consult an infectious diseases specialist. ID specialists can provide special insight into tests that will be helpful in diagnosing and understanding the infection and preventing recurrent infections. They can often help determine what treatment you need, if any, and whether you should receive antibiotics. You may not require any treatment, but if you do, they may confer with your personal physician about which diagnostic testing and forms of treatment are best suited to your needs. If you are hospitalized for an infection or acquire an infection while hospitalized, ID specialists will follow and help direct your hospital care. In some cases, they may continue to see you after you go home from the hospital.
How infectious disease specialists work with other physicians
Although infectious diseases specialists sometimes serve as primary care physicians, in most cases you will still need your regular doctor. Usually you will be asked to return to the ID specialist for a follow-up visit to review test results and to be sure that your infection has been eliminated. ID specialists may wish to follow up with you until we feel confident that the infection will not recur. You will resume care with your regular physician when your condition has stabilized or is cured.Doctors for Adults
See also: Infectious Disease Doctor
Thursday, November 15, 2007
Lymphedema - Medicare - What You Can Do
Lymphedema - Medicare - What You Can Do
I'd like to start everyone off with the following three steps. Take on as much as you all can but don't over-do. I know we all have limited time and energy. The first thing to do is to get your lymphedema under control, then we can start educating and lobbying.
1. If you have recently been denied compression bandages, garments or devices, and you are still within the time period for an appeal, let's get the appeal going. I'll supply the proper forms and help you fill them out. If you have paid for compression materials and have not been formally denied, I'll send you a Medicare claim form. Otherwise I'll help you write a claim letter.
2. I must also know whether you wish to work towards national Medicare legislation or State legislation for the diagnosis and treatment of lymphedema.
Tell me your 9-digit ZIP code and I'll tell you the name and contact info for your legislators with suggestions as to the best ones to contact.
3. When you have some spare time, call your legislators to urge them to support (or introduce) legislation which affects your ability to access quality lymphedema care. Some current bills are as follows:
Stopgap legislation has been introduced in both the Senate and House (S. 543 Nelson/H.R. 1459 Tanner) that would freeze implementation of 75% Rule and prevent additional access problems for individuals requiring lymphedema treatment.
The House recently passed the Children's Health and Medicare Protection (“CHAMP”) Act of 2007, which includes a freeze in the implementation of the 75% Rule at the 60% threshold indefinitely.
The legislation would also allow patients' co-morbidities to continue to be considered for purposes of meeting the 75% Rule quota.
In March 2005 CMS changed their interpretation of the Social Security Act to limit coverage of manual lymph drainage to physical and occupational therapists, thereby eliminating coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists.
This effectively reduced the numberof available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced to close as a result of this policy change. H.R. 1846 Towns attempts to partially rectify this ill-advised policy by restoring physician authority in selecting qualified medical personnel to perform “incident to” services.
Also in March 2006 lymphedema was exempted automatically from therapy caps that were re-imposed on January 1, 2006. But in January 2007 exemption was made dependent on existence of a co-condition. This constitutes another roadblock to access to physician-prescribed treatment for lymphedema patients.
S. 450 Ensign/H.R. 748 Becerra would permanently eliminate therapy caps.
Thanks for helping.
BobRobert Weiss, M.S.Lymphedema Treatment Advocate
Email: LymphActivist@aol.com
I'd like to start everyone off with the following three steps. Take on as much as you all can but don't over-do. I know we all have limited time and energy. The first thing to do is to get your lymphedema under control, then we can start educating and lobbying.
1. If you have recently been denied compression bandages, garments or devices, and you are still within the time period for an appeal, let's get the appeal going. I'll supply the proper forms and help you fill them out. If you have paid for compression materials and have not been formally denied, I'll send you a Medicare claim form. Otherwise I'll help you write a claim letter.
2. I must also know whether you wish to work towards national Medicare legislation or State legislation for the diagnosis and treatment of lymphedema.
Tell me your 9-digit ZIP code and I'll tell you the name and contact info for your legislators with suggestions as to the best ones to contact.
3. When you have some spare time, call your legislators to urge them to support (or introduce) legislation which affects your ability to access quality lymphedema care. Some current bills are as follows:
Stopgap legislation has been introduced in both the Senate and House (S. 543 Nelson/H.R. 1459 Tanner) that would freeze implementation of 75% Rule and prevent additional access problems for individuals requiring lymphedema treatment.
The House recently passed the Children's Health and Medicare Protection (“CHAMP”) Act of 2007, which includes a freeze in the implementation of the 75% Rule at the 60% threshold indefinitely.
The legislation would also allow patients' co-morbidities to continue to be considered for purposes of meeting the 75% Rule quota.
In March 2005 CMS changed their interpretation of the Social Security Act to limit coverage of manual lymph drainage to physical and occupational therapists, thereby eliminating coverage of treatment by specially-qualified nurses, physicians, osteopaths, chiropractors and massage therapists.
This effectively reduced the numberof available trained therapists by some 30 percent. A number of lymphedema treatment clinics around the country have already been forced to close as a result of this policy change. H.R. 1846 Towns attempts to partially rectify this ill-advised policy by restoring physician authority in selecting qualified medical personnel to perform “incident to” services.
Also in March 2006 lymphedema was exempted automatically from therapy caps that were re-imposed on January 1, 2006. But in January 2007 exemption was made dependent on existence of a co-condition. This constitutes another roadblock to access to physician-prescribed treatment for lymphedema patients.
S. 450 Ensign/H.R. 748 Becerra would permanently eliminate therapy caps.
Thanks for helping.
BobRobert Weiss, M.S.Lymphedema Treatment Advocate
Email: LymphActivist@aol.com
Saturday, November 10, 2007
Lymphedema - Medicare News (Not Good)
Lymphedema - Medicare News (Not Good)
My proposal to CMS to add over 150 new and revised codes to the HCPCS Codebook for lymphedema treatment supplies was just rejected again by the CMS HCPCS Workgroup in Baltimore. This was very depressing because they never referred to my legal and medical arguments--only stated that "no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operatingneed to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available."
This reiterates my feeling that I have not gotten the required support from providers, suppliers, patients, manufacturers to convince "Medicare, Medicaid and the Private Insurance Sector" that there could be a "program operating need", and that there is a proposed solution to the problem which has a rational legal and medical basis. My record with Medicare Administrative Law Judges recently, since developing my "prosthetic devices" argument, is 4 favorable, 1unfavorable decisions. Two cases have been appealed to the Medicare Appeals Council in Washington. My argument, in brief, is that compression bandages, garment and devices meet the definition in the Social Security Act of "prosthetic devices" when used in the standard treatment of lymphedema, and are covered by Medicare. They are usually denied because they do not meet the policies on surgical dressings benefit category, which is not their medical use or their benefit category.
I am in the process of preparing a formal request for a national coverage analysis on the coverage of the treatment of lymphedema that would lead to a new national coverage determination and policy, but progress is slow. I am also preparing a formal request to SADMERC for a reclassification of compression sleeves and bandages from uncovered S-codes to covered L-codes, and of compression stockings used in treatment of lymphedema from uncovered A-codes to covered L-codes. The request is also to add codes for other compression garments which are not currently described.
Another important reason for reclassifying compression garments from A-codes (Secondary surgical dressings) to L-codes (prosthetic devices) is that the specifications for elastic compression garments are different for the two functions, and the costs can be different. For example, an off-the-shelf elastic compression stocking used to hold a primary dressing on a venous ulcer (A-code) is reimbursed at $43.27. A custom flat-knit stocking used in the treatment of a lymphatic leg (L-code) has far more stringint technical specifications and costs far more than the circular-knit elastic stocking to manufacture.
Differences in use, medical requirements, manufacturing costs, etc warrant two different code groups.
I hope that I can get more support from patients, providers, suppliers and manufacturers this coming year in my efforts to get CMS to change their lymphedema treatment coverage policies. Only by appealing every denial of medical treatment for lymphedema can we impress on CMS that there IS a program operating need for new coverage policies and codes. Denials are based on non-relevantpolicies, HCPCS codes are being used incorrectly, and there are inadequate codes for the medically necessary coverable items used every day by lymphedema patients.
And if CMS does not chose to understand the issue, and in the absence of a lymphedema lobby, we must rely on legislators' constituents (that means YOU) to create the awareness of a need for legislative change.
Robert Weiss, M.S.
Lymphedema Treatment Advocate
My proposal to CMS to add over 150 new and revised codes to the HCPCS Codebook for lymphedema treatment supplies was just rejected again by the CMS HCPCS Workgroup in Baltimore. This was very depressing because they never referred to my legal and medical arguments--only stated that "no insurer (i.e. Medicare, Medicaid, Private Insurance Sector) identified a national program operatingneed to establish unique codes to distinguish all the products listed in this application. Existing codes adequately describe the array of products available."
This reiterates my feeling that I have not gotten the required support from providers, suppliers, patients, manufacturers to convince "Medicare, Medicaid and the Private Insurance Sector" that there could be a "program operating need", and that there is a proposed solution to the problem which has a rational legal and medical basis. My record with Medicare Administrative Law Judges recently, since developing my "prosthetic devices" argument, is 4 favorable, 1unfavorable decisions. Two cases have been appealed to the Medicare Appeals Council in Washington. My argument, in brief, is that compression bandages, garment and devices meet the definition in the Social Security Act of "prosthetic devices" when used in the standard treatment of lymphedema, and are covered by Medicare. They are usually denied because they do not meet the policies on surgical dressings benefit category, which is not their medical use or their benefit category.
I am in the process of preparing a formal request for a national coverage analysis on the coverage of the treatment of lymphedema that would lead to a new national coverage determination and policy, but progress is slow. I am also preparing a formal request to SADMERC for a reclassification of compression sleeves and bandages from uncovered S-codes to covered L-codes, and of compression stockings used in treatment of lymphedema from uncovered A-codes to covered L-codes. The request is also to add codes for other compression garments which are not currently described.
Another important reason for reclassifying compression garments from A-codes (Secondary surgical dressings) to L-codes (prosthetic devices) is that the specifications for elastic compression garments are different for the two functions, and the costs can be different. For example, an off-the-shelf elastic compression stocking used to hold a primary dressing on a venous ulcer (A-code) is reimbursed at $43.27. A custom flat-knit stocking used in the treatment of a lymphatic leg (L-code) has far more stringint technical specifications and costs far more than the circular-knit elastic stocking to manufacture.
Differences in use, medical requirements, manufacturing costs, etc warrant two different code groups.
I hope that I can get more support from patients, providers, suppliers and manufacturers this coming year in my efforts to get CMS to change their lymphedema treatment coverage policies. Only by appealing every denial of medical treatment for lymphedema can we impress on CMS that there IS a program operating need for new coverage policies and codes. Denials are based on non-relevantpolicies, HCPCS codes are being used incorrectly, and there are inadequate codes for the medically necessary coverable items used every day by lymphedema patients.
And if CMS does not chose to understand the issue, and in the absence of a lymphedema lobby, we must rely on legislators' constituents (that means YOU) to create the awareness of a need for legislative change.
Robert Weiss, M.S.
Lymphedema Treatment Advocate
Wednesday, November 07, 2007
Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis
Elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis
Arch Orthop Trauma Surg. 2007 Nov 3
Turhan E, Ege A, Keser S, Bayar A.
School of Medicine, Department of Orthopaedics and Traumatology, Medicine Faculty of Zonguldak Karaelmas University, Kozlu, 67100, Zonguldak, Turkey, dregementurhan@yahoo.com.
Arch Orthop Trauma Surg. 2007 Nov 3
Turhan E, Ege A, Keser S, Bayar A.
School of Medicine, Department of Orthopaedics and Traumatology, Medicine Faculty of Zonguldak Karaelmas University, Kozlu, 67100, Zonguldak, Turkey, dregementurhan@yahoo.com.
Keywords: Elephantiasis nostras verrucosa - Tibial - Osteomyelitis - Amputation
Elephantiasis nostras verrucosa represents an infrequent clinical entity with cutaneous changes characterized by dermal fibrosis, hyperkeratotic verrucous and papillamotous lesions resulting from chronic non-filarial lymphedema secondary to infections, surgeries, tumor obstruction, radiation, congestive heart failure, and obesity. Although recurrent streptococcal lymphangitis is believed to play a critical role in the origin of elephantiasis nostras verrucosa, the exact pathogenesis of the disorder is not yet clear. Therapeutic efforts should aim to reduce lymph stasis, which will also lead to improvement of the cutaneous changes but unfortunately there is no specific treatment for advanced cases. In this report, we present a patient who was treated by below knee amputation as a result of elephantiasis nostras verrucosa complicated with chronic tibial osteomyelitis.
Springer Link
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