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From our Newsletter

This page is dedicated to providing you with the latest articles from our lymphoedema newsletter. We hope that you find the news interesting and useful. Please share this page with your colleagues.

Join this Exciting New Lymphoedema Community

Introducing a brand new patient and healthcare professional platform, helping to support awareness, education and living with lymphoedema.

Visit www.LymphConnect.co.uk and register today to become part of this exciting new lymphoedema community.

Follow these steps for registration:

  • Click ‘register as a healthcare professional’
  • Create a username (this will be seen by other users)
  • Enter your email address
  • Review the consent information
  • Click ‘register’
  • An email with a registration link will be sent to the email address provided
  • Click on the link within the email to complete the registration process
  • Important! You must click on the link to complete your registration. If you cannot find the email, check your ‘junk’ or ‘spam’
  • Any problems in registering, please email support@lymphconnect.co.uk

October is Breast Cancer Awareness Month

Breast cancer is the most common type of cancer, affecting 1 in 8 women in the UK and this month raises awareness with 'Wear it Pink' on the 19th October, a campaign to support life-saving breast cancer research.

Lymphoedema can be one of the most dreaded and unfortunate outcomes of cancer treatment. The JOBST® team are helping to raise awareness of breast cancer related lymphoedema, supporting your patient’s to understand:

  • The lymphatic system and lymphoedema
  • Why cancer patients are more at risk of developing lymphoedema?
  • What can be done to help prevent the development of lymphoedema?
  • The signs and symptoms of lymphoedema
  • How lymphoedema can be effectively managed

Please contact your BSN medical Account Manager to request hard copies for your patients.

Prompt and Hassle-free Delivery

We know that ease of ordering and quick delivery of compression garments is extremely important to you and to your patients. With this in mind, we are now able to offer you the choice of sending your JOBST® Drug Tariff orders to JOBST Delivered. With our specialist Customer Service Team able to offer support and guidance every step of the way, we are confident you will not be disappointed. Why not give JOBST Delivered a try? Click here for more information or email jobstdelivered@bsnmedical.com.

PROCESS YOUR JOBST® DRUG TARIFF ORDERS THROUGH JOBST® ONLINE FROM 4 OCTOBER 2018!

We are excited to announce that JOBST ONLINE has now expanded to allow your JOBST Drug Tariff orders to be processed, as well as your invoice orders via an account. The majority of the functionality remains the same, however, at check-out a new payment option is now available, ‘prescription’. If this option is selected, the prescription must be obtained and sent to JOBST Delivered1. On receipt of the prescription form, your JOBST order will be processed. Our free and prompt delivery service, JOBST Delivered, will then dispense the product(s) to the delivery address you requested.

In addition, the layout of the ‘invoice’ and ‘approver’ function has been improved to prompt for the approver to be selected, if it is an invoice order, and to allow addresses to be more easily managed.

These exciting developments will be live from Thursday 4th October. Contact your Key Account Manager or our Customer Service team on 0845 122 3600 if you have any queries or need support.

Thank you for continuing to use JOBST ONLINE.

Twitter @JOBSTUK

We are excited to announce that JOBST twitter account ‘@JOBSTUK’ is now LIVE!

Twitter gives us the opportunity to provide you with the very latest news! Our posts will support events, education and raising awareness about lymphoedema to name just a few. Be sure to #JOBST if you are debating, discussing, talking about us or our products!

Thank you for supporting JOBST and we hope you enjoy being part of our Twitter community.

One month until the BLS Conference

The British Lymphology Society Conference takes place at the end of the month.

Being held at Yarnfield Park Training & Conference Centre, Staffordshire, this fantastic educational event has confirmed a number of well-respected speakers who will be presenting during the conference, including Dr Hakan Brorson -Consultant Plastic Surgeon, Dr Kristiana Gordon - Consultant in Dermatology and Lymphatic Medicine, Dr Sinclair Gore - Consultant Plastic Reconstructive and Aesthetic Surgery and Professor Vaughan Keeley - Consultant Physician specialising in lymphoedema.

For further information on the conference please click here.

New additions to the JOBST® FarrowWrap® family - NOW on Drug Tariff

JOBST® FarrowWrap® 4000 (30-40mmHg) is for the treatment of leg ulceration, venous and lymphatic conditions. This new compression wrap system has been developed with:

  • An integrated donning aid for those patients with limited strength and dexterity
  • Four simple bands for ease of application
  • Choice of colours; black and beige
  • Choose from a wide range of sizes
  • A JOBST® FarrowHybrid sock (20-30mmHg) is supplied with JOBST FarrowWrap 4000

JOBST FarrowHybrid are discrete and provide compression from the foot to the ankle; available in 20-30mmHg and 30-40mmHg. Looking just like a normal sock, the JOBST FarrowHybrid is designed to be worn instead of a compression wrap footpiece and supports the wearing of normal shoes.

If you would like further information please click here to send us an email.

LymphAletics 2018

This month, on 15th September, the Children's Lymphoedema Special Interest Group (CLSIG) is holding the 4th Lymphaletics event at The Concord Sports Centre, Sheffield. This fun-packed day is an annual event supporting teenagers and children living with lymphoedema, and their families. Many activities are planned including a special educational session delivered by Professor Mortimer.

For more details please click here.

Cancer Related Lymphoedema - A Patient's Guide

Lymphoedema can be one of the most dreaded and unfortunate outcomes of cancer treatment. BSN medical are committed to provide quality education for both healthcare professionals and patients, as greater awareness of the condition will lead to better treatment outcomes for the patient. 

Education for patients at greater risk of developing lymphoedema is key in gaining early diagnosis and treatment. Educational materials will also help patients come to terms with their condition and provide them with reassurance, that with the right diagnosis and prompt treatment lymphoedema can be well managed.
Introducing new patient materials to support patients in understanding:

  • What the lymphatic system is
  • What lymphoedema is
  • Why cancer patients are more at risk of developing lymphoedema
  • What can be done to help prevent the development of lymphoedema
  • What the signs and symptoms of lymphoedema are
  • How lymphoedema can be effectively managed

To view the Cancer Related Lymphoedema Patient Booklet click here, or contact your BSN medical Account Manager to request hard copies for your patients.

2018 BLS Award Nominations

The deadline for nominating a colleague for a BLS award, someone you feel makes an outstanding contribution to lymphology, is 31st August. For more details click here to visit the BLS website.

Professional Education on Breast Cancer-Related Lymphoedema and it's Relation to Patient Well-Being

This narrative synthesis’s aim was to examine the information delivered to breast cancer patients about the risks of developing lymphoedema.

After a literature review, the retrieved studies were taken forward for thematic analysis. The process identified four themes:

  1. Lack of information
  2. Healthcare Professional’s (HCP) lack of knowledge
  3. Perceived risks and triggers
  4. Information provision

Overall the themes identified a general lack of knowledge on both the patients and HCP’s part. This led the patient to be shocked due to misunderstanding and lack of risk awareness when receiving a lymphoedema diagnosis. Despite the lack of information, it was also identified that the diagnosis delivery required improvement, with multiple delivery points preferred. Patients within the studies expected one comprehensive team to deliver and fulfil both the clinical and educational patient needs. The study supports initiatives and projects to address these key concern areas.

Reference: Conway, M. (2016) Professional education on breast cancer-related lymphoedema and its relation to patient wellbeing. WOUNDS UK, 12(03), pp 22-29.

New JOBST Academy Module: Breast Lymphoedema

BSN medical are pleased to introduce the new JOBST Academy module ‘Breast Lymphoedema’. The new module joins our 19 current modules increasing BSN medical’s educational offering. The modular approach of the BSN Educational Academies allows optimum flexibility and choice, without compromising learning content.

Module 20 Breast Lymphoedema: learning objectives

  • To understand the prevalence and types of breast cancers
  • To understand how lymphoedema affects the breast and torso
  • To gain understanding of assessment methods used for breast lymphoedema
  • Recognise relevant treatment options for the management of breast lymphoedema
  • How to measure for compression therapy

Interested in organising a JOBST Academy event? Please click here.

The Impact of Chronic Oedema on Quality of Life in the Elderly

This article focuses on the notion of quality of life (QoL) of those deemed as elderly who are diagnosed with lymphoedema / chronic oedema (LO / CO). Due to the limited research in this area, the article comments on the research that has been undertaken in LO / CO and how this compares to other research focusing on long term conditions (LTC’s).

The notion of elderly and frailty are key concepts that appear within healthcare policy, due to this population growing in number, but also the resources required to meet their needs.

Research across LO / CO and LTC’s, highlight the negative impact upon QoL related to their conditions, such as feelings of shock, anger, perception of being disabled, or an altered sense of normalcy. This extended to social situations in which people experience difficulties and their relationships. However, it is also noted that these factors can be altered, dependent upon the individual’s motivation and social support, leading to their condition becoming the normality. This is fed by the mechanisms to empower patients’ to self-care, with health literacy and expert patient program providing examples of approaches to improving QoL.

To read the full article please click here.

New Colour Options

BSN medical are pleased to announce the exciting new colours options for our JOBST® Elvarex® custom-fit, flat-knit lower limb range.

Three new colours henna, denim, and graphite are not knitted from one colour, but from two different coloured yarns, creating fashionable, modern and elegant tones that fit every occasion and any outfit, enhancing patient wellbeing and confidence in everyday life.

Alternatively liven up existing colours with a ‘Coloured Seam’, a new option to add a bit of flare, style and individuality to our existing colours range.

All colours are available on the new order forms. If you would like an updated order form or further information, please click here.

Transforming Practice with Night-time Compression

Watch again: If you missed out on the BSN medical webcast education event presented by Justine Whitaker and Rebecca Elwell on the 18th June 2018, do not worry, as you can now download the webinar to watch again. Simply click here to access.

Justine Whitaker  and Rebecca Elwell discuss the importance of night-time compression including the following key topics:

  • Outlining the problems
  • Challenging the myths
  • Benefits to patients
  • Patient examples
  • Improvements in healing
  • Statistics and evidence of cost savings

Chronic Oedema and Associated Complications

This product review demonstrates the benefits of combining compression therapy with wound care to combat common treatment complications.

Abstract:
Managing chronic oedema with complications such as leg ulceration, lymphorrhoea or infection / cellulitis can present a number of treatment challenges. These challenges are often costly to the NHS in terms of time, resources and staffing, and has an impact on patient quality of life.

This article highlights a number of treatment solutions, including the benefits of using Sorbact® technology with Cutimed® Sorbact® dressings to help combat infection.
 
To read more about how this article might benefit you and your patients click here.

New Action Group

In March at the Westminster Hall debate, MP's discussed issues relating to the lack of lymphoedema services and positive responses have been received. This raised the matter of political lobbying at the recent National Lymphoedema Partnership (NLP) meeting and it was agreed to set-up a new action group focused on "political lobbying and raising awareness of the inadequate provision in lymphoedema services".

The British Lymphology Society (BLS) are actively contacting their members to obtain feedback from responses received from MP's. To get involved and share your response, please contact the BLS.

Transforming Practice with Night Time Compression

BSN medical are pleased to announce the upcoming webcast education event facilitated by Wounds UK on the 18th June 2018 at 3pm.

Presenters Justine Whitaker and Rebecca Elwell will discuss the importance of night time compression including the following key topics:

  • Outlining the problems
  • Challenging the myths
  • Benefits to patients
  • Patient examples
  • Improvements in healing
  • Statistics and evidence of cost savings

Don’t miss out; register now: click here.

The 8th International Lymphoedema Framework (ILF) Conference - 6th - 9th June, 2018

On Wednesday 6th June, the 8th ILF Conference will be opened at Rotterdam's City Hall, Netherlands. This three-day conference is being held at the SS Rotterdam, the former flagship of the Holland-America Line. SS Rotterdam steamship has sailed the seven seas and some sailing topics on the agenda are:

  • Lymphoedema management conservative
  • Lymphoedema management surgical
  • Oncology rehab
  • New lymphatic developments
  • National guidelines
  • Paediatric and primary lymphedema
  • Pain related to chronic oedema
  • Lipoedema

To see the full agenda visit the ILF Conference website, click here.

Breast Cancer Related Lymphoedema (BCRL)

Lymphoedema can be one of the most dreaded and unfortunate outcomes of breast cancer treatment. It can affect not only the upper limbs but may also affect midline structures such as the breasts and torso. BSN medical’s new campaign is designed to:

  • Improve awareness and understanding of BCRL
  • Help clinicians recognise the signs and symptoms of BCRL
  • Help increase early diagnosis and referral
  • Provide appropriate therapeutic interventions

BCRL is a growing condition, that affects approximately 20% of patients treated for breast cancer.

To pre-order your Breast Cancer Related Lymphoedema brochure click here to email us your request.

BLS - Call for Abstracts / Conference Educational Grants

Call for Abstracts

The abstract guidelines for this year’s BLS conference are now available. If you are thinking of submitting an abstract, these guidelines will help you with your submission. All abstracts must be submitted by midnight on Friday 18th May. Find out more by visiting the BLS website - click here.

BLS Conference Educational Grant 

BSN medical, an Essity company, is signed up to the MedTech Europe Code of Ethical Practice. The code is designed to ensure fairness and transparency in all aspects of member’s operations. Under the terms of the code, sponsorship or financial support cannot be offered by the member company to named individuals. BSN medical will therefore be supporting the 2018 BLS Conference through an educational grant scheme.

The BLS have introduced this scheme to help those clinicians, who would be unable to attend the conference without sponsorship. People wanting to attend the BLS conference will be able to apply for a sponsored place by completing an application, which will be made available via the BLS website.

Once the application is completed and submitted to the BLS, the board will allocate places to the successful applicants.

BSN medical has agreed to sponsor a number of delegates via the educational grant and wish you good luck with your application.

Further information will be made available via the BLS website.

Events

MLD UK Conference

The MLD UK Conference is being held this month at the Mercure Daventry Court Hotel & Spa, Sedgemoor Way, Daventry, on the 12th -13th May. This conference has a packed two-day programme, with key speakers delivering education around diagnosis and treatment of lymphoedema.

BSN medical Account Managers will be on hand to discuss how JOBST® compression garments can support patients. We are looking forward to seeing you there!

Dates for Földi College Course for MLD / CDT

26th - 27th May 2018 in Ringwood, Hampshire - Book to avoid disappointment

The Földi review course is a comprehensive course given over two days and consists of 18 training units. Importantly, it allows each participant to stay fully up-to-date with the latest techniques and professional requirements.

Course contents:

  • Brief repetition of the anatomy, physiology and pathophysiology of the lymphatic system
  • Development of treatment strategies of various lymphatic diseases
  • Complementing existing bandaging techniques
  • Broadening advanced bandaging techniques
  • Exchange of experience and opportunity to discuss problems of the practical treatment

More information and registration details can be found by visiting the Földi College website.

Otley Lindsay Leg Club Launch

Last month the first Lindsay Leg Club in the North of England was opened in Otley, Leeds. The Otley Leg Club opening saw 25 patients in attendance, all receiving support with leg related conditions in the community.

The team researched the Leg Clubs with a road trip to Powys, joined on the journey by BSN medical Senior Product Manager Sam Williams and Strategic Healthcare Partner, Richard Maddison. The experience of Sam and Richard supported the teams research with discussions on the benefits to the community, and how the club can support the growing case load of nurses and their practices.

BSN medical look forward to continuing their support of Otley Leg Club and seeing it successfully grow. To learn more about The Lindsay Leg Club Foundation click here to visit their website.

 

Management of Chronic Oedema in Patients with Multiple Morbidity

Chronic oedema and lymphoedema can often present with complex symptoms and coexisting polymorbidity. This article highlights the need for skilled practitioners, comprehensive patient assessment and access to a range of treatment options for optimal treatment outcomes.

Chronic oedema is considered complex if one or more of the following is present: significant obesity, recurrent cellulitis, concordance issues, progressing life-threatening / life-limiting disease, significant skin damage including wounds.

The growing numbers of older, obese and polymorbid patients are likely to increase the burden on community nurses and lymphoedema practitioners.  

Reference: Todd, M. (2018) Management of Chronic Oedema in Patients with Multiple Morbidity, British Journal of Nursing

To read the full article click here.

4th Advanced Specialist Lymphoedema Event

This March BSN medical took a small number of customers to the JOBST® manufacturing site in Emmerich.

During the two day educational event, the guests were taken on a factory tour, where they were able to see the technology and people behind each and every garment that is made and how we maintain the high quality of JOBST. Guests were also able to gain a greater insight into the technologies and innovations that go into making JOBST garments so unique.

A fun and informative two days was had by all, with a lot of discussion and collaboration.

Thank you for your contribution to a fantastic couple of days!

Have you heard that the Westminster Hall Debate has lymphoedema on the agenda next week?

On Tuesday 27th March, lymphoedema is being debated at Westminster Hall. The debate session is an opportunity for MPs to raise local or national issues and receive a response from a government minister. Leading lymphoedema clinicians are asking people to contact their local MP to raise issues relating to lack of lymphoedema services…join the twitter campaign at #lymphoedema

To visit the Parliamentary Office website and find out more about the confirmed debate schedule click here.

Lipoedema Management: Gaps in Our Knowledge

This article brings together varying pieces of literature. It considers that the gaps in knowledge relate to the causes, whether they are hereditary, hormones, adipose cell function or the effect of fibroblasts upon weak connective tissue development.

As research within lipoedema grows, it may prove that there are subcategories, with multifaceted reasons for lipoedema’s presentation. The association with an increased interstitial fluid is considered, within those patients staged as moderate to severe.

Obesity is stated as being present in 50% of women attending clinics for lipoedema, leading to an increased risk of venous hypertension. The complexities of this condition, can lead to further degenerative changes, such as arthritis.

The case study within this article illustrates potential benefits when a multi-disciplinary approach is used in the management of patients, with or without compression therapy. However, it also highlights that the approaches and their benefits within lipoedema management, vary. It is inferred that until causes are established via research, such as genetics, treatment outcomes will vary, but these are based upon the current best available evidence.

Reference: Hodson, S., Eaton, S. (2013) Lipoedema Management: Gaps in our knowledge. Journal of Lymphoedema, 8(1), pp.30-34.

JOBST® Elvarex® Soft New colours

BSN medical are pleased to announce the new colour options our JOBST Elvarex Soft,  custom-fit, flat-knit range.

New colours now match the JOBST® Elvarex® range, as well as an exciting new 'ruby red' colour option for the lower and upper limb, enhancing patient wellbeing and confidence in everyday life.

New lower limb colours: cranberry, dark blue, dark brown, grey and ruby red

New upper limb colour: ruby red

 

Lipoedema Module Launched in JOBST® Academy

BSN medical are please to introduce the new JOBST Academy module ‘Lipoedema’. The new module joins our 18 current modules, increasing BSN medical’s educational offering.


The modular approach of the BSN Educational Academies allows optimum flexibility and choice, without compromising learning content.

Lipoedema module 19 learning objectives:

  • To understand what lipoedema is
  • How to recognise the difference between lymphoedema and lipoedema
  • Identify the classification and possible pathophysiology
  • Understand the assessment of a patient with lipoedema
  • Recognise relevant treatment options for the management of lipoedema including psychological support, weight management, compression and skin care

Interested in organising a JOBST Academy? please click here to find out more.

Predicting Concordance with Multi-layer Compression Bandaging

This article was published in 2011 but with relevance in regard to current practice. It is was estimated that non-concordance (NC) with multi-layer compression bandaging (MLCB) was between 2%-42%. Within this study concordance with treatment was 48.8%.

The primary focus of the study was to compare two antimicrobial wound care dressings for venous leg ulcers alongside MLCB. This separate article focuses on the secondary outcome of the study, to identify predictive factors that may lead to NC.

The study involved 281 patients, and initially identified eleven factors that would increase the likelihood of NC. This was further analysed and led to four main factors:

  • Age - every year increase led to an increased likelihood of NC
  • Pain – an increase in pain (one unit) increased the likelihood of NC
  • Wound size – increases in size led to increased likelihood of NC
  • Wound depth – increasing depth led to NC, but the deeper wound reverse NC

The study has limitations; NC not being its main focus, sample size and missing data.  However, its findings can be seen in other studies, and empirically in the work undertaken in clinical practice. Its contribution is to  make clinicians consider other factors that may lead to NC.

Reference: Miller et al. (2011) Predicting concordance with multilayer compression bandaging. Journal of Wound Care, 20(03), pp. 101-112.

A Lymphoedema Self-Management Programme

This study focuses on the delivery of a self-bandaging patient programme within a Canadian lymphoedema service, with the aim to increase access to multi-layer lymphoedema bandaging (MLLB).

30 patients took part in the programme with the highest proportion being breast cancer related lymphoedema.

Delivered over a two year period, with patients attending intensive MLLB training lasting between 3-12 weeks. Breaking down the components of self-bandaging:

  1. Education on the theory of MLLB
  2. Demonstration of each part of MLLB
  3. Patient / carer reapplying MLLB under supervision   

At each stage MLLB would be demonstrated, and then removed, to allow the patient or carer to reapply.  Follow up times included a monthly appointment for three months, and then every three months for a year. This allowed a review of the bandaging technique, and time to take limb volume (LV) measurement.

The results demonstrated a 48% reduction in LV in those diagnosed with severe lymphoedema, and a 52% reduction in LV in those diagnosed with moderate lymphoedema. Outcomes also revealed:

  1. Patients feeling in control of their condition
  2. Recognition of the effectiveness of bandaging    

The study has limitations in terms of methodology and small sample size. However, it presents ideas that can inform future patient programmes that facilitate empowerment and self-care, which is relevant within current healthcare policy.

Reference: Tidhar et al. (2014) A lymphedema Self-Management Programme: Report on 30 Cases. Physiotherapy Canada, 66(04), pp. 404-412.

Looking After Legs

Looking after legs is BSN medical’s campaign to raise awareness of lower leg conditions such as chronic oedema and ulceration. These are common and costly conditions for the NHS, with greater awareness of appropriate prevention and treatment options needed in the non-specialist setting.

Our aim at BSN medical is to support education within the community to help identify signs and symptoms of these conditions, along with appropriate therapeutic interventions.

To pre-order your Looking After Legs brochure click here to email us your request.

Knee's up with JOBST® FarrowWrap®

MODIFIED KNEE PIECE available NOW with the JOBST FarrowWrap thigh piece.

  • Composed of three easy to apply bands providing easier application
  • Two fabric choices
  • Two compression levels (20-30mmHg or 30-40mmHg)
  • Integrated pocket behind knee accommodates optional foam pad
  • Can be machine washed and tumble dried

For more information please contact your local BSN medical Account Manager or click here to send us an email.

University of Wolverhampton Provide Lymphoedema Care Postgraduate Course

This one year part-time course includes a range of modules that explore issues and factors around the assessment and management of mild / moderate and complex lymphoedema and the contemporary approaches to lymphoedema service delivery in health and social care.

To find out more click here to visit their website.

Living with Lipoedema: Reviewing Different Self-Management Techniques

This article states that there is an estimated 11% of the female population affected by lipoedema, but only 5% of GPs recognising the condition, despite the condition being medically recognised for over 60 years.

Management of this chronic adipose / fat disorder follows similar lines involved within lymphoedema. Alterations in diet have ranged from the Rare Adipose Disorder (RAD) diet, to a low carbohydrate / calorie diet for two days, but there is still limited research to support any of these approaches with 95% stating that weight loss had no affect on the areas affected.

Exercise is considered beneficial through tailored, low impact exercise with 78% reporting that they found aqua exercise beneficial, despite reported knee pain.

55% stated that pain levels decreased with bandaging, and 50% stated the same with compression hosiery when compression therapy was utilised. The psychological impact of the condition is stated as affecting 85% of people, from low self-esteem to depression.

Reference: Fetzer, A., Wise, C. (2015) Living with lipoedema: Reviewing different self-management techniques. BJCN: Chronic Oedema.

Click here to read the article.

JOBST® Ranked #1 Physician Recommended Compression Therapy Brand in USA

BSN medical USA announced last month that JOBST compression therapy garment range has been ranked the number one physician recommended brand in the USA among American Medical Association physicians, who recommend a brand, according to a survey conducted by SERMO, the world’s largest healthcare professional polling company.   

The JOBST brand started it's journey back in 1950, with Conrad Jobst, developing innovative compression products. 50 years later in 2000, the brand received it's first #1 ranking of physician recommended brand and again acknowledged as #1 this year!

New Dates for 2018 - Földi College Course for MLD / CDT

In 2018, the Földi College course dates are:

  • 9th - 13th February
  • 16th - 20th February
  • 4th - 8th May
  • 11th - 15th May

More information and registration details can be found by visiting the Földi College website.

'Best Foot Forward' Leg Club News

The Adam Practice's 'Best Foot Forward' Leg Club in Dorset was awarded four awards during 2017, both national and local recognition for the life changing impact their service is having on members.

BSN medical is a proud sponsor of The Lindsay Leg Club Foundation and offer local support and training. Simon Rowles, BSN medical Account Manager visits the Leg Club in Dorset regularly and is delighted that their work has been recognised, with over 350 members weekly benefiting from this great service.

To learn more about the Lindsay Leg Clubs please click here.

New Pre-registration Education Standards

Pre-registration nursing education is currently under review, following the Willis Report (2015). The review is being led by the Nursing and Midwifery Council (NMC), and is leading to the redesign of standards upon which nursing education is based. This will affect the delivery of education within Universities and the role of clinical practice placements.

Since the draft proposals were announced there have been number of consultation events across the UK.

The Royal College of Nursing (RCN) support a number of changes to the standards, such as student nurses being prescriber ready, and for the assessor and mentor role to be split into two distinct roles. Launch of the new standards is expected in April 2018 and will become embedded into nursing education either in September 2018 or 2019.

To read the RCN’s full response to the consultation please click here.

New JOBST® Academy Module

BSN medical are please to introduce the new JOBST Academy module ‘Head and Neck Lymphoedema’; the new module joins our 16 current modules, increasing BSN medical’s educational offering.

The modular approach of the BSN Educational Academies allows optimum flexibility and choice, without compromising learning content.

Head and Neck Lymphoedema Module 17: learning objectives:

  • To understand the prevalence and types of head and neck cancers
  • To understand how lymphoedema occurs / affects the head and neck
  • To gain understanding of how to assess patients with head and neck lymphedema
  • To understand the treatment options for head and neck lymphedema

If you are interested in organising a JOBST Academy please click here to find out more.

JOBST Wizard

Download our app to make ordering your garments easy. Click here to read more.

Functional Zones

Introducing a new clinical publication supporting the use of JOBST® Elvarex® custom-fit, flat-knit compression garments, with knee and elbow functional zones used to enhance patient choice, garment suitability and potential for improved quality of life.

Abstract:
Lymphoedema management consists of volume reduction, addressing shape distortion and improvement of skin condition. Treatment consists of a two-phase approach, comprising an intensive and maintenance phase. The maintenance stage of treatment or self-care consists of skin care, exercise and compression garments.

The case studies demonstrate how knee and elbow functional zones enhance patient choice, garment suitability and potential for improved quality of life.

To read more about how JOBST Elvarex functional zones might benefit you and your patients please click here.

 

Optomising Concordance with Compression Hosiery in the Community Setting

This article provides an interesting platform for the debate surrounding concordance with compression hosiery. It suggest that practitioners should avoid blaming patients for not adhering to treatments. The potential factors that may impact upon patient concordance are seen as more relevant when set against holistic considerations. These include seven relevant factors:

  1. Pain
  2. Constriction
  3. Choice / acceptability
  4. Loss of control
  5. Mobility / dexterity
  6. Cognitive ability
  7. Application / removal

These are not exhaustive factors, but they offer further thoughts in this area, and provide possible reasons as to why a patient may be concordant or non-concordant. These areas could be addressed through education (staff / patients), leading towards greater knowledge and understanding, but also competence.

Reference: Anderson, I. (2015) Optimising concordance with compression hosiery in the community setting. BJCN, 20(02), pp.67-72

Nursing Associates (England)

Nursing Associates (NA) is a new support role for registered nurses in the delivery of care to patients’. The Willis Report (2015) recommended multiple routes into nursing, which has led to the creation of this role. The two-year program will lead to an expanded nursing role, when compared to a Healthcare Assistant, and will be regulated by the Nursing and Midwifery Council (NMC).

When launched there were 2,000 Student Nursing Associates (SNA) in 11 pilot sites. Now there are a further 1,000 SNA’s who started in April 2017 at twenty-four additional pilot sites. The educational programs for NA’s are delivered in partnership with universities and the NHS, and are set against an agreed educational curriculum.  The pilot sites will form part of an overall evaluation of the viability of the NA role with Health Education England (HEE).  If the NA role remains viable, it will complement the current route into nursing via university education, and the new higher education apprenticeship scheme.

To find out more please click here.

UCLan Course: Introduction to Chronic Oedema Management

Starting January 2018, the University of Central Lancashire is running the Advanced Certificate in Introduction to Chronic Oedema Management, designed to enhance the student’s capacity to manage lymphoedema in the clinical setting. The course leader is Justine Whitaker, Senior Lecturer at UCLan. For more details click here or email: healthcpd@uclan.ac.uk or telephone 01772 893839.

Highlights of this year's BLS Conference

The 2017 BLS Conference kicked off in style at new venue Yarnfield Park, with Sunday ‘Introduction to Lymphoedema  Workshops’ for community practitioners, to help raise awareness and understanding of this chronic condition. Guest speakers Professor Vaughan Keeley and Dr Sharaf  Eldin, presented on obesity and the importance of skin care. The workshops proved a success with more than 100 Community Nurses, Podiatrists, Tissue Viability Nurses and Leg Ulcer Nurses in attendance.

The following two day event delivered extensive education to clinical lymphoedema professionals, including a presentation by Justine Whittaker on Lymphoedema Management at Night: Views from Lymphoedema Patients in 5 Countries, sharing the impact on patient’s lymphoedema and limb volumes when night compression is used.

Professor Peter Mortimer was awarded the ‘Lifetime Achievement Award’ for this outstanding contribution to lymphoedema over the years and was on site to promote his new book ‘Let’s Talk Lymphoedema’.

Diagnosis of Upper-Quadrant Lymphoedema Secondary to Cancer

This clinical practice guideline from the American Physical Therapy Association (APTA) commissioned the writing of an evidence-based guideline for secondary lymphedema.  The goals within its development focused on the ability to 1) describe evidence-based diagnostic methods and criteria for cancer-related Secondary Upper Quadrant Lymphoedema (SUQL), 2) identify gaps in the research for the diagnosis of cancer-related SUQL, 3) create reference publications for identifying best practice related to diagnosis of SUQL. The guideline located a number of research articles that considered the multiple methods of diagnosis from 3D camera to bioimpedance analysis (BIA) as examples.  It was suggested that not one tool was seen to be absolutely accurate, or reliable, in all stages of lymphoedema. However, it was suggested BIA could be used in the diagnosis of subclinical or mild stages, whilst tape measure could be used in moderate to severe stages as examples.  There are noted limitations, such as search strategy dates, and the publication of research studies outside these dates.  However, it provides a useful reference and insight into an area that is developing in both innovation and reliability.

Author: Levenhagen, K., Davies, C., Perdomo, M

Reference:  Levenhagen, K., Davies, C., Perdomo, M. (2017) Diagnosis of Upper-Quadrant Lymphedema Secondary to Cancer: Clinical Practice Guideline From the Oncology Section of APTA. Physical Therapy, 97(7):pp729–45. https://doi.org/10.1093/ptj/pzx050

Self-measurement of upper extremity volume in women post-breast cancer: reliability and validity study

The aim of this cross-sectional study was to assess the reliability and accuracy (validity) of self-measurement (tape measure).  The 17 women who participated in this study, were measured in their clinic on day one and then day ten, through the use of water displacement and tape measure. The participants were educated/trained to perform self-measurement under supervision, and then performed self-measurement by themselves on day seven. The results suggest  that the use of self-measurement was reliable and valid. However, the study has limitations in terms of study design and sample size, which limits application, but adds further knowledge in this area.

Author: Mori T, Lustman A, Katz-Leurer

Reference: Mori T, Lustman A, Katz-Leurer M. Self-measurement of upper extremity volume in women post-breast cancer: reliability and validity study. Physiother Theory Pract. 2015;31:283–287.

https://www.ncbi.nlm.nih.gov/pubmed/25539094

Improving patient concordance in lymphoedema management with SoftFit technology

Lymphoedema and chronic oedema patients are cared for by all members  of the community nursing team. With limited knowledge and understanding of  how to improve the condition, nurses feel under immense pressure in caring  for their patients. This article includes four case studies in which lymphedema  patients were prescribed JOBST® Elvarex® or JOBST® Elvarex® Soft custom-fit, flat-knit graduated compression garments with the addition of SoftFit which proved to provide greater comfort to the patient. All four case studies indicate that wear time and concordance is improved by the addition of this new technology. SoftFit is a unique system of silicone yarns knitted into the inner welt of the compression garment.

Author: Dawn Heal, Lymphoedema Nurse Specialist, The Hampshire Lymphoedema Clinic, Basingstoke

Publishing Journal: British Journal of Community Nursing

For more information about the benefits of SoftFit and to read the full article, please click here or click here to send us an email.

Penile Reconstruction for a Case of Genital Lymphoedema Secondary to Proteus Syndrome

Primary lymphoedema is a complicated area however our understanding is developing as a result of genetic research. Proteus syndrome is considered to be a mosaic syndrome that can affect skin, bones, muscles, fatty tissues and blood and lymphatic vessels. Penile lymphoedema, secondary to Proteus syndrome, is considered to be a rare manifestation. This case report focuses on a 16 year old male undergoing surgery as result of penile oedema. This report is a an interesting case on an area that is considered rare and may not be observed by many lymphoedema practitioners.

To read the full article please click here.

Author: Ashouri, F., Manners, J., Rees, R.
Publishing Journal: ISRN Urology

Motivational interviewing: Experiences of primary care nurses trained in the method

Motivational interviewing (MI) is a technique that has gained prominence due to its perceived success within behavioural change and the focus upon the patient. This person-centred counselling approach was explored within this qualitative study. The study explored the experiences of primary care nurses trained in the technique and its application within the primary care setting. The study applied a number of approaches in gathering and analysing data (semi-structured interviews/content analysis). The themes generated centred on the mutual benefits in facilitating work with patients in need of lifestyle change. However, it also noted that resistance to change, time, support and interest were reasons for not using MI. This approach has the potential to be a beneficial tool when we consider patients who are non-concordant and who may require to be empowered, alongside the nurse.

To link to the full article visit Athens access or NHS library services.

Author: Ostlund, A., Wadensten, B., Kristofferzon, M., Haggstrom, E.
Publishing journal: Nurse Education In Practice

Sensitivity and Specificity of the Toe-Brachial Index for Detecting Peripheral Arterial Disease

The assessment of the arterial system, to establish if peripheral arterial disease is present, has a number of challenges, especially when oedema is present.

The use of ankle brachial pressure index (ABPI) is challenging with those patients diagnosed with lymphoedema / chronic oedema.  This study’s aim was to assess the sensitivity / specificity of toe brachial pressure index (TBPI) compared to ABPI.  It focused on known populations in which an ABPI accuracy would be challenged, such as the elderly, diabetic and those with renal disease.  The results of the study (119 participants) indicates a difference, with TBPI sensitivity (71%) and specificity (78%) compared to an ABPI sensitivity (45%) and specificity (93%).  The study indicates that TBPI has a role within arterial assessment when used in specific populations.

Reference: Tehan, et al. (2015). Sensitivity and Specificity of the Toe-Brachial Index for Detecting Peripheral Arterial Disease. Journal of Ultrasound in Medicine, 34(10), pp

To find out more click here.

Evidence Summary; Managing Lymphoedema: Low Level Laser Therapy

Low level laser therapy (LLLT) has been used to treat wounds and accelerate wound healing and a summary from Wounds Australia supports LLLT being used in the management of lymphoedema. The summary reviewed recent research studies which indicate LLLT has benefits in volume reduction for those diagnosed with upper limb breast cancer related lymphoedema, pain reduction and improvement in limb mobilisation. The most appropriate regime for LLLT is unclear but suggests greater benefits when LLLT is combined with compression therapy and MLD.

Reference: Haesler, E. (2015) Evidence Summary; Managing lymphoedema: Low level laser therapy

To find out more click here.

Study Finds First Possible Drug Treatment for Lymphoedema

A study led by the Rockson Lab, Stanford University School of Medicine, USA has resulted in the discovery of a potential new drug treatment for lymphoedema. The study is the collaboration between two labs, looking at two different diseases, and uncovered for the first time the molecular mechanism responsible for triggering lymphoedema, as well as a potential drug for inhibiting this process.

To learn more about the study please click here.

Footless Tights for the Management of Lipoedema

As per the Best Practice Guidelines for the Management of Lipoedema (1), custom-fit, flat-knit garments may allow more accurate fitting and accommodate uneven or distorted limb shapes better than circular-knit garments (1). If there is no oedema and no risk of oedema in the feet, footless garments can be prescribed (1). BSN medical is pleased to announce that a new style ‘thigh high footless’ is now available on Drug Tariff for both JOBST Elvarex and JOBST Elvarex Soft. This can be combined with the current ‘body bandage style’ already listed on the Drug Tariff to create ‘footless tights’. For more information, please click here.

(1) Source: Best Practice Guidelines: The Management of Lipoedema. London: Wounds UK, 2017.

June is Lipoedema Awareness Month. For helpful advice and information about lipoedema visit Lipoedema UK.

Compression Where You Need it Just Got Easier with Bellisse® and JOBST® JoViPads

Now Available

BSN medical is committed to ensuring clinicians have the products they need to manage lymphoedema / chronic oedema.

BSN medical is pleased to announce the launch of Bellisse and JOBST JoViPads a new ready-to-wear compression garment and pad range that enables you to address lymphoedema, in many areas of the body, including the head and neck, genital and breast / chest.

Bellisse is exclusively distributed by JOBST and is a medical compression garment that:

  • Helps to reduce discomfort
  • Provides gentle, even compression around the torso
  • Facilitates drainage of excess lymphatic fluid from the breast and chest-wall area
  • Offers support and compression following surgery
  • Can be used in combination with JOBST JoViPads

JOBST JoViPads offers a number of solutions to help target and address areas of stubborn oedema and fibrotic tissues and can be used in combination with compression bandaging, wrap compression systems and compression garments.

To find out more please click here.

NEW Compression Therapy Catalogue OUT NOW!

Our popular BSN medical Compression Therapy catalogue has been updated and now includes our very latest product additions and some user-friendly features to support ease of navigation and use.

Available in hard copy and digital format. To view our digital catalogue click here or to order a printed catalogue click here.

A Gripping New Idea

SoftFit technology is a new and unique benchmark standard in the treatment of lymphoedema / chronic oedema. Armsleeve and knee high styles of our leading flat-knit, custom-fit brands, JOBST® Elvarex® and JOBST® Elvarex® Soft, are now available with the additional option of SoftFit technology. This unique system of silicone yarns, knitted into the inner welt (knitted top band area of the garment) provides more gentle, seamless friction on the skin which means there is no cutting in and less slipping down, even when moving about. SoftFit is fully reimbursable and available on the Drug Tariff. 

BLS - Call for Abstracts

The oral presentation of abstracts and the display of posters detailing work done by both members and non-members is a key element in the exchange of good practice at the British Lymphology Society Conference.

Abstracts for oral and poster presentations may be submitted on the following:

  • Research studies
  • Clinical audits
  • Case reports
  • Service developments / educational initiatives including user involvement
  • Literature reviews

The deadline for abstracts is 26th May 2017. To find out how to submit click here.

The 7th International Lymphoedema Framework (ILF) Conference

This year's ILF Conference is being held in Siracusa, Italy from the 21st - 24th June. The programme is packed with key speakers and topics that we are sure will have enormous appeal to those healthcare professionals managing all aspects of care for lymphoedema, chronic oedema and lipoedema patients. We are excited to hear that Karen Morgan, National Lymphoedema Education and Research Lead in Wales has been accepted to present the findings of the ‘On the Ground Education' and the development of the 'Chronic Oedema Wet Leg Pathway' programme that took place in South Wales. To find out more about this conference click here.

JOBST® FarrowWrap Drug Tariff Range Expanded

BSN medical is pleased to announce that the JOBST FarrowWrap Drug Tariff range is now expanded to include the gauntlet.

We believe the addition of the gauntlet onto the Drug Tariff will be welcome news to healthcare professionals and patients. It can also be combined with the JOBST FarrowWrap armpiece, which is already fully reimbursable on the Drug Tariff.

Best Practice Guidelines for Lipoedema

BSN medical is proud to be a corporate sponsor of the ‘Best Practice Guidelines for the Management of Lipoedema’ produced by Wounds UK. These guidelines were produced by expert clinicians involved in the treatment of lipoedema from all around the UK, and who are passionate about improving awareness and care of patients with lipoedema. The guidelines highlight the need for compression therapy in the treatment of lipoedema and lipo-lymphoedema patients, and also post-liposuction.

To read the guidelines click here.

Lymphoedema Courses Now Available

You can find out which education route is right for you with the University of Glasgow. One of their lymphoedema courses might be what you are looking for to develop new skills and knowledge in lymphoedema management. 

To find out more please click here.

3rd Advanced Lymphoedema Specialist Event

Thank you to all the delegates that attended BSN medical’s 3rd Advanced Lymphoedema Specialist Event at the Park Regis Hotel in Birmingham this week. This engaging event included the launch of the revolutionary new JOBST® Relax custom-fit compression garment range for the management of lymphoedema at night and the delegates received a technical presentation from the designer of the product. This was preceded by an informative presentation from Justine Whitaker on the ‘Lymphoedema management at night: views from patients across five countries’ study that was published in the BJCN in October 2016 and provides an insight and understanding into the use of night-time compression in the management of lymphoedema from a patient perspective. Rebecca Elwell’s early product evaluation feedback on the use of JOBST Relax on two patients prompted lots of discussion. In support of the BLS Lymphoedema Awareness Week and the launch of this product, all delegates participated in ‘the big shleep over’ in their JOBST Relax garment, which provided valuable feedback in the management of lymphoedema.

Please click here to learn more information on JOBST Relax and click the clinical tab to read the article.

Dorset Lymphoedema Steering Group Event

A “Chronic Oedema Awareness Day” was held this week to help educate and raise awareness of lymphoedema / chronic oedema in the community, with a focus on; management of obesity-related chronic oedema, the compression garment choices available on FP10 and the local referral pathway.

The day was supported and sponsored by BSN medical Lymphoedema Development Manager Joe Emms and Account Manager Simon Rowles.

Genetics and Lymphoedema

The future of genetics is an evolving story, with new techniques that enable manipulation of DNA, and whether they may serve as a progressive means in re-writing this story.  However, genetics can be a confusing subject to navigate.  This comment piece summarises some of the key terms used within genetics, historical developments and how these relate to lymphoedema.

To find out more please click here.

References: Cooper, G. (2017) Genetics and lymphoedema: a future yet to be fully discovered. British Journal of Community Nursing, 22(1), pp. 646–648

Lymphoedema Awareness Week Begins!

The second day of the annual British Lymphology Society (BLS) Lymphoedema Awareness Week begins and many events are taking place up and down the country.

Today is also recognised as International Lymphoedema Awareness Day and around the world events are taking place to support awareness, research and education. 'Choose your Walk' is being supported by BSN medical USA. It follows on from the good work at last years event which featured Kathy Bates and friends, the well-known actress who lives with lymphoedema following breast cancer. To find out more click here.

To assist in raising lymphoedema awareness, BSN medical is dedicating a  newsletter to lymphoedema, with information that you will find interesting, as well as feedback on local awareness events. To keep up-to-date with the BLS activities please visit their website, click here.

BLS Conference 2017

The BLS has confirmed that Yarnfield Park Training and Conference Centre in Stone, Staffordshire is the new venue to host this two-day event.

Date for your diary: 1st - 3rd October

For further conference details and to submit an abstract click here.

What are the perceived barriers that prevent patients with lymphoedema from continuing optimal skin care?

Patient concordance and its impact upon treatment / management options is an area that creates debate amongst healthcare professionals and therapists.  This qualitative study focuses on the patient experience and how they live with lymphoedema.  It also considers how a patient feels about the need and therapeutic benefit in relation to skin care, and why they appear to be non-concordant. The results of this study recommend patients education and support to help influence patient understanding of the consequences of secondary complications and exacerbations of symptoms when skin care is not maintained.

To find out more please click here.

Reference: James, S. (2011) What are the perceived barriers that prevent patients with lymphoedema from continuing optimal skin care?', Wound Practice & Research, 19(3): 152-157. 

Commissioning Guidance for Lymphoedema Services for Adults Living With and Beyond Cancer

The political and economic environment has led to NHS service provision coming under greater scrutiny.  England has yet to develop national standards regarding the provision and structure of lymphoedema services.  However, work in London has led to a PAN London commissioning document that may have importance and impact beyond the capital.

This commissioning guidance document focuses on services for people with lymphoedema as a result of cancer treatment and sets out what a good service looks like, including patients with primary or secondary lymphoedema. This document which was endorsed last year by the Cancer Commissioning Board, provides a compelling account and strong economic reasoning to why there is a need to improve services.

To find out more please click here.

A review of the evidence for adjustable compression wrap devices

Adjustable compression wrap devices (ACWD) are a recognised effective treatment solution in the treatment of lymphatic and venous conditions.  This evidence review considers the clinical efficacy and the economic implications surrounding ACWD and concludes that claims against cost savings are compelling, alongside scope for improved quality of life for patients.

There is also recognition that further clinical research needs to be carried out in this area to better understand the long term nature of this treatment option.

To find out more please click here.

Reference: Williams, A. (2016) A review of the evidence for adjustable compression wrap devices ACWD

New Developments in Clinical Aspects of Lymphatic Disease

Research in lymphoedema is gaining pace and so is our understanding of the lymphatic system.  This article discusses some new developments in the understanding of the lymphatic system and its major functions. You can also read about the developments in understanding genetics related to primary lymphoedema. This clinical investigation concludes that more work needs to be carried out in this area. The hope is that with these developing technologies, in lymphatic science, there will be meaningful advances in the future.

To find out more please click here.

Reference: Mortimer, P., Rockson, S. (2014) New development in clinical aspects of lymphatic disease.  The Journal of Clinical Investigation. 124(3), pp.915-921

The Foeldi College in the UK

The Foeldi College, established in the 1980's, is one of the world's leading training providers for lymphoedema management and delivers exceptional levels of theoretical and practical based training.

In 2017 the Foeldi College is again coming to the UK with an educational programme covering basic, full therapy, and review courses in manual lymphatic drainage (MLD) / decongestive lymphatic therapy (DLT).

For more information on these courses and how to register please click here.

BLS - New Updated Guidelines

The BLS has recently issued updates to two key documents, supporting members with revised cellulitis guidelines and the benefits of using Amoxicillin over Flucloxacillin for the treatment of cellulitis in lymphoedema patients.

These documents are available in the members area of the BLS website www.bls.com or simply by clicking on the link below.

National Lymphoedema Conference 2017

We are pleased to announce that BSN medical will be attending the National Lymphoedema Conference in London on the 2nd March 2017.

The focus of the event is “Considering the physical and psychological impact of lymphoedema”.

Now in its fourth year and with the full backing of the British Lymphology Society (BLS) and Lipoedema UK, this conference benefits from a very strong and enticing programme aimed at attracting Lymphoedema Clinical Nurse Specialists, Community Nurses and Nurse Specialists interested in new and progressive treatments in lymphoedema management. The British Journal of community Nursing (BJCN) have partnered with the BLS for this conference to ensure current topics are incorporated into the programme, making it fresh and up-to-date. Speakers include Alex Munnoch, Jane Wigg, Denise Hardy and Dr Karen Robb.

Manual lymphatic drainage (MLD) for lymphoedema following breast cancer

This systematic review undertaken by the Cochrane collaboration, was to assess the efficacy and safety of MLD in treating breast cancer related lymphoedema (BCRL). The review searched a number of databases which resulted in six studies being reviewed. The studies looked at MLD and compression treatments. The results of the review suggest MLD is safe and may offer greater benefit in addition to compression treatments, particularly when treating mild to moderate BCRL. Trials with an armsleeve had volumetric inconsistencies therefore further research is required. Despite these inconsistences 60-80% of participants felt better (reduction in pain and heaviness) regardless of which treatment was received. Additional outcomes are also included within this study and it is worth reading the full systematic review.

To find out more please click here.

References: Manheimer, E et al. (2015) Manual lymphatic drainage for lymphoedema following breast cancer (Review). London: Cochrane database.

Associations between the treatment and outcomes of patients with upper and lower limb lymphoedema in Japan: a cross-sectional observational study

This cross-sectional study took place in Japan with the objective of examining the association between lymphoedema treatments and outcomes. Lymphoedema outpatient clinics were the setting with a total of 170 patients participating in the study.  Data collection involved medical records, physical assessments and interviews. Results from the study suggest that secondary lymphoedema was present in 92.9%, with 53.8% of this figure represented by lower limb conditions.  Patients using compression garments were 2.85 times more likely to be satisfied with their treatment compared to those not using compression garments (p<0.01).   Patients receiving simple lymphatic drainage (SLD) exhibited a greater level of satisfaction compared to those not in receipt of SLD (p<0.01). It was also noted that patients quality of life (QOL) was higher in those receiving complete decongestive therapy (CDT) compared to those not in receipt of CDT.

To find out more please click here.

References: Luchi, T. et al (2015)Associations between the treatment and outcomes of patients with upper and lower lymphoedema in Japan: A cross-sectional observational study. London: International Journal of Nursing Studies, 52, pp.913-919.

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