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OBJECTIVE: To evaluate methods to assess peripheral edema for reliability, feasibility and correlation with the classic clinical assessment of pitting edema. DESIGN: Cross-sectional observational study. SETTING: Large primary care clinic in Marshfield, Wisconsin, USA. PARTICIPANTS: Convenience sample of 20 patients with type 2 diabetes and a range of edema severity, including patients without edema. METHODS: Eight methods of edema assessment were evaluated: (1) clinical assessment of pit depth and recovery at three locations, (2) patient questionnaire, (3) ankle circumference, (4) figure-of-eight (ankle circumference using eight ankle/foot landmarks), (5) edema tester (plastic card with holes of varying size pressed to the ankle with a blood pressure cuff), (6) modified edema tester (edema tester with bumps), (7) indirect leg volume (by series of ankle/leg circumferences), and (8) foot/ankle volumetry by water displacement. Patients were evaluated independently by three nurse examiners. RESULTS: Water displacement and ankle circumference had high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left). Agreement was inconsistent for figure-of-eight (0.64, 0.86), moderate for indirect leg volume (0.53, 0.66), and low for clinical assessments at all locations. Agreement was low for the edema testers but varied by the pressure administered. Correlation with the classic, subjective clinical assessment was good for the nurse-performed assessments and patient questionnaire. Ankle circumference and patient questionnaires each took 1 minute to complete. Other tools took >5 minutes to complete. CONCLUSIONS: Water displacement and ankle circumference showed excellent reliability; however, water displacement is a time-consuming measure and may pose implementation challenges in the clinical and clinical trial environments. Patient-reported level and frequency of edema, based on an unvalidated questionnaire, was generally well correlated with the physician assessment of edema severity and may prove to be another reliable and accurate method of assessing edema. Additional study is needed to evaluate the validity and responsiveness of these methods.

A lipedema is characterized by the bilateral and symmetrical en-largement of the lower limbs without the involvement of the feet and a negative Stemmer’s sign; it may cause skin hypothermia, alteration in the plantar support, and hyperalgesia. The current study aims to report a rare type of ulcerative lesion in a patient with lipolymphedema treated with a damp low-stretch bandage. The patient is a female, age 50, with a family history of lipedema, and who has suffered many episodes of erysipelas in the lower left limb for approximately 20 years. For over five years ulcers which are difficult to heal have appeared. She was treated with a damp low-stretch bandage and the healing of the wound has shown significant improvement. Ulcerative lesions are rare in lipolymphedema; however, their occurrence is associated with difficulties in healing.

The challenges of providing effective treatment for patients with lymphoedema-related disorders have never been more prominent. Conservative management of lymphoedema remains of central importance, however, there is increasing evidence that other therapies, such as surgical approaches, may have an important part to play in the arena of treatment. The findings from these proceedings highlight the potential role that surgical approaches, including liposuction, can have in transforming the lives of patients. Conservative approaches, while effective in many patients, do not provide a solution for some of the complex issues patients face, nor do they always provide sustained results even after periods of expensive, intensive treatment. Relatively little attention has been placed on the impact that lymphatic conditions have on the lives of patients and their families. However, research is beginning to show that patients’ health-related quality of life is significantly affected and that previously dismissed symptoms, such as pain, are a feature of the condition. Lymphoedema and lipoedema are both likely to have a deleterious effect on the body image of patients who live day-to-day with distorted limbs. Treatments such as liposuction have the potential to reverse some of the crippling effects of these disorders on the psychosocial health of patients. The indications from these proceedings are that this is an important and encouraging area of practice that must be considered as part of the armoury of treatment. Liposuction has often been viewed negatively by the lymphoedema community, who have been sceptical about its value and concerned for its safety. This document shows that when it is used appropriately, by well trained surgeons, it can be very effective. In fact, the area of liposuction now has a growing evidence base that rivals many of the other conservative areas of lymphoedema management. Management of lymphatic conditions demands that the professional groups begin to work together in a more collaborative way in order to develop treatments that really address the growing number of patients with these types of conditions.

Knowledge of both the morphology/ pathomorphology and physiology/pathophysiology of adipose tissue is limited and the behaviour of fat tissue has not been widely researched. Changes in adipose tissue (hyperplasia, hypertrophy and atrophy) are defined differently and, as a consequence, diagnostic failures frequently occur. Figure 1 shows the complicated regulatory mechanisms which are responsible for lipolysis and lipogenesis. Even if body weight is normal, appearance depends on the distribution of subcutaneous adipose tissue (Figure 2) . The amount of fat we carry and how we look are, in part, subject to fashion. What was still sexy several decades ago, a bigger waist and more on the hips, no longer corresponds to how we see perfection today. Figure 2 shows the different ideals of beauty — ‘Wonderwoman’, for example, where you can detect as little fat as possible. Recently, there has been a mania for slimness. In order to comply with the current trend in fashion, young girls starve or undergo surgical procedures to have the typical female fatty tissue removed.

Lipoedema is a disease characterised by an abnormal, circumscribed accumulation of subcutaneous fat, mainly in the lower extremities, in combination with oedema. This results in an obvious disproportion between the upper and lower half of the body, as well as pain (Figure 1). Although lipoedema was first described in 1940 by Allen and Hines in the United States of America, the discussion still continues today as to whether this disease really is an entity, with some clinicians even doubting that it exists. In the 1940s it was described as a symmetrical subcutaneous deposition of fat in the buttocks and lower legs, together with an accumulation of fluid that begins almost imperceptibly, progressing gradually. Lipoedema was often associated with weight gain and accentuated by orthostatic activity.

Lymphoedema is a debilitating, progressive and incurable pathological condition caused by a chronic imbalance between the production and transport of lymph within the lymphatic system. There are many reasons for this damage or disruption to the lymphatic system. Lymphoedema results in significant physical and psychological morbidity. Approximately 140–250 million people worldwide are affected by this condition, mostly in developing countries as a result of lymphatic filariasis, a parasitic infection transmitted by mosquitoes. In the majority of cases, treatment is non-curative, complex and requires a multidisciplinary clinical approach. Surgery takes place as a last resort when conservative treatment has proven ineffective to restore function, reduce comorbidity or the frequency of erysipelas attacks.