v-WINter international meeting in Phlebology, Lymphology & Aesthetics 2019

A Pernille é Italiana e já, aqui, tinha estado connosco. Desta vez vem partilhar connosco o Congresso em que participou deixando-nos a sua experiência e aprendizagem

Com tanta coisa para partilhar foi difícil, para a Pernille,  parar de escrever. Abaixo podem ler o texto na sua integra - sugiro que utilizem o google translate (ao lado direito), em caso de necessidade:

Pernille Henriksen
The v-WINter international meeting in Phlebology, Lymphology & Aesthetics was concluded with great success, under the chairmanship of Sergio Gianesini, surgeon of the University of Ferrara held recently in Cortina. 

The scientific event ran over 3 days and gathered 500 experts, in venous and lymphatic pathology, from more than 40 countries. The focus of the meeting was guidelines/evidence, nutrition, venous and lymphatic health, compression and sessions dedicated to regions of the world. 

There was a very in-depth analysis of the current guidelines and medical recommendations where an "under 40" had been given the task to research and find similarities and disparities among them while presenting to the "masters" for an open discussion with some very thought provoking questions. This analysis will be published in the Journal of Phlebology. 

Some of the challenges mentioned were that practice and consensus guidelines are published in many different journals, there are variations in recommendations (i.e. carotid disease has 32 guidelines and non agree), often based on opinion without grades, need frequent revision when new procedures are developed, expensive to produce, influenced by the industry, often not used by the clinicians. An important slide was talking about the appropriateness vs outcomes where appropriateness was the right doctor, the right patient, at the right time, with the right procedure in the right place. The speaker asked for international documents that were developed and endorsed by venous specialists and are consistent. With regards to writing the guidelines a different speaker asked for full sentences answering one clinical question, practical and clear messages, using proper wording, make it understandable and easy to read, avoid acronyms and defining subpopulations to whom it applies. An important slide, seen with the eyes of the patient was to select the appropriate panel which would be a multidisciplinary group of all stake holders including patients. 

During the "Compression School" session it was mentioned that allied health (non medics) are very important to deliver communication to patients. In this respect we are talking about concordance to compression. Professor Mosti talked about compression dynamics and everyday practice. He said "compared to elastic, inelastic material is significantly more effective in improving the impaired venous hemodynamics by reducing ambulatory venous hypertension through reducing/abolishing venous return and increasing venous pumping action". Compression by mild or strong pressure was the question...it depends on the clinical stage of the patient. Compression needs to be based on clinical indications. Bandages and adjustable compression wraps during the therapy phase (venous ulcer, post-procedures, superficial and deep vein thrombosis and lymphedema treatment) and stockings and adjustable compression wraps during maintenance phase (CEAP C0-C5, thromboprophylaxis, post-thrombotic syndrome, post-procedures, lymphedema long term)

Els Brouwer from medi presented on the issue with regards to compliance to compression and how this could be adjusted. Some of the challenges were that expectations of the professionals are too high and the ability of the patients often low, it is age dependant, and the emotional intelligence and circumstances of the patient has an impact. So she urged to educate and coach the patients towards self management. Also in self-applying compression (such as a velcro adjustable wrapping system). Some of the take away messages were it is not easy but knowledge of the compression and the condition increases concordance as poor concordance leads to recurrence (of wounds) and more infections. Activity and movement enhances healing (wound healing) and self management. There is a fear that compression would increase pain and sleeplessness. Obese patients are more likely to complain of constriction compared to normal weight patients. Josefin Damm from Presscise presented a new project with Sahlgrenska University Hospital of Sweden involving a development of an innovative compression sleeve for breast cancer-related arm lymphedema. It would have precise compression, fit all arm shapes, less sizes so there would be no need for custom made, it would maintain the pressure even after the swelling reduced. 

At the introduction of the session on "Fake News in Nutrition" the speaker said that 3 out of 10 patients in the hospital are malnourished and that there is evidence that clinical nutrition is not being enforced...not even in the medical institutions themselves. Urging to find out how to use nutrition/food rather than just feeding medications. There was a very interesting presentation on fasting and it's possible therapeutic capabilities. The speaker, L. Lucchin, distinguished between alternate fasting, caloric restriction, intermittent fasting, fasting mimicking diets and time restricted feeding. Fasting helps cells to multiply - regenerate, even after only 24 hours. He talked about birds migrating, fasting, yet not loosing muscle mass. There were many activities on a cellular level connected with fasting. For sports people intermittent fasting can help with the restoration. He also discussed the need to respect the biorhythm of the body. The liver needs to work at night, and our body is not adjusted to work at night. He urged us to listen to the internal clock. To consider fasting periods for a week every month or every other month. 

During the "Lymphedema" session the first speakers talked about standardisation of guidelines but also the need to individualise and personalise for each patient. There is a failure in the treatment as patients needs to be informed/educated. They might be looking for a cure (I.e. microsurgery) but lymphedema is a chronic condition and they should never leave CDT. Lee BB., from The George Washington University School of Medicine & Health Sciences said: we should learn from our mistakes. Not all lymphedema are the same. Stan Rockson said that data is clear that the use of CDT might reduce or negate soft tissue infection. But even with aggressive therapy the condition might progress. An important slide said that indeed secondary and primary lymphedema are as different as apple and orange in terms of its etiopathogensis and subsequently its clinical behavior including the response to the clinical management although they look like taking same clinical path as a chronic lymphedema.

The "Have a healthy lunch & meeting" session discussed the two cardiovascular appropriate diets, the Mediterranean and the DASH diet. In another presentation some of the key nutritional factors generating inflammation was discussed. These were wrong nutrition habits, degeneration of the Mediterranean diet, modern cereals and industrialised foods. They increase the chronic low-grade pro-inflammatory cellular processes which generate and perpetuate any edema condition. Edema generating foods are carbohydrates, salt, hydrogenated fats/trans omega 6 and 9, caffeine, theobromine, alcohol, dairies and cereals. (lumped together here). Also being overweight can have an impact as fat deposition recalls fluids, there is a dysfunction of the diaphragm and veno-lymphatic return etc. Foods which is "anti-edema" are anti-inflammatory and include proteins (eggs, grassfed meat), citrus fruits, kefir, omega 3, spices (turmeric, garlic, curry), bioflavonoids, inulin, colored berries/salads and olive derived foods (lignans).

With regards to new innovations in products the team from Presscise showed a new bandaging system which included a single use bandage and to add stiffness moldable patches. The bandage material is highly elastic, and is provided with longitudinal markings for correct overlap and transverse markings for correct amount of material for each turn around the leg. The markings function as a guide for how the bandage should be applied. 

A machine from the medical division of Muster & Dikson showed some very promising case studies with patients with long term lymphedema and skin issues. The machine uses lipolaser, radio frequency and ultrasound. In one case study the patient with lymphedema since 20 years and at stage 3 had significant reduction and skin improvement only after 8 sessions. 

Another technology was the carboxytherapy. Carboxytherapy refers to the cutaneous and subcutaneous administration of carbon dioxide gas [CO2] for therapeutic purposes. Little sterile needles are inserted in the skin and a machine delivers the gas. Recent studies have demonstrated the effect of subcutaneous CO2 therapy performed to improve local parameters of circulation, and to reduce localized adiposities. The therapy is also indicated for lymphedema patients.

Overall the meeting was very interesting to attend and It strengthened my belief that the lymphatic system is finally getting recognised as essential to our overall health, elevated to higher importance with dedicated guidelines, research into lymphatic diseases being carried out and new innovative products being trialled. My fellow patient and friend Anna Testa was invited to share her view as a lymphedema patient appealing for increased awareness, not only directed at the medical institutions, but urged patients to be inspired and empowered to take more informed decisions and better care of their lymphoedema. 

As we wait in anticipation for the publication of the LIMPRINT data, from the International Lymphoedema Framework, the impact chronic oedema has on the population and the health care systems will finally be demonstrated. If you are a patient I encourage you to join a national or international patient association/organisation and to make sure World Lymphedema Day (as campaigned by Lymphatic Education & Research Network) on March 6 is celebrated. Lymphoedema is a global problem, it does not discriminate and it is time we make sure our fellow patients does not suffer for years without a diagnosis or the correct treatment.-- 

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