Ulises Baltazar and MD, Joseph J. Naoum, MD discuss venolymphatic:the new trend.
Hello. Good afternoon. Welcome to the the Baking Cardiovascular Life Studios. I am Ulysses Baltazar. I am a vascular surgeon with Houston Methodist Cardiovascular Surgery Associate group. And I wanna welcome you to this new segment of this, uh, this program that Methodists has put together The Becky cardiovascular life. Um, lectures. Today is the first episode off the vein and emphatic forum in this segment that will be streamed on every Wednesday off every fourth Wednesday of every month. We'll try to bring you the latest in diagnostic treatment, path of physiology, off paying disease. We will interview leaders in the field around the country. Present cases and, most importantly, have an interaction with our viewers in order to enhance our practices. We learn from each other so well, encourage you, Thio. Send your questions, your comments, the information, how to reach us during this. Um, this transmission is gonna be on the screen in a few seconds and feel free Thio to contact us. So without further ado, uh, today's show will be divided into two segments. The first segment I'm gonna discuss, uh, some of these new trend to join, um, veins and lymphatic six in one single pathology on the pathology one single field that has been happening for the past 15 20 years. And in the second segment, we're gonna, uh, interview one of our partners here in Houston. Dr. Joseph, known who has done ah lot of Bain work, and he is gonna help us out with some questions and some comments. So without further ado, let's start with this presentation about the vino lymphatic trained that is happening in and all over the world for that matter. So when you're a hammer, everything looks like a nail. And you wanna try to use your skills in one way. I like this phrase because it exemplifies a lot off Ah, lot of us what we do in our fields. So when I trained when I did my fellowship in vascular surgery here at Methodist Hospital, I was one of the first class. Is that Dr Lums? They graduated in 2000 and one and two. Somewhere around that that year, arterial surgery was the golden boy and vein surgery Waas, the the you know, the step child. But lymphatic surgery, lymphatic pathology, waas not even in the family. So he's being relegated throughout the years, and now it's coming back. And they there is a huge push in order to bring the lymphatic vessels within active part off the circulation arterial on Venus. So the veins were relegated somehow in the back of the of the of the of the screen until 1999 when the FDA approved radio frequency ablation in the United States. This technique has been used in Europe prior, but in 1999 wasa proving in our country. And this is a minimally invasive procedure that opened tremendous opportunities to treat vein disease with local to mess in an institution. No need for general anesthesia minimally invasive as well. And it's an office very procedure. So what happened is that in the year 2000, there was a boom off vein treatments, uh, insurance companies that, as you know, they are based their reimbursement. According to the C. M s. Uh uh, the way the CMS pay and reverse the procedures start, you know, Brazil. I'm sorry all these procedures were well paid. So the boom began and everybody started trying to do vain procedures in the office thinking that waas easy or waas easy to manage with you know, no problems at all, but hey, waas basically an abuse off the system. But what did we start encountering? We start encountering patients with oedema, uh, but no evidence of venous insufficiency. And that presented a conundrum in the diagnostic of the patient. What are we going? Thio offer this patient if the veins are okay, What is the Causing the Dema and therefore we got to learn about lymphatic physiology and lymphedema. So the trend that I say earlier that for the past 15 20 years to bring the lymphatic within the family of the vascular, uh, surgery, the vascular medicine eyes being, um, supported by many, many off our organizations, like the American College of Live Ology, one of the most respected organizations in our country in regards off, uh, vein disease in 2018 change the name to the American Bain and Lymphatic Society. Try to include the lymphatic into this, uh, into their purview. So American Venus forum then added as well the, uh promoting Venus and lymphatic health and other organizations that have been developing throughout this few years. Foundation for Venus and in fact, disease. And also the American Board off Venus and lymphatic medicine. So there is this trend toe unite the vein and the lymphatic path. A physiology and and treatment in a very active role. Even one off where Most respected Journal, The Journal. So vascular surgery, founded by Dr DeBakey, now has three different, um, brothers or sister has two brothers or sister, whatever you wanna call it, you know, now one of them is the Journal of Vascular Surgery, Venus and Lymphatic Disorders. And the other one is, of course, the general vascular surgery cases and innovative techniques. So this trend thio bring lymphatic closer to the veins is inevitable. So we need to learn and find out why this is happening. And during the this talk, I'm gonna talk about micro circulation and what happens in the capital? A. Is that change the perception of the lymphatic? That's the importance of this thesis talk. I know it's not surgically inclined for us that we love surgery. Sometimes these topics are a little bit, um, on attractive, let's say, but I think it's important that we understand what are the basis off the physiology that happens at the capillary level that make the lymphatic so important that previously they were not considered that important. Um, and we're gonna touch in during this presentation a very simple way in a very rapid way. We're not gonna dive too deep into the questions and all that different environment, because, frankly, I'm not an expert. I'm just wanna learn about this because I think it's important. And I found so s so much, uh, new material that has helped me understand the path of physiology and what has happened at the cap Ilary level? Well, in the micro circulation in the capital, early levels, the you know, is being defined. In many ways, it's a dynamic organized chaos because there are empty and feel capillaries at the same time in different areas. And there is a There is a movement that is called flocks motion that has puzzled some of the researchers. Andi, we're not gonna talk about too much about this, but it's important to know this flux motion is like this. Uh, I will call it may be a Paris static movement that the capillaries, uh, do in order to propose the blood from one end to another without having any muscle layers within within, and obviously is, uh, controlled by metabolic physical humor and nervous, uh, stimuli. So the three, the three segments off the flow of the blood flow in the micro circulation are the capillary flow regulation that is getting the blood there, the hydrostatic on college equilibrium that we know it's a starling principle and filtration. That is how the live is formed. And this is explained by their revise starting principle. That's something that we need to learn. We're gonna concentrate in this segment, uh, more than anything else, and we're going to review the story real quick. I think this, uh, researches positions investigators that dedicate their life toe, develop this knowledge and pass this knowledge to us. They deserve to be mentioned even briefly. But I think we need thio respect the time and effort that they put sometimes lifetime toe find the answers that now they are semi easy for us to find in any any any website, etcetera but everything behind with not big that waas the first one that suggested that limp was formed by plasma that was Phil traded through the cap Ilary walls and hiding Hain, another German physiologist, he published the theory of the secretion of lymphatic fluid through lymph agog. There are substances that stimulate the production of the lymphatic. So there were two different theories the secretion and the filtration. But it wasn't until 18 93 with Ernest Henry Starling that was working and hiding. Himes, uh, laboratory in Germany did an experiment in which he injected Tipton's into the, uh circulation into inter muscular and then recover those spectrums not on Li, not only in the bloodstream, but also in the lymphatic stream. So that brought him to think that there was some sort of filtration absorption mechanism within the tissues that waas taking place in order to move these substances. And in 18 96 he presented his work, and the was the first time that the equilibrium between absorption and filtration, Waas explained in that revolutionized the understanding of fluids fluids in 18 96. But of course it was incomplete. But nobody proposed this because we were lacking of technology to explain this and for more than 100 years when I went to medical school, that's the starting principle that I was taught. You know, the equilibrium between the arterial side, the Venus side, the pressures on Codec and hydrostatic pressures. So this is the original paper off Starling. When he presented this and his experiments where the way he started this thinking about absorption, he isolate the the hind leg of a dog and with a continuous perfusion of blood in the first, uh, dog, he injected, uh, sodium chloride. And this was absorbed from the muscle into the bloodstream, diluting the the blood, decreasing the hematocrit account etcetera account. And this waas What prompted Thio understand and proposed the filtration off fluids from Mosul to the blood stream. But when he injected serum, the absorption was minimum or not. And that obviously explained, uh, explained that gave mawr, um, basis for his theory of equilibrium according to the pressures, uh, young Codec pressure, the hydrostatic pressure that brought in and plasma give into the into the fluids. So with all that being said, then the starting hypothesis waas created and it's basically the equilibrium, and some of these animations are gonna be basic. But I understand also that met students might be watching maybe, uh, college students that wanna going to med school, so bear with me. So the equilibrium is between the filtration from the inside of the vessel to the extra vascular space that eyes gonna be regulated by the on Codec pressure off the outside of the blood vessel and the hydrostatic pressure inside versus the absorption. The absorption of the fluid in the Venus side with the same forces but inverted inside the and chaotic pressure is the one that is gonna bring him in and from the interstitial. Um, the hydrostatic pressure is the one that is gonna push it back in there. One of the researchers in Italy, Luciani, he flat out in 1911. He said that starlings conclusions were so mechanical, self simple, and he wasn't far from the truth. But again, he could improve it neither. It wasn't until 1927. That land is in in the United States. Were being med student, actually. Devise a way, Thio, explain and give some back upto starlings. Uh, styling theory. Uh, principal. I'm sorry. The starting principle of the fluid equilibrium. He measured the hydrostatic pressure on a filtration in the frog Messan Terry, who was able to measure the pressure of the fluid and also how much Waas Phil traded in base of the Red cells. He marked the red cells. So he developed a hey plot the the amounts of filtration and absorption and, uh, found that at the oh, he theorized, And when there was not filtration or absorption What no movement of fluid? That should be the point of equilibrium. Therefore, that pressure should be the pressure off the on Codec. I'm cutting pressure inside the blood vessels that let the keep the fluid from from filtration. So he assigned that pressure to be 24 25 centimeters off water and also further assay byproduct off this this, uh, experiments. He found out that when the teachers were injured, the curve waas execute to the left, and therefore the filtration occurred to less pressure. That's why when there is trauma, injury burns, the teachers swell. Mawr on faster is because the pressure moves toe to the left. So, having these numbers that he, uh, he found he was able to measure the capillary pressure in human fingernail fault at her level. And these are the numbers he found again. Remember the ministerial, uh, capital Arian Codec pressure waas just, um, deducted from that plot they that I showed you earlier about filtration and absorption, and he put it at 24 millimeters of mercury. And and the mean arterial capillary pressure that he found in the arterial in the arterial side genocide and in the capital decide are shown on the screen. So now we have the starling hypothesis. So Landis could give a formula to this hypothesis could express in mathematical language and the filtration per area JV slash a is gonna be equal to the hydraulic permeability. That is the ability of the fluid through, uh, to go through the through the vessel wall, minus the hydrostatic pressure that, as you can see in that cartoon, is Maurin the arterial side than in the Venus side, minus the interstitial pressure that is going to try to push the fluid back into the into the into the inter calculated space and all that subtracted from the from the product off the, uh, intra the capillary in Codec pressure. That is the force that is going to try to keep the fluid inside the blood vessels minus the interstitial han Codec pressure. Now, once we have a mathematical formula, for this becomes a principle, the land this equation is not the Starling Starling. Hypothesis is the starting principle. So this waas, the formula that we a Smet students learn on still in some places still is the one that is not so based on this, uh, discoveries on this experiments for many people, we didn't talk about Oppenheimer and Sorrow Rivera, because for sake of time, this is the drawing that the cartoon that all of us will learn from material side the blood pressure is gonna force the blood, the the filtration from the capillary. The blood pressure is the hydrostatic pressure, and the Codec pressure is gonna try to keep that fluid inside the blood vessel because the blood pressure is higher. The net pressure pushes the fluid out of the vessel when it passes to the Venus side, this is reverse. The blood pressure decreases. Does Martic Pressure is the same. And then the net filtration. The net pressure is negative and the filtration on the filtration stops and the fluid is reabsorbed into the vein site. This explain, according Thio, starting and all the subsequent research is beautifully the equilibrium in the cap Ilary and how this works. So in this other animation, we can see that some of the fluid will be returned by the lymphatic vessels, but minimum amount because most of it is gonna be reabsorbed in the Venus side of the Capitol. Arian the venue. And we stayed there for again for more than 100 years in, uh, 1951. Another variant waas added to the equation stub Erman, uh, developed the reflection coefficient. What is this? This is the original paper that he produced, and we know that some molecules are going across the the blood vessel easily that equals to zero. Sigma is a reflection coefficient symbol, but didn't other that they don't cross it all because the size don't allow that. That is 11 is total. Uh, it was Number one is when the membrane is totally impermeable. Number zero is was permeable. But something happens with those of molecules, so molecules can change, adapt and then go through it, and therefore the number can be can be different and can be adjusted. What? This broad is another variant to the equation. Now we need to add that sigma into the on Codec side of the off the question because not all the proteins are going across the blood vessel main brain, and that will give us more accurate information regarding precious, uh, that are going to maintain inside or outside off the blood vessel in 1963. Guyton, uh, was able to measure the interstitial, hydrostatic and narcotic pressures that wasn't done before. This was very tricky, but he was able to figure this out. And to his surprise, the numbers were way smaller than he thought. And now the numbers were completed along with the ones that land is found earlier, and landis and popping heimer actually calculating the values of absorption and filtration. And those are the numbers These two researchers brought us. The numbers that we manage now that from 7000 liters off blood that yeah crosses the capitalist in 24 hours. 20 leaders are Phil traded 16 to 18 and reabsorb, giving a net lymphatic production of four leaders. So going back a little bit in history. And Earnest Rose Can Max No. And they developed the electron microscope in 1931. You can see there in the slide. In the beginning, the numbers were, uh, 10 nanometers resolution and then improved so much in 1944 that went two nanometers per resolution. The importance of this And why am I mentioning electron microscope when we're talking about the capillary is because in 1940 Danielli was the first one to see this fuzzy like and Otilia layer that was named like Okay, Alex, By loved in 1966. Um, this is like, Okay, Alex plays a huge role in fluid equilibrium, as we're gonna see in this last part of the presentation. So it's a hydra hydra jail like layer that, um, you know, has a human dynamic function that was discovered in 1970 has a lot off total surface in our body. I know we're not used to metric system in the United States, but it's about 4000 to 7000 square meters. That equals to 0.98 to 1.7 acres. This is huge. The thickness depends of the vessel. And they have a negative charge that is given by the proteins and have different functions. The hydrodynamic exclusion layer, uh, modulating leukocyte attachment. They are transducer, mechanic, mechanic receptors, a lot of functions, but the one we are gonna concentrate here. Uh, today is the molecular receive that determine the on Codec forces across in deuterium as well as the reservoir. So the structure is complex, and we're gonna just go, uh, in a brief way through the components. We're not gonna go one by one. Uh, but, you know, has product likens that are mainly mainly the Cindy cans and Olympic cans. And I mentioned this because the Cindy cans are being used now or they are in research in, uh, for research purposes. They are gonna They're measuring as one of the indicators or how severe the disease. Yes. Impatience in I c u. Because the degradation of the black Okay, Alex the syndicate one. So, like a proteins like selecting zinta grins and immunoglobulin like us. I mean black kinds with heparin sulfate that, as you know, is the natural anti quite violent that we have in our blood vessels and other components, as we can see in the slide. So from this simple diagram that we start on, the starling hypothesis becomes this complex when the like okay, Alex is hydrated and has a human trap within structure, etcetera. It's also known, and the material surface layer, if you can. You can find it that way. SL. And as you can see, it's a very complex structure. This is an original picture from Wayne Bond that is one of the lead researchers in like. Okay, Alex. As you can see, all the components are very well organized, and they interact with each other in a very, uh, intimate way. Is a beautiful design incredible from this view from above one of those miracles that life has for us. And if I need to mention for people that have revolutionized understanding off the black. Okay, Alex and the physiological functions in fluid equilibrium are these four gentlemen, there are many. But those are These are the leaders Charles, Michelle, Roger Adamson, Rodney Levick and Sheldon Web. Um, I didn't find it. Picture of the doctor Levick so is not is not being I'm not trying to be funny, is just I didn't find a picture, so I put that generic figure. Now off all these gentlemen, Roger Adamson is the one that we're going to discuss briefly here because gave the foundation toe the new revised theory in 2000 and four. Hey, was measuring pressures and concentrations, etcetera outside and outside inside and outside the blood vessels, and he was able to control the amount of protein inside and outside the blood vessel. And despite that, the young Codec pressure waas the same. There was a 70% difference off pressure in intra Luminal on extra Luminal institutional fluid. And that took him to and go deeper into the like Okay, Alex And is when the sub like, Okay, Alex space, uh, was better described in this space is like the name says is under the black. Okay, Alex, almost in the, uh, in the vessel wall. And this area has their own pressures, hydrostatic and narcotic pressure that that interacts with the intra vascular pressure intra Luminal pressure and then then interacts with the interstitial pressure. So it is a filter. There is no direct communication between the inside of the blood vessel and the interest issue. This is this is shocking, because changes the whole understanding of the physiological, uh, equilibrium in the blood vessels. And, uh, this is from one of the papers that by Levick, another of those four gentlemen that are leaders in the, um, like, Okay, Alex studies that you can see the difference. A huge difference between the classic static principle on the top off the picture and the revised, uh in the bottom. And this also went to describe the to him, a dynamic states. The steady state is when the constant capillary pressure is present and produce constant filtration throughout the cap Ilary. There is no re absorption in the vein side. The transition state is when we have a sudden variation in the pressure when there is an acute bleeding. And then there is some absorption in the vein in the Venus site for a short period of time. Some researchers have found off toe 15 minutes 20 minutes After this happens, the equilibrium reassumes and they, uh, steady states resume and filtration happens. So what happened with the initial concept that Starling had? Well, was he wrong? No, he waas The theory was incomplete because by him having an isolated leg of a dog and having the perfusion somehow rudimentary. But, you know, the time was done. He kept this in a transition state, therefore waas absorption in the Venus side. So he never got the chance to get into the steady state and disprove this, uh, his conduct concept that he tried to promote. So the the starling principle is not wrong is not just in complete. But now, with this new information, we can, uh, correct some of these concepts that we have managed throughout the throughout the whole these years. And once again, we need to correct the equation. Then Doesn't need to be the instead, interstitial eyes the sub like Okay, Alex pressure, hydrostatic pressure and the on Codec pressure, and that will give us a better value off the fluid exchange. So some concepts that now makes sense that you can see there. Uh, I'm just gonna mention one of them, You know, the, uh, in the last one, in septic and on septic patients of rural visitation without human improves cardiac output. But no pulmonary oedema. No, because the equilibrium noise with the outside, Uh, the number two, you know, mentioned that you can give up human. Wait. Some people we used to do a giveaway human and then lay 66 sandwich toe removed through it from the long side. He never work. Why? Because the only thing what's happening is the like of Alex was being dehydrated. So that that cartoon that we have at the beginning now is different after the revised standing principle by led by Adams on and, uh, those four researchers that I mentioned earlier. And this is important thing. Most of the interstitial water or fluids returned through the lymphatic circulation. There is no absorption in the V inside. So suddenly the lymphatic, those puny vessels that nobody wanted really to mess with them become significantly important in the equilibrium and the physiology off fluids. So this is just a brief, brief review off. Why? I think this new trend of bringing the veins and the lymphatic together has exploded all over the world because the lymphatic play a huge role. Aziz we saw here, and they cannot be ignored or put aside anymore. They need to be integrated into the circulation. Uh, anyway, this is the end of the presentation of one apologized for some of the tongue twisters. I'm not used. Thio do live TV. This is the first one, and I'm all excited. But a second part, we're gonna bring Dr Joseph Gnome. It's one of our partners. It's a vascular surgeon here in Houston. He is in Clear Lake, uh, in the Methodist hospital in Clear Lake. And he has vast experience in vain disease. He has published articles. Uh, Joe, how are you? Thank you for joining us. How can you hear me? OK, I can hear you. Just find her. How? It's clear. Leg is raining a lot. Well, we're past the rain. We had a few rainy days, but now we're old. Okay. Well, I'm glad to hear you guys are doing okay. So, Joe, I know you being interested in vain. Salif attics. And what? Tell us, Uh, you know what? Some concept that you manage so well between, uh, the video lymphatic pathology, part of physiology and the relation between the two of them. What is your experience in that? What have you encounter in that relationship? Yeah, So thanks for the question. When I think about Venus disease, I always think about Venus disease as being sort of arising from three distinct components. One of them is the increased hydrostatic pressure that can lead Thio, venous distension involved dysfunction and so forth. And then we know that the increase in hydrostatic pressure that can occur in the Venus system can potentially overwhelmed slightly the lymphatic system. The lymphatic system has about a 1 to 4 millimeter of mercury pressure where they can accommodate that sort off, uh, increased, uh, transportation or the increased amount of fluid that occurs within the lymphatic. Beyond that, that lymphatic get overwhelmed and they and the stroke volume within the lymphatic does not keep up with Oh, I think it for us. I can't believe I want to say the worst of the videos Disease. The worst thing. The Dema, the demons Not necessarily due to the veins. Joe. Joe. Joe, I'm sorry. You We lost you for a few seconds. Can you repeat this? The last part. Uh, please. When you were saying about the the pressures that the lymphatic star managing and then the volume increases eso the lymphatic can tolerate about a 1 to 4 millimeter of mercury pressure within their trans mural pressure. So if the transmitter pressure increases over four millimeters or so, then the lymphatic scan overwhelmed and their stroke quality. They will not be able to push that excess lymphatic fluid up, and that leads to worsening oedema. So that's one of the correlations between Venus disease and lymphatic disease as they come together and present with symptoms. Number two is sort of the bio chemical or hormonal changes that occur within the vessel wall, and we know that there's a lot of inflammatory markers within lymphedema and a lot of inflammatory markers that also lead to varicose veins and varicose veins are associated with increased inflammation, super oxides and so forth, and treating those elements have been shown to help with swelling oedema. Unfortunately, here in the US for our listeners abroad, they will be more familiar with Zoladex side and calcium dove. Isolate these air two compounds that will help decrease inflammation, uh, increase Venus Stone and also improve lymphatic flow. So by addressing those elements, we can address the chemical component. And lastly, the way I think about Venus disease and how it correlates with lymphatic disease is genetics. There is, for example, the fox T two gene variant, so the foxy to Gene has been associate ID Thio, or sort off. It appears to be over, expressed in patients with very close veins and lymphedema, and we know that the fox to Jean one of its various maybe associate ID with the formation of Venus valves and lymphatic valves. So, by putting these three together, we can kinda happen. The sort of the association between varicose veins and lymphedema and vice versa. Great. Yes. So, you know, you touch a point there That I think is very interesting. Uh, for us, you know, surgeons, that is a train that is going all over the world and frankly, has helped explain some of these issues in many diseases. But I don't see why in vinyl, in fact, disease it would not is about inflammation. The inflammatory, Uh, the general information that we are, uh, seems like apart every day in everything we do, everything we eat, etcetera. So, um, do you have any experience with, you know, antioxidants in this kind of disease or what? What alternative medication have you have you used or you have any experience, uh, in your patients for main disease on in fact disease, That might ameliorate the inflammatory response. So exactly. So if I find the patient that I'm suspicious that there may be more of a lymphatic component to their to their symptoms, you know, patients who have a few spider veins, varicose veins. Not a lot of reflux or Venus pathology. And I'm more suspicious at the swelling of the inflammation. Maybe more related to the lymphatic. Uh, you know, I think calcium the vessel, it will work very well. Unfortunately, don't have that available here that's available abroad. And I use that a lot when I was abroad. Solo deck side is also available abroad, not here abroad. We also have other medications, such as just plain old die Usman or the That Flown, which is the sort off brand name for the medication on then, in Italy, you will find, um ah, cycle of three fort. I believe it's probably I think it's an Italian, uh, brand, and they have other other medications here in the U. S. Unfortunately, we don't have these medicines as a sort of a pharmaceutical grade, but we do have options. Uh, if we're gonna be a purist, we have We can purchase a plain old dyas me. You can go on Amazon or any other site, and you can order pure die assessment. And they also have other medications are a combination where they have spared in horse chestnut grape seed extract, die assessment extract available in combination. The way I look at it is if somebody has purely Venus component or significant varicose veins. I tend to lean towards using, uh, diocesan once or twice a day. 500 mg 2000 mg will work if I find that somebody has a sort of a mixed inflammatory kind of think on them suspiciously. Probably some component of lymphedema. I may be more inclined to use a combination, uh, group of herbs, something that may contain grapeseed extra, his paradyne by Austin and so forth. Because I think just kinda having a multi pronged approach to the problem may help. Um, I've looked a lot to see if I can finds, uh, calcium to wrestle it here in the US but we don't We don't have that here. Unfortunately, eso eso those are the alternatives that we have. Um I'm sorry. I'm sorry, Joe. When when you were abroad. Because you know how many people know this But Dr no home, uh, practicing in Lebanon for a few years And when you were abroad. And you have access to those those components Do you have good result? Do you use them? What was your experience with them if you use them? So the experience was actually great symptom. Relief was fantastic. Many patients who experience heaviness, tiredness of the legs, itching at the site of the veins and so forth. They did have some relief. Some patients responded, Better toe medication versus others. So if one doesn't work, you can switch it. Because each medicine has a different combination of different weight on what compounds they're using, uh, basis with Venus ulcers. Then to do much better, their healing improves. And that's also one of the guidelines where, you know, Die. Osman is recommended as part of the guidelines for patients with C AP six uh, disease, Right? So So I find that that helps helps with some of the swelling, but the swelling alone will improve 58 12 15%. But it will improve significantly more with compression. And for those spaces who have sort off, Uh, you know, Class one lymphedema or sort off C A P three Venus disease. The combination off compression and the medication will help them regress at least one level, you know, get rid of the oedema and get them back to the C. A. P two compression alone works, but I think the combination of the two medications will help improve symptom relief. There's some data suggesting that almost 60% of the patients, after about 2 to 3 weeks may, may find that most of their symptoms improve with the combination therapy. Correct? You talked about another, another important topic in the video lymphatic arena. That is compression, you know, And, uh, here in Houston, you know, I mean, it's hot, it's humid, Um, and it is difficult for patients. Thio, where the compression garments, you know throughout the year the way it's supposed to be. So you know any any? What is your experience regarding the pressures that we use, uh, that you use for being a lymphatic disease combined? You know what is the grading that you prefer using or when they have ulceration involved? Any any advice regarding the pressure management eso Again, the recommendations are especially for lymphatic disease. The higher the pressure, the better. Of course, the problem is, it's so hard to wear something that's very tight for a long period of time, especially if it's hot, because then you itch. You start when you want to scratch, and then you break down the skin and so forth, so my approach with patients is where. Start with low pressure and go up with the pressure as much as you can tolerate wearing the compression garment all day. So if you cannot get toe to the 30 to 40 it's okay. Stay 20 to 30 but wear it all day because that's better than wearing the 30 to 40 or the 40 to 50 on Lee a couple hours a day and then removing it, not wearing it for the rest of the day. Because the moment you remove the government, that's it. You return back to almost baseline, so I find that that's important. Patients will have ulcers. I like to use sort of the compression wraps. Not necessarily that wanna boots and stuff, but there. These compression garments are kind of come with Velcro. So the government comes together and you tighten the Velcro, and then you can gradually figure out where the compression is. So my rule there is if you have an ulcer, you start with, you know won't care daily because I think cleaning the wound every day is very important. This thing about, you know, wrapping a boot and keeping it in there for a few days and letting all the fibrin of stuff remain in place. I don't think it's conducive to healing. We know that fabulous extra day kind of decreases wound healing and so forth. So we clean it everyday. We put the compression garments, and then they're easier for the patient to wear because it's just the Velcro. Sometimes they need a second hand to help them adjust the Velcro. But I find it that in general, with good compression within 6 to 8 weeks, most wounds will heal to the point that now you can actually get a good ultrasound to look at the perforate Er's and see what's there to go for the next day? Yeah, no, that that makes complete sense. You know, I've been a an advocate and you know this openly, that when we prescribe compression stockings for patients with vinyl in fact disease and alterations, you know, the textbook has a specific numbers that we need to recommend, because the pressure is the one that is gonna help relief the mechanically the fluid from the from the affected area. But it's true also that the pages are not able to put him on, you know, if you have inpatient that you know is, you know, 70 80 years old with arthritis, there is no way they are gonna put a 30 to 40 millimeters of mercury compression successfully. No way. Right, So I'm with you. I agree completely in the patients that are just starting with with this therapy, I like to start low and then slowly going up to get some benefit out of that compression and normally started with 15 to 20 millimeters of mercury. And I've been criticized about that, but it is more likely the patient is gonna wear it doesn't help writing a prescription for, you know, 30 to 40 or 20 to 30 millimeters of mercury. If the compression is going to stay in the drawer, what good is that gonna do? So I completely understand and agree with you in some patients, even in some patients, I got to the point to recommend wearing leggings. You know, they are not even graded, but it's some pressure versus nothing And get some benefit out of it. Especially patients that are overweight. That is gonna be expensive to get the government because they are expensive when they are custom made Then you start having, uh, problems in regards off cost and time. So I, rather than buying a pair of leggings made of Spanx or Lycra, that are going to deliver some pressure. So I'm just echoing your comment because it doesn't help anybody, right? The correct prescription for those compressions if the patient is unable to put him on or take him off. No, I agree with you. One of the biggest complaints of patients is for not wearing the compression stockings that they hurt and they're too tight. So the goal is to kind of ease them into wearing something light, letting them get used to the tightness and moving on. But you bring one good point about patients who are overweight. Um, you know, the problem with overweight patients is that the problem is, the overweight is in that increased hydrostatic pressure and so forth. So, you know, wearing compression stockings is almost like trying to dry up the floor because the faucet is leaking. We've got to stop the leak. It So I've been in the past few years more aggressive. You know, having the patient understand the problem and recommending by a trick surgery because many patients know they have to lose weight. They've tried to lose weight, and they're not losing weight. And the weight is actually going up. Since they first start having symptoms and eso I've been sort of more, uh, sort of more of a proponent off bariatric surgery. Get them to lose weight because it's been proven that once they lose the weight, you know, a lot of the changes of Venus insufficiency tend to regress. Uh, except for the pigmentation so forth. But most of the stuff regresses inflammation goes down, the swelling goes down, everything gets so much better And s o that, that's that's something. I've kind of changed a lot of my practice. Yeah, You know, I I personally when I discussed the weight with my patients, um, you know, I tried to encourage him to lose the weight healthy in a healthy way. You know, I personally personally think that those diets that make you lose £10 in one week or something crazy they they're just starving your your body and you're gonna rebound with more. Most likely, um, there are some papers out there that recommend losing weight about a pound a week until you lose about 10% of your weight and then you decrease to have a pound until you reach the way you wanna you wanna achieve. That is more official, logical physiologic in orderto lose weight. But it is important. And another thing that I explain to them is on. And I think I discuss this with you before. Yes, I tell them. You know, the fact that is in your your body is not just sitting there doing nothing. That issue is actively producing inflammatory substances that are slowly killing you. 24 7. They're attacking your heart, your brain, your kidneys. So it is very important toe to understand that it's not just there, and I'm gonna start losing the way tomorrow or next week. Now is something that is actively killing you right now. And when they perceived that different, that different angle seemed like they can commit better toe. Do something about that silent killer that is in their bodies, you know? But wait, It's a tremendous problem in being a lymphatic disease and we're fighting against, uh, all the you know, all the system, all the food products and all the advertising and everything and and and you know I'm guilty of that. I'm not saying, you know, all of us and and then events that happened like this panda panda mia that we are going through Many people, without even noticing, have increased their weight because their life changes, their life changes and and and it is difficult. So, Joe, we are almost out off time way. A few more minutes. Anything else you can add about being a lymphatic disease? I'm I really think patients need to be approached with that sort of a multi modality kind of mindset where it's not just, you know, facing. I've been with varicose veins. We're gonna see if there's reflux and treat the reflux and that that's the end of the story. That's like the last part. Because even if you treat reflux, we know that recurrences usually occurs after five years and and so on. So we need to really have the patient understand the problem we got. We have to treat all the causes and trees hydrostatic pressure. Well, is that a valuable problem? Is it that the increase weight is there something going on? Is you know, then we have to treat these sort of inflammatory markers. They're not like to use these Vienna tonic medications for the genetic part genetic part. We can't do anything, but at least we can treat two out of the three major causes. And then then, uh, the most important element now for treatment is compression. Stockings were fortunate here in the US that almost every place we go to has an air condition. So it's our condition. So wearing the saw that compression is not as difficult. Indoors. Outdoors is a different story here in Houston, but in the winter time, I think most people, if not everybody, should have compression stockings at home because my daily socks and compression talking because we're standing. What we see is, as we get older, 70% of the 75 year olds will have varicose veins or some form of veins. So we're so this way by by changing our lifestyle wearing compression garments, you know, taking ah thes anti inflammatory medications for those who have varicose veins. For those who don't have varicose veins, avoid information. So avoid these hand foods avoiding, uh, you know, being overweight and so forth exercising is good. All those things are important. So we really need toe, see a patient and start attacking the chemical changes that happening. Varicose veins, the actual changes of the veins, then looking at the patient's realizing, Is there lymphatic component? Because not all varicose veins just cause a lot of like swelling a lot of the swelling, it appears with the big varicose veins. But those patients who have just these little spider ridiculous veins without massive reflux, that's probably more lymphatic related. And it's a matter of kind of changing that The last thing I want to make sure people understand is swelling in the face of very close veins is not necessarily very closely related. You have to look for other causes. Are the hyper thyroid right? Is there right sided heart failure? Probably heart attention, especially in the elderly. You know? Are they fluid overloaded Trump just congestive heart failure. And they're not taking enough the heretics or are they eating? You know, a lot of salt in their diet, a lot of soy sauce or they're taking a lot of Raman noodles, which has a significant amount off off salt in it. So probing into the patients die, It is also important, because again, varicose veins alone don't necessarily caused swelling in the leg. There's a multi modality for that. Yeah, and agree you touch another good point. Every I think everybody in, uh, needs to have some sort of compression garments because another thing that I that I have discussed with my patients is, uh, you know, people that have normal Venus system that is competent in the lower extremities. But they work as tellers, teachers, nurses. They swell, and they panic. Why am I swelling? My veins are fine. Well, because we're not designed to be standing with no movement, just steady. We're not. The body is not designed for that. So even normal, competent functioning veins in the lower extremities. When you stress them by no moving by not contracting the caps, they will swell to some degree. So obviously is recommended to wear compression stockings. I completely agree with you. Well, Joe, I I wanna thank you for joining us today in our in our first show. You are, uh, you know, a special guest today. You help us, uh, kick this, uh, things up and start Start the Vienna lymphatic form. I appreciate. Of course, we're gonna be working together in the future and with Mawr shows. And and I'm excited about this job. But thank you for coming at our show. And, uh, and share your knowledge. Thank you so much. Thanks for having me anytime, my friend Bob. Thank you. Well,