Hrev_master Veins and Lymphatics 2015; volume 4:4851 [Veins and Lymphatics 2015; 4:4851] [page 7] A phlebo-lymphology humanitarian trip to Matagalpa, Nicaragua Sergio Gianesini,1 Attilio Cavezzi,2 Giovanni Mosti,3 Lorenzo Tessari,4 Francesco Zini,5 Simone Urso,6 Fausto Campana,7 Mirko Tessari,1 Patrizia Dalla Caneva,1 Freddy Espinoza,8 Ruth Rocha,8 Diana Neuhardt,9 Eric Mowatt-Larssen,10 Joe Zygmunt,11 Susan Cortesi,12 Terri Morrison,12 Nick Morrison12 1Vascular Disease Center, University of Ferrara, Italy; 2Eurocenter Venalinfa, San Benedetto del Tronto (AP), Italy; 3Angiology Department, Clinica MD Barbantini, Lucca, Italy; 4Glauco Bassi Foundation, Trieste, Italy; 5Surgical Department, Città di Parma Private Hospital, Parma, Italy; 6Phlebology Department, Prof. Nobili Private Hospital, Castiglione di Pepoli (BO), Italy; 7Vascular Medicine, Bufalini Hospital, Cesena, Italy; 8Fara Foundation, Matagalpa, Nicaragua; 9CompuDiagnostics, Phoenix, AZ, USA; 10The Vein Specialists of Monterey, Monterey, CA, USA; 11Veinz Phlebology Consulting, Kure Beach, NC, USA; 12Morrison Vein Institute, Tempe, AZ, USA Abstract Amigos de Salud and Vene e Linfatici Foundation took part in a volunteer medical trip in Nicaragua. A detailed description of the provided healthcare is reported. Background Chronic venous disease (CVD) is an extremely widespread pathology, affecting up to 60% of women and 56% of men in the indus- trialized Caucasian race. With the bias of extremely sparse literature about the topic, the population in limited- resource countries seem to be less prone to this disorder.1,2 Nevertheless, worrisome data in the few investigated resource-poor population have recently emerged regarding the most advanced stages of the disease, including venous ulcers.3 Under-estimated co-morbidities such as infections, diabetes, arterial disease and trau- ma have been identified as determinants of this burden.4 A dysfunctional lymphatic system and its pathophysiology are directly related to the venous pathophysiology. Even more than this, when lymphatic system is affected, skin infec- tions may more easily occur, which eventually establishes a vicious circle in the venous- lymph drainage impairment. Phlebo-lymphatic disease (PLD) misman- agement, together with lack of appreciation of its co-factors, severely impacts patients in underdeveloped areas. The real drama lies inside the relatively easy avoidance of this scenario by means of adequate disease management. Indeed, severe PLD can lead to disabling conditions such as infections, impaired ambu- lation and even limb amputation. Moreover, considerable working days are lost, potentially severely impacting the social life. Nevertheless, the modern scientific and therapeutic achievements of the industrialized countries have not yet reached the poor coun- tries, leaving these populations in a vicious circle of severe impairment of quality of life and indeed economic distress. Amigos de salud activities Amigos de Salud is a non-profit organiza- tion, which for the last 25 years, by means of medical volunteer trips, has been providing diagnostic and therapeutic interventions for local people in Central and South American countries (Costa Rica, Ecuador, Nicaragua, Peru; http://www.amigosdesalud.org/). The international medical team pays its own travel, covering all their own expenses, assembling all the needed equipment and providing industry contacts that can eventu- ally support the poorest population health- care, as well as scholarships and food programs. Together with the medical team, invaluable help is provided by nurses, assistants, inter- preters and family members of the healthcare team. All together this extra group becomes fundamental to the realization of the whole humanitarian act. This year Amigos de Salud supported med- ical activities in Matagalpa, Nicaragua, in col- laboration with the Italian Foundation Vene e Linfatici, gathering some medical and non- medical personnel dedicated to the care of venous and lymphatic diseases (Figure 1). Thanks also to the conjunction with a local Foundation, an American/Italian team of eleven expert phlebologists was in charge of the treatment of 846 CVD patients for a total of 942 lower limbs. Amigos de salud and Vene e Linfatici Foundation 2014 medical support in Nicaragua Population recruitment and demographics In the months prior to the arrival of the vol- unteer medical group, two physicians of the local Nicaraguan Foundation screened 1000 patients coming from different regions of the country, exhibiting signs of CVD and complain- ing of the related symptoms. Within this population, 117 patients presented with an active ulcer, of which 10 were bilateral. The two local assessors excluded 50 patients because of major co-morbidities that were con- sidered to significantly increase the risk of post-procedural complications. On the patients’ procedural day 104 patients missed the appointment because of unavail- able economic funding to cover the trip to the hospital. Of the residual 846 patients examined and treated by the Amigos de Salud team, 74 were males (8.74%) and 772 were females (91.25%) (Figure 2). The patients’ age is reported in Table 1. Correspondence: Sergio Gianesini, Vascular Disease Center, University of Ferrara, via Aldo Moro 8, 44128 Cona (FE), Italy. E-mail: sergiogianesini@hotmail.com Key words: volunteer, medical trip. Conflict of interest: none Acknowledgements: the volunteer members of Amigos de Salud and Vene e Linfatici Foundation express their deep gratitude for the passionate work that was done and that is still going on by Dr Ruth Rocha and Dr Freddy Espinoza, together with all the members of the local Fara Foundation (http://www.farafoundation.org), and it’s direc- tors, Marcela Cisne, Manny and Maria Farahani. Moreover, extreme gratitude is expressed also in favour of the Industries that supported the volun- teer medical trip (in alphabetic order): Angiodynamics, Cook Medical, Eufoton, Farmax, Flebysan, Gloriamed, HK Surgical, Juzo, Kreussler, Lohmann-Rauscher, Medi, MyCli, Sigvaris, STD Pharmaceuticals, Techlamed, 3M, Trafita-Terason. Received for publication: 30 November 2014. Accepted for publication: 29 January 2015. This work is licensed under a Creative Commons Attribution 3.0 License (by-nc 3.0). ©Copyright S. Gianesini et al., 2015 Licensee PAGEPress, Italy Veins and Lymphatics 2015; 4:4851 doi:10.4081/vl.2015.4851 No n c om me rci al us e o nly Technical Note [page 8] [Veins and Lymphatics 2015; 4:4851] Of the 846 treated patients, 688 (81.32%) were never treated before, while 158 (18.67%) had recurrent or residual disease. Management of the diagnostic and therapeutic process Over the course of the 6 working days the American-Italian team was able to provide all the following diagnostic and therapeutic pro- cedures to the previously screened patients: i) specialist clinical and colour-duplex ultra- sound investigation; ii) ultrasound-guided foam sclerotherapy; iii) preliminary saline flush followed by ultrasound-guided foam scle- rotherapy; iv) endovenous laser ablation; v) laser assisted foam sclerotherapy; vi) catheter directed foam sclerotherapy; vii) ulcer debride- ment and advanced medication; viii) compres- sion therapy; ix) hook phlebectomy. In three cases a sapheno-femoral junction high ligation was performed without major or minor complications at one-month follow-up. All the screened patients underwent a clinical and CDU assessment by the American/Italian team member. Patients then underwent the therapeutic procedure directly with the examin- er physician, or were sent to colleagues who were ready to offer another kind of technical therapeutic option, whenever more appropriate for that specific case. Once treated, in case of an ulcer presence, the patient was sent to the physician in charge of treating the ulcer itself. The age of this ulcer subgroup population ranged from 30 to 84 years. The ulcer etiology was: superficial CVD (36.9%), deep CVD (25.8 %), deep and superfi- cial CVD (33%), not determined (4.3%). The average ulcer area was 60 cm2 (ranging from 1 to 460 cm2), with an onset going back from 3 to 420 months. An active inflammatory ulcer was reported in 69.9% of cases, while 28% already presented granulation and 2.1% re-epithelization. All the patients were treated by surgical debridement, advanced dressings and inelastic bandages. A second wound healing session was possi- ble and performed just in 8.6% of cases. All of them demonstrated improvement from the inflammatory to the granulation state. In Table 2 numbers of performed procedures are reported. Quite impressively, neither minor nor major peri-procedural complications were sponta- neously reported by the patients, whereas two minor post-phlebectomy hematomas and a post- sclerotherapy superficial thrombophlebitis were identified by the treating physicians. Post-procedural management A post-procedural elastic stocking of proper size, length (below or above-knee) and com- Figure 1. Amigos de Salud and Vene e Linfatici Foundation group. Figure 2. First patients joining the Fara Foundation clinic in early morning. No n c om me rci al us e o nly Technical Note [Veins and Lymphatics 2015; 4:4851] [page 9] pression class (15-20, 20-30, 30-40 mmHg) was donated and applied to all the patients (Figure 3). After the treatments, the two Nicaragua physicians were available to follow-up and assist all the patients within the local Foundation clinic whenever needed, even after the American-Italian team’s departure. At one-month follow-up the two physicians were visited by 72 (7.6%) patients. The reasons for the patients returning to the clinic following the original treatment are reported in Table 3. Further to the patients listed above, so far (November 2014) the doctors from the local Clinic are still weekly medicating and bandag- ing 75 out of the initial 117 active ulcers. Considerations on the Nicaragua 2014 experience Despite the short (6 days) commitment to the volunteer medical trip, the medical team was able to provide phlebological health-care to a large number of patients. The 18.67% patients exhibiting residual/ recurrent disease illustrates the need to estab- lish local follow-up expertise, enabling the local physicians to treat signs and symptoms of recurrences at the very early stages. In this way it would be possible to complete the first therapeutic act, guaranteeing the longest dis- ease-free time possible. The 12.34% (104 out of 950) patients who had to drop out because of unavailable eco- nomic funding to cover the trip to the clinic is illustrative of the poverty afflicting these regions. These data highlight the need to pro- vide further support to increase the potentially treatable population, which may benefit from such volunteer medical trips. The presence of a well-trained and experi- enced medical and support team, together with an adequate fundraising campaign and the availability of very generous industry support allowed the creation of a temporary phlebolog- ical unit. A high level diagnostic and therapeu- tic approach was put in place in the local clinic, reaching standards typical of western country health providers. General considerations on volunteer medical trips In poorly resourced countries a major possi- ble cause of drop out from the check up and treatment is the lack of nearby health struc- Table 1. Treated population age. Age (years) 14-25 26-35 36-49 50-60 61-74 >75 0.7% 8.3% 32.2% 30.9% 22% 5.9% Table 2. Performed therapeutic procedures. Procedures Number of treated cases % Ultrasound-guided foam sclerotherapy 605 63.8 Preliminary saline flush followed by ultrasound guided foam sclerotherapy 45 4.7 Endovenous laser ablation 96 10.1 Laser assisted foam sclerotherapy 39 4.11 Catheter directed foam sclerotherapy 15 1.6 Ulcer debridement, advanced medication 117 12.3 Hook phlebectomy 15 1.6 High-ligation 3 0.3 Compression (bandaging) 130 13.7 Figure 3. Amigos de Salud members teaching elastic stockings compression to the patients. Table 3. Issues leading the patients to come back for a visit at one-month follow-up. Patient issue Male Female Check-up 10 Pain 2 14 Superficial thrombophlebitis 4 40 Post procedural skin lesion - 2 No n c om me rci al us e o nly Technical Note [page 10] [Veins and Lymphatics 2015; 4:4851] tures and obviously the lack of sufficient funds for the necessary travel to the clinic. The local physicians who are involved in the patients’ management all year long are partic- ularly devoted to their humanitarian mission in favour of this poor population. Nevertheless, the overwhelming amount of work and the need to be a multi-specialty physician can result in complex management of all patients’ needs especially their PLD. Reports on social health data in under- developed countries are lacking, leading to an unclear scenario of the on-going critical situa- tions and actual needs.5 This kind of data col- lection could also shed some light on those co- factors in PLD development that are not com- monly known in industrialized countries. Conclusions The 2014 medical volunteer trip of the Amigos de Salud and Vene e Linfatici Foundation team to Matagalpa resulted in an effective and safe diagnostic and therapeutic approach to nearly 850 patients affected by var- ious, mostly severe, stages of CVD. Notwithstanding the objective limitations encountered during this experience, the med- ical and non-medical personnel was able to deliver proper care to 846 patients affected by varices, ulcers, lymphedema, post-thrombotic syndrome, venous malformations. Further developments of similar humanitari- an phlebology trips, such as adequate provisional of economical support for educational and diag- nostic/therapeutic needs, are to be expected. References 1. Beebe-Dimmer JL. The epidemiology of chronic venous insufficiency and varicose veins. Ann Epidemiol 2005;15:175-84. 2. Milic DJ. Prevalence and socioeconomic data in chronic venous disease: how use- ful are they in planning appropriate man- agement?. Medicographia 2011;33:253-58. 3. Shukla VK, Mumtaz A, Gupta SK. Wound healing research: a perspective from India. Int J Lower Extremity Wounds 2005;4:7-8. 4. Nag F, De A, Hazra A, et al. Chronic venous ulceration of leg associated with peripher- al arterial disease: an underappreciated entity in developing country. Int Wound J 2014;11:546-9. 5. http://chileangringo.blogspot.it/2009/05/ latin-america-gdp-pp.html No n c om me rci al us e o nly