The 6th national colloquium on Evidence Based Integrative Medicine for Lymphatic Filariasis and other chronic dermatoses have focus on public health and advanced research. The meeting aims to invite the experienced experts in the field to Kasaragod. A few of them have already confirmed their participation. These experts will discuss the ranked list of priorities for advancing research in morbidity control of Lymphatic Filariasis and reverse pharmacology studies of Integrative medicine through collaborations. Discussion will also focus on a design for public health course in India, by answering, ‘how to develop an inclusive training program that doesn’t keep out AYUSH systems of medicines and is open for Integrative Medicine’. The colloquium is jointly hosted by
IAD organized similar five symposiums in the past that contributed to advancing the knowledge in Morbidity control of Lymphatic Filariasis and Evidence based Integrative Medicine. The technical reports of these symposiums are available for free download
2005 The first National Seminar on Integrative Medicine for LF
2007 The second National Seminar on Integrative Medicine for LF
2008 The third National Symposium on Integrative Medicine for LF
2009 The fourth National Symposium on Integrative Medicine for LF and Dermatology nursing in India
2011 The fifth National Symposium on Evidence Based Integrative Medicine
Priority setting workshop on Morbidity control of Lymphatic Filariasis and Integrative Medicine
Lymphatic Filariasis (LF) is transmitted by mosquito and caused by a worm like parasite. Common presentation of the disease is lower limb lymphoedema and hydrocoele of testes scrotum. The disease causes deformity of affected limbs affecting the health related quality of life of patients. The WHO classifies LF as ‘a neglected disease of the poor’. The treatment for this has received low priority from the Governments and pharmaceutical industry. Global Programme for Elimination of to Lymphatic Filariasis (GPELF) was formed by 78 nations which are endemic to the disease. Its morbidity control programme is currently focusing on the programs to be delivered to the masses. During the half time review of global Alliance, Integrative treatment of IAD for LF was discussed.
The objectives of priority setting workshop:
1. To list top five priorities for future studies in morbidity control of Lymphatic Filariasis.
2. To stimulate and steer the future research in Integrative Medicine.
3. To design a course for Public Health in the Central University of Kerala.
Steps of Priority setting for morbidity control of LF
Step 1: Initiation and setting up a coordinating committee* Step 2: Literature Search* Step 3: Contacting experts and patients (i.e stake holders ) Step 4: Listing priorities for research Step 5: Random collation of priorities Step 6: Ranking exercises Step 7: Short listing through video conferencing Step 8: Final prioritization work shop on 9th December Step 9: Submitting the recommendations to the Central University of Kerala Step 10: Submission of recommendations to the department of health research, New Delhi, GAELF and other health funding agencies.
What is priority setting for research on LF?
Priority setting for future research attempts to list all research questions which doctors, paramedical workers, therapists and scientists feel important in their routine practice. Priority setting meetings also invite patients to participate in the discussion. Patients have tried several treatments for long and they are able to judge the benefits of these treatments. They have thoughts on which treatments should be evaluated or modified. Anyone interested in morbidity control of LF or Integrative Medicine can participate. Your ideas and experiences either based on pilot observations or ‘gut feelings’ are important for research priority setting. You should log in to the website and submit your ideas. If you wish to know more about priority setting workshops please read James Lind Alliance guidebook.How can you participate in priority setting workshop during the 6th National Colloquium?
There is no separate registration fee for priority setting workshop. If you have an idea on treating Lymphoedema or improving their quality of life or if you have conducted any studies and wish to recommend your thoughts for future research you qualify to participate in this research priority setting program. You can log into www.indiandermatology.org and submit your ideas and research questions. You may also review others opinions and add your observations.
Who can participate?
Anyone interested in the morbidity control of Lymphatic Filariasis and Integrative Medicine is welcome. You may submit your research questions on any aspects of morbidity control. Patients suffering from LF and Lymphoedema are welcome to participate. Physician, Lymphologists, social health experts, Doctors qualified in any system of Medicine (including Ayurveda), therapists, Paramedical experts, nurses, scientists, pathologists are especially invited to participate.
How is your submission processed?
A coordination committee is set up at IAD led by Dr. Aniruddha B Kanjarpane and Dr. Rajendra Pilankatta, supported by other faculty members of IAD and CUK. Submissions are processed on the daily basis. None of the suggestions or priorities submitted will be rejected. When necessary they will be restructured in consultation with the person who submitted the research question. All research questions will be collated by November 15, 2013 under the broad objectives of this work shop.
Aim of ranking exercise is to create a short list of priorities. All research questions later are randomized under each objective to avoid response bias. ‘Random List’ of collated priorities will be published in the colloquium website on 15th November 2013. Those of you participating in the priority setting exercises will be intimated and invited to rank the priorities. Participants will be requested to vote on the priorities before expert review
Interim Prioritization workshop:
Following voting for ranking exercise video conferencing will be held with Lymphologists, molecular biologists, pathologists, ayurveda doctors and patients. Maximum of 12 can participate in a video conferencing through the media of service. They will peer review the ranking exercise and reset the priorities. This group shall short list a maximum of 10 priorities for future research in morbidity control of LF and Integrative Medicine.
Final Prioritization workshop on the 9th December 2013
The aim of this face to face discussion is to identify top five priorities for future research. All participants in the priority setting process are to participate in this workshop. Those who are registered for the 6th national colloquium will also be invited. Prof. Terence Ryan, Prof. Christine Moffatt, Dr. Vaughan Keeley from UK and Prof. Charles Meekenzie from GPELF will participate during the final prioritization workshop.
Expected outcome of priority setting workshop in the 6th national colloquium
The priority setting workshop for future research in morbidity control of LF and Integrative Medicine is expected to identify lacunae and opportunities in the area of advanced research to take the Integrative Medicine to the next level. This will aid in various aspects of progression especially in the area of morbidity control of Lymphatic Filariasis. A new dimension of thoughts will help policy makers, funding agencies and physician scientists to work in favor of the same. Therefore, the following are few examples of questions that are expected to be solved at the end of 6th national colloquium.
1. Which intervention should be evaluated for morbidity control of Lymphatic Filariasis?
2. What kinds of evidence should be looked for to support morbidity reduction of Lymphoedema: clinical, cellular, molecular and biochemical?
3. What are the social factors that need primary consideration to educate stakeholders on the importance of priority setting in integrative medicine and morbidity control?
Hence it is important therefore, to bring about a huge storming session to norm the priorities and leap to the next level of research and advanced treatment delivery.
Compliance of treatment is an unresolved issue in the morbidity control of Lymphatic Filariasis. The integrative treatment should be simple and more complaint friendly. Further work is needed to explore factors leading to better compliance by randomizing the interventions such as washing and emollient, compression vs Ayurvedic and yoga interventions
What are the cellular changes following lymphoedema treatment?
Will lymphoedema aggravate if treatments and compression bandaging is stopped for few days?
Is there skin reversibility following treatment? What are the evidences?
Can lymphoedema be reversed following treatment?
How long patients should wear compression bandages?
Which is the best antibiotic suited for prevention of fever?
Can we stop treatment when lymphoedema is reverse to grade.2 early ?
How can you reduce the cost of the treatment?
How does Yoga work in lymphoedema ?
Is there reversal in grading of lymphoedema?
Which is the frequently grown bacteria and fungi in the intertrigo of lmyphodema?
Determining the underlying structural changes in response to the integrative treatment - is it a matter of change in the fibrotic network? If so, what is the active ingredient causing the change?
Deciphering the Ayuverdic system for the 21st Century Dermatology Looking into translating language of Ayuverda with clinical Images, if possible, quanitfying these differences using modern imaging modalities Creating a biomedical model for treatment of dermatoses using ayuverdic remedies, thus determining the active ingredient for further drug development, and determining toxicity and side effects of ayuverdic treatment.
Why is collagen formed in lymphoedema
Why is elastin fibers destroyed in lymphoedema?
What are the histopathological changes in lymphoedema?
Is venous is associated with Filarial Lymphoedema ?
How much the skin barrier functions compromised in lymphoedema?
Is there more collagen production or less collagen removal?
Is collgenase inhibited?
Why adipose tissue gets deposited in chronic lymphoedema?
Which cytokines should be measured to determine the response to treatment in lymphoedema ?
Is there lymphangiogeneses as response to treatment?
Which outcome measures should be employed to determine the response to treatment?
Epidemiology of LF morbidity and treatment seeking practices need to be studied (Dr. A. C. Dhariwal, Director, NVBDCP, Dte.GHS, Min. of Health & FW, 22 Sham Nath Marg, Delhi-110054, has sent a mail discussing on future priority in his personal view.)
Are all cases diagnosed clinically as lymphatic filariasis genuine cases or do other phenotypes get misdiagnosed as filariasis? I suspect many cases of lymphoedema in India are due to causes other than filariasis and genetic factors will be a likely factor.
Would there be induction of hypoxia inducible factor-α (HIF-1α) due to obstruction of the lymph flow and possibly of blood circulation due to LF? If so, What could be the lymphangiogenic cytokine profile? Would it serve for assessing the treatment progress?
Would there be any cytokine release due to the mechanical stress induced by the obstruction of the lymph flow in the case of LF?
Whether the cytokines released due to LF can increase the expression level of Collagen? If so, TGF-beta as well as IL-1 and PDGF could be a better marker for that ? Then, what could be the role of IFN -gamma?
1.Does downregulation of Toll like receptors on antigen presenting cells and T cells evade deleterious pathological effects in filarial lymphedema? 2. does antagonising profibrotic cytokines limit fibrosis in elephantiasis? 3.mast cells in filarial edema - blocking H1 and H2 receptors will improve epithelial barrier function? 4. targeted therapy for angiogenic factors. will it help in therapy?
I am suffering lympoedema from 9yrs,am so happy that god has given me the chance to get the treatment from IAD.After taking treatment from there showing so much improvements,yoga helped a lot to maintain good health and the oil massage also Worth full. Thanks to IAD & wishing all the success to the team for all activities. please clarify my doubt Q: Can a woman suffering from Primary Lymphoedema conceive and give birth to a child? is there any chance to effect the same to the child also?
Can there be a bio-control system to control the fungus growth in the folds and clefts of lymphoedema patients
1.If compression is the important component in MLD then how to maintain the required and uniform pressure across the limb length in oedematous limbs 2.Reduction of oedema is assessed by measuring the volume and girth .Whether 3D image of the limb can be used to measure the volume and girth to simplify the investigations
Developing a good well fitting foot ware for lymphoedema patients in Indian conditions When to stop the treatment or what is the minimum maintenance DOSAGE of each component of the treatment once the desired reduction is achieved?
Can there be a better yoga / exercise to improve the range of movements (ROM) and muscle strength in lower limb lymphoedema patients with deformity
Earlier studies on lymphatic filariasis shown females have more impact on quality of life while comparing to male and less concordant. The health interventions and education should focus on female since the family health issues will be well managed by females in India and they are least bothered about their health.
No effective management strategies available for hydrocele associated with lymphedema
1. Is ‘whole science’ research possible in Lymphatic Filariasis? Is this possible to use reverse pharmacology approach to understand the response to Integrative treatment? In ‘whole Science’ research studies would be patient centric. Physicians, scientists and patients will work as a team. Physician treating lymphoedema using integrative approach will be able to clinically define the subset of patients who are responding to treatment. They are able to quantify the response and clinical changes documented by photography. Biopsy of the Lymphoedema tissue is done for analysis. Histopathological and immunohistochemical analysis will reveal the changes in collagen, elastin, lymph vessels, inflammatory cells, epidermis and dermis. Same biopsy sample may be simultaneous analysed in vitro to understand why these tissue changes occur. Analysis of cytokine level other molecular and cellular changes such as evidence for angiogenesis, gene expression etc if any should be done before treatment and after treatment. Single procedure of biopsy in willing patients can lead to this multi centre research through participation of patients, physicians and scientists. This is in my opinion whole science research. 2. How long it takes for biopsy wound to heal in Lymphoedema legs? 3. Which are the common bacteria growing over intertrigo? 4. How can patients avoid using toe bandaging? 5. Is it possible to simplify Integrative treatment for Lymphoedema ? 6. Is renal involvement more common in lymphoedema patients? 7. Would thick, non stretchable cotton cloths become substitutes for short stretch compression bandages? 8. How long compression bandages should be worn during day time. ? 9. Should oil massages of integrative treatment be done daily? Whether frequency can be reduced once patients begin responding? 10. If the lymphoedema grading reverse and skin becomes normal is there any further need Indian Manual Lymph drainage? 11. Should there be any diet restriction to Lymphoedema patients? 12. Which antifungal is most effective for intertrigo Lymphoedema legs? 13. How to eliminate intertrigo between toes in lymphoedema patients of coastal region?
What could be the lipidomic profile associated with lipidema ? Would there be any global change in the lipid metabolism during this condition? Can we use the lipidomic change as a marker to understand the response to integrative treatment?
There are good number of drugs mentioned in Ayurveda classics and later books for Shleepada (filariasis), are there any evidence based studies on these recipes? It is claimed by many practitioners that it helps a lot, but to what extent? What may be the mode of action in terms of modern pharmacology view..... any histopathological studies.... changes in structure etc... recorded? Do these drugs have any action on Lymphatic system and also on lipid metabolism?
The internal organs participate in the breathing motion. The manner in which the abdominal cavity and chest cavity are connected by the diaphragm plays an important role in maintaining the entire torso erect. In this way: · The hydrostatic pressure in the both cavities plays a role in erecting the torso · Pressure in the abdominal cavity supports the bearing function of the organs in lifting the thorax via the diaphragm can erect the torso · Maintain posture by using muscular tension erects the torso But improperly used they restrict the motility of the structures involved to the breathing motion. In treating lymphoedema we want to provide changing pressures, mobility and motility of the intra-abdominal and thoracic space and changing muscle tension to decongest the fluid in all possible ways. In the yoga therapy we can find a method in which in all exercises are contributed and controlled by adequate breathing and breathing motion. That’s why it is such a good instrument in treating lymphoedema but also in stress management. Question: The base of the lymphoedema treatment is formed by the pranayama’s which are supported by mudras. The chin mudra facilitates extension of the thoracic spine and facilitates proper breathing and breathing movement. (if the 2e finger and may be the 3e is placed under the thumb). The mrigi mudra gives by the advanced resistance of the airstream a stronger appeal to the diaphragm and makes the breathing in and out longer during in time and also facilitates although less the thoracic extension. This is my experience and western interpretation of the yoga given in the IAD. In Pubmed I didn’t find a review or article about such a vision.
How does yoga work in lymphodema?
How does Yoga correct the gair deformities associated with lymphodema?
What are the comorbid conditions prevalent with filarial lymphoedema patients? How do these conditions affect the management of lymphoedema
Why not think integrating the age old Ayurveda & Traditional Chinese Medicines? Which have both proven track record of success and instilled confidence, in the mankind for several thousands of years, in the various parts of the world
Leveraging the best-of-bread technology advancements in compression therapy & integrating with the current offering, will make the “Post Treatment Care", a simplified & encouraging Experience, for the Needy
Can there be an offering to the needy in-line with today’s technology offering of “Saas” for the Post Treatment Care ie., “PTCaaSO - Post Treatment Care as an Service Offering”, to the needy
Would you please explain your three questions in more detail? Kindly expand the abbreviations used
What is in a name-Scrap the term “Elephantiasis” in more ways than one, it is not true. Lymphoedema may sound very medical, but for the victim/patient it is an appropriate acceptable term. A low I.Q person, can no more be called, an imbecile, moron or Idiot Time Requirements- How does a young patient spend 2 hours of quality time on himself/herself every day, seems criminal and an unprecedented demand on the family? Please find a solution – Is there a simpler format to keep the swelling at bay?. 24 Hours or 48 Hours of inability to attend to the leg for some unavoidable reason will bring the swelling back to square one!. The weight and accompanying fatigue will also follow. Cost of Quality-My financial situation and family co-operation permits me to avail expensive stockings but that is not the general norm. All of us patients will be deeply indebted, if the medical community involved with Lymphoedema will research and come up with Solutions – Affordable quality stockings may help to a large extent.
does a simple case of head ach or fever can be filaria attach.where does parasites reside?how long medications required? is it nessesary to localise or visualise the parasite to start treatment .can the antiparasitics used in injectable form? why we are not using subcutanious antiparasitics and fibrinolitics? if parasites are not visualise or antigen test negative does it means there is no hidden parasite at all. how much reliable a single dose therapy of allopathic mdt resime. does massage and other things required to do life long?
1. Adipose tissue, firbrosis and lymphodema, mechanisms of formation and removal, what is the evidence? 2. skin as a barrier: what does it means when it fails when lymphodema is present? 3. how does yoga work in lymphodema?
Even when there are no signs of nutritional deficiency in the patients, majority of the filarial lymphoedema patients’ HB% is far below normal . Is there a direct relationship with LF and bone marrow (erythropoiesis)?
Since bystander massage and compression is not likely, is it really possible to develop an easy and alternative MLD system for the patients with genital (penile, scrotal and vegainal) oedema ?
Is there any influence of heating (Swedana) in cytokines?
How effectively the skin (Lymphatic plexus) can drain the lymph during MLD when there is a clear evidence of lymphnode blockage in primary lymphoedema and secondary lymphoedema (excision of lymphnode)?
Why do filarial lymphoedema patient without bacterial entry point develop with ADLA when they strain more
What are the investigation to be done during pregnancy to detect primary lymphoedema, if the parent is suffering from the same
Is there any association with primary lymphoedema and heart disease?
Hello All. I am suffering from filariasis and visited IAD centre on May this year and have been continuing the treatment regime since then on a daily basis. The treatment and care was extremely helpful. The staff and doctors were all very co operative and am really grateful to all of them. Before coming to IAD I was operated on my left limb three times as initially it was suspected to be a case of cellulitis by the local doctors at my place. Following the surgery there were depressions left on my left leg - Ankle region and in front of the toe region. I am seeing good results by following the treatment process in my entire leg except for the regions (near the toes and fingers) below the depressions due to surgery. Due to this my toes and fingers are always swollen despite bandaging them and are also painful at times. Can you please advise me if I can do something different for my fingers as the compression and oil massage is not yielding comparable results in this region?
Is their Anny research about comparison of long stretch and shortstrech compression materials?
1) What is an appropriate shoe/chapel for someone suffering from LF? 2) Would the patient concord with wearing said sandal? 3) Would wearing appropriate footwear suitably reduce the risk of further infections? 4) Could rubber/verrucae/swimming sock could be used for those in the rice fields to reduce incidence of fungal infection? 5) To improve mobility could we assessment for limb length discrepancies for possible use of footwear modification?
What is the attern of hair in lymphodema limbs?
Record and analyze the amount of fluid that gets shifted overnight. what is the Quantity of reducible oedema in LF?
ABPI in lymphodema patients is it important?
What determines the concordance to treatment in lymphodema patients?
What is the Critical care of lymphodema patients ?
What factors determine whether patients comply with the use of the bandaging techniques taught at IAD for long term management? would patients consider wearing made to measure compression garments for long term management instead of bandages? would there be an improved outcome?
Due to the overwhelming response the ‘Random List’ of collated priorities will be published in the colloquium website only after 25th November 2013
Are traditional medicines practiced in Bihar for Hydrocele effective?
Do acidic soap or triclosan containing soap reduced number of bacterial entry points on lymphodema legs?
How to manage lymphodema in arterio- venous malformations?
How safe is to give compression bandages in pregnant lymphodema patients?
What is the differential impact of integrated theraphy protocol wise for LF on the lymphatic system
Capturing evidence across phases/stages/complexities of LF, for individual protocol component for tis effectiveness
Establsihing Low cost best practices to adress LF phase wise and complexity wise.
Idnetify reusable, recyclable indigeneous materials and methods for Morbidity control in endemic regions of India.
Critical analysis of individual LF intervention methods with evidence, and arriev at best practices
1. Is there a role of medication once the lymphoedema (irreversible) sets in and once the blood tests are negative? will this help in prevention of spread? 2. How reliable are the blood tests for initial diagnosis and followup during the treatment? 3. What is the role of mass drug administration in prevention of filariasis? 4. Just a wishful thinking.....! Since IAD has developed integrative treatment module for lymphoedema which it trains the patients attending IAD, can the same module be taught to all the medical students in all the colleges during their MBBS course itself as one day training session (certificate) by IAD initially and later continued by trained staff? Since we are aware that this treatment will not be focused much practically during undergraduation degree unless we find a case in the hospital, and such training will help doctors treat efficiently when they are posted in primary health centers and even train his/her paramedical staff.
Do'Shakotaka'-a plant much appraised in Shushruta Samhita in the mgmt of Sleepada has any evidence or research data?
Do Virechana(medically induced controlled purgation therapy) has any effect on the limb size reduction? Any study conducted?
Will Raktamokshana (blood letting) help in better/speedy relief? (there are physicians who practice this and claim as it helps, do you have any such recorded data?
What is the IAD experience on the role of Panchakarma therapy in lymphedenoma management?
What may be mode of action of herbomineral preparations like Kaishora Guggulu vati, Nityananda Rasa etc. in modern parlance?
How do we develop a community based model for lymphoedema management.