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Background and aims: Lipoedema is a little-known condition that is often misdiagnosed. Lipoedema presents with nodular to swollen areas that can lead to induration, nodular, uneven skin, as well as dimpling and skin flap formation, most commonly on the lower extremities, more rarely on the upper extremities The accumulation of adipose tissue results in characteristic symmetrical swelling of the extremities, ending above the ankles or wrists (cuff-sign). Primary pain phenomena include localized pain, tenderness, painful tightness, and pain on touch and pressure during activities. To get an insight in necessary self-management of pain and symptoms, a narrative review was conducted to identify requirement of self-management for coping with phenomena of pain in lipoedema and associated comorbidities. Methods: The narrative literature review includes international medical and guideline databases, as well as social media reports from affected persons. Analysis was performed using the content analysis method. Requirements of self-management, coping behaviour as well as individual case descriptions were searched. Results: 48 publications were identified. Guidelines and publications on guidelines accounted for a large proportion. Presentation of results outlines the range of requirements to manage pain with a bio-psycho-social pattern in the synthesis. Limiting spontaneous and pressure pain and secondary pain phenomena such as joint pain and mobility limitations are described. The prevention of chronification of pain in association with lipoedema has not yet been a direct aim in the therapeutic strategy. Conclusions: A knowledge gap regarding the incidence of pain syndrome and chronification shows major deficits of self-management strategies and implies further research needs.

In recent years, more attention is being paid to the hormonal aspect of lipoedema. There are suggestions that lipoedema patients may have particular imbalances or sensitivities with regard to oestrogens and/ or progesterone. This article examines the specifics of gluteofemoral fat storage during pregnancy: increased gluteofemoral storage with strong resistance to lipolysis. It then asks if hormonal dysregulation in lipoedema patients could result in a hormonal profile that mimics pregnancy. Such a profile may include high levels of oestrogens, progesterone, prolactin and relaxin, or any combination of the above. This pseudopregnancy hormonal profile would instruct the body to store gluteofemoral fat and strongly resist all attempts to mobilise it.

Lipedema is a chronic, progressive disease of adipose tissue with unknown etiology. Based on the relevance of the stromal vascular fraction (SVF) cell population in lipedema, we performed a thorough characterization of subcutaneous adipose tissue, SVF isolated thereof and the sorted populations of endothelial cells (EC), pericytes and cultured adipose-derived stromal/stem cells (ASC) of early-stage lipedema patients. We employed histological and gene expression analysis and investigated the endothelial barrier by immunofluorescence and analysis of endothelial permeability in vitro. Although there were no significant differences in histological stainings, we found altered gene expression of factors relevant for local estrogen metabolism (aromatase), preadipocyte commitment (ZNF423) and immune cell infiltration (CD11c) in lipedema on the tissue level, as well as in distinct cellular subpopulations. Machine learning analysis of immunofluorescence images of CD31 and ZO-1 revealed a morphological difference in the cellular junctions of EC cultures derived from healthy and lipedema individuals. Furthermore, the secretome of lipedema-derived SVF cells was sufficient to significantly increase leakiness of healthy human primary EC, which was also reflected by decreased mRNA expression of VE-cadherin. Here, we showed for the first time that the secretome of SVF cells creates an environment that triggers endothelial barrier dysfunction in early-stage lipedema. Moreover, since alterations in gene expression were detected on the cellular and/or tissue level, the choice of sample material is of high importance in elucidating this complex disease.

2 Abstract 2.1 Participating professional associations and organisations These guidelines for the diagnosis and treatment of varicose veins were prepared under the guidance of the Deutsche Gesellschaft für Phlebologie e. V. (DGP) in cooperation with the Deutsche Gesellschaft für Gefäßchirurgie und Gefäßmedizin—Gesellschaft für operative, endovaskuläre und präventive Gefäßmedizin e. V. (DGG), the Deutschen Gesellschaft für Angiologie, Gesellschaft für Gefäßmedizin e. V. (DGA), the Deutsche Dermatologischen Gesellschaft (DDG), the Deutsche Gesellschaft für Dermatochirurgie e. V. (DGDC), the Berufsverband der Phlebologen e. V. (BVP), and the Arbeitsgemeinschaft der niedergelassenen Gefäßchirurgen Deutschlands e. V. (ANG). This updated 2018/2019 version is based on the guidelines agreed and drafted by the same associations in 2004 and 2009, and it was adopted by the Boards of the participating professional associations on 30 April 2019. 2.2 Development stage of the guidelines These guidelines are based on a structured consensus process, drawing on published data to create consensus-based guidelines at development stage S2k. 2.3 Delegates of the professional associations See: https://www.awmf.org/uploads/tx_szleitlinien/037-018l_S2k_Varikose_Diagnostik-Therapie_2019-07.pdf. 2.4 Selected literature The recommendations are based on the same publications used in previous versions and a systematic literature review carried out on 21 July 2016 in the German Institute for Vascular Public Health Research (DIGG). The review included randomised studies, meta-analyses, and controlled studies. The literature search was carried out in the Medline and PubMed databases with the following search fields in German and/or English: sclerotherapy, endovenous thermal ablation, mechanochemical ablation, cyanoacrylate glue, surgical procedures (stripping), and diagnosis, prognosis, and postoperative care of varicose veins. A manual search was carried out for later publications up to December 2018.

High-quality three-dimensional (3D) microscopy allows detailed, unrestricted and non-destructive imaging of entire volumetric tissue specimens and can therefore increase the diagnostic accuracy of histopathological tissue analysis. However, commonly used IgG antibodies are oftentimes not applicable to 3D imaging, due to their relatively large size and consequently inadequate tissue penetration and penetration speed. The lack of suitable reagents for 3D histopathology can be overcome by an emerging class of single-domain antibodies, referred to as nanobodies (Nbs), which can facilitate rapid and superior 2D and 3D histological stainings. Here, we report the generation and experimental validation of Nbs directed against the human endothelial cell-selective adhesion molecule (hESAM), which enables spatial visualization of blood vascular networks in whole-mount 3D imaging. After analysis of Nb binding properties and quality, selected Nb clones were validated in 2D and 3D imaging approaches, demonstrating comparable staining qualities to commercially available hESAM antibodies in 2D, as well as rapid and complete staining of entire specimens in 3D. We propose that the presented hESAM-Nbs can serve as novel blood vessel markers in academic research and can potentially improve 3D histopathological diagnostics of entire human tissue specimens, leading to improved treatment and superior patient outcomes.

Lipedema is a multifaceted chronic fat disorder characterized by the bilateral and disproportionate accumulation of fat predominantly in the lower body regions of females. Research strongly supports that estrogen factors likely contribute to the pathophysiology of this disease. We aim to help demonstrate this link by quantifying estrogen factor differences between women with and without lipedema. For time and lipedema adipose tissue conservation, the Protein Simple WES machine will be utilized in place of traditional western blotting. Here, we are interested in evaluating estrogen related factors, such as, but not limited to, estrogen receptors and enzymes involved in the successive conversions of cholesterol and androgens to estrogens in human subcutaneous adipose. Evaluation of these factors within adipose tissue, however, is novel for this instrument. Thus, we optimized tissue lysis and protein extraction for 11 proteins of interest. Antibodies and their working concentrations were determined based upon specific and distinguishable (signal-to-noise) peaks from electropherogram outputs across different tissue lysate concentrations. We found that overnight acetone precipitation proved to be the best procedure for extracting protein from lipid rich adipose tissue samples. Six of the eleven proteins were found to migrate to their expected molecular weights, however, five did not. For proteins that did not migrate as expected, overexpression lysates and empty vector controls were used to validate detection antibodies. Protein extract from subcutaneous adipose tissue and overexpression lysates were then combined to understand if migration was specifically altered by adipose tissue. From these results, we concluded that the lipid rich nature of adipose tissue in combination with the separation matrix designated for use with the WES were preventing the appropriate migration of some proteins rather than non-specific antibody binding or inappropriate preparation methods.

Background: The lymphatic contribution to the circulation is of paramount importance in regulating fluid homeostasis, immune cell trafficking/activation and lipid metabolism. In comparison to the blood vasculature, the impact of the lymphatics has been underappreciated, both in health and disease, likely due to a less well-delineated anatomy and function. Emerging data suggest that lymphatic dysfunction can be pivotal in the initiation and development of a variety of diseases across broad organ systems. Understanding the clinical associations between lymphatic dysfunction and non-lymphatic morbidity provides valuable evidence for future investigations and may foster the discovery of novel biomarkers and therapies. Methods: We retrospectively analysed the electronic medical records of 724 patients referred to the Stanford Center for Lymphatic and Venous Disorders. Patients with an established lymphatic diagnosis were assigned to groups of secondary lymphoedema, lipoedema or primary lymphovascular disease. Individuals found to have no lymphatic disorder were served as the non-lymphatic controls. The prevalence of comorbid conditions was enumerated. Pairwise cooccurrence pattern analyses, validated by Jaccard similarity tests, was utilised to investigate disease–disease interrelationships. Results: Comorbidity analyses underscored the expected relationship between the presence of secondary lymphoedema and those diseases that damage the lymphatics. Cardiovascular conditions were common in all lymphatic subgroups. Additionally, statistically significant alteration of disease–disease interrelationships was noted in all three lymphatic categories when compared to the control population.

Recommendations: 1.1 Evidence on the safety of liposuction for chronic lipoedema is inadequate but raises concerns of major adverse events such as fluid imbalance, fat embolism, deep vein thrombosis, and toxicity from local anaesthetic agents. Evidence on the efficacy is also inadequate, based mainly on retrospective studies with methodological limitations. Therefore, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page. 1.2 Further research should report: • patient selection, including age, effects of hormonal changes (which should include effects seen during puberty and menopause) and the severity and site of disease • details of the number and duration of procedures, the liposuction technique used (including the type of anaesthesia and fluid balance during the procedure), and any procedure-related complications • long-term outcomes, including weight and body mass index changes • patient-reported outcomes, including quality of life. 1.3 Patient selection should be done by a multidisciplinary team, including clinicians with expertise in managing lipoedema. 1.4 The procedure should only be done in specialist centres by surgeons experienced in this procedure.

Tarlov Cysts is a pathological condition, with low incidence, characterized by a painful component with a strong impact on quality of life. The therapeutic options are surgery or analgesics and/or anti-inflammatory medications; however, the condition is still without resolution. Herein, we are reporting a case of a woman who expressly followed a low-calorie ketogenic diet program for 3 months. In addition to the change in diet, an appreciable decrease of weight (−5 kg) and body circumferences were recorded; there was also a marked improvement (evident from the questionnaires administered) in the quality of life, of sleep, and in the perception of pain. It is interesting to note how, in conjunction with the Christmas period, upon leaving the ketogenic regime, there was a recurrence of symptoms, confirming the beneficial effect of the low-caloric ketogenic diet at least on the management of pain and, very likely, on inflammation.

The Polycystic ovarian syndrome is a feature of the various menstrual cycles, infertility, hormonal irregularities, and hyperandrogenism. Insulin resistance, lipedema and hyperandrogenism are the most widespread endocrine disorder in PCOS. Most half of women with PCOS suffer from hirsutism, weight gain, metabolic syndrome, insulin resistance, hypothyroidism, and dyslipidemia. The Aim of the Study is to measure thyroid function, especially hypothyroidism in women with the polycystic ovarian syndrome and its association with insulin resistance. It also aims to estimate the effect of hypothyroidism on the level of each of the following biochemical parameters: lipid profile, glucose, insulin, anti mullerain hormones, sex hormone and thyroid disorders frequency (hypothyroidism) in PCOS. Subjects, Materials and Methods: This study was performed on patients in the outpatient clinics of the Obstetrics, Gynecology and Infertility Clinic and at the al-Yarmouk Teaching Hospital in 2020, and it included 30 (control group) and 70 patients, including 35 euthyroid PCOS and 35 hypothyroidism PCOS (PCOS group), in the age group 15-45 years. Thyroid hormone levels Thyroxine (FT3, FT4) and Thyroid Stimulating Hormone (TSH), Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Prolactin (PRL), Testosterone, Progestogen, Estradiol (E2), Anti Mullerian Hormones (AMH), Thyroperoxidase Anti Bodies (anti TPO), Insulin were measured by using a device cobas e411, and Lipid profile and Glucose by using a device cobas c311. Results: There was an increase in TSH levels, a decrease in thyroxine, an increase in lipid profile levels, an increase in the sex hormones levels, increase glucose and insulin resistance which is a sign of diabetes type 2. However, the reverse is noticed in the relation of hypothyroidism on PCOS with weight gain, lipids, insulin resistance, androgynism and hirsutism. The most frequent thyroid disorders affecting PCOS in this study were found to be autoimmune thyroiditis and hypothyroidism. Conclusions: More than half of the women with PCOS suffer from hypothyroidism, compared to the normal women. As it was observed that dyslipidemia, weight gain, hirsutism, insulin resistance and sex hormones were more in hypothyroidism PCOS women compared to normal control subjects. We also concluded that PCOS and hypothyroidism are interrelated, as the presence of either is a cause of the other and that means the PCOS is more than just oligomenorrhea, amenorrhea, or infertility.

Background: An adequate dietary energy supply is particularly important in patients with lipedema as it promotes weight and fat loss. Accurate estimation of resting metabolic rate (RMR) allows implementing a proper calorie restriction diet in patients with lipedema. Therefore, an accurate assessment of energy demand in patients with lipedema is crucial in clinical practice. Our study aimed to compare actual resting metabolic rate (aRMR) with predicted resting metabolic rate (pRMR) in women with lipedema and to determine the association between individual anthropometric measurements and aRMR.Methods: A total of 108 women diagnosed with lipedema were enrolled in the study. aRMR was measured by indirect calorimetry (IC) using FitMate WM metabolic system (Cosmed, Rome, Italy). pRMR was estimated with predictive equations and BIA. All anthropometric measurements were based on BIA (bioelectric impedance analysis).Results: The mean aRMR in the study group was 1705.2 ± 320.7 kcal/day. Most methods of predicted RMR measurement used in our study significantly underpredicted aRMR in patients with lipedema. We reported statistically significant high correlations between all anthropometric measurements and aRMR/pRMR and a moderate correlation between visceral fat level (VFL) and aRMR. Conclusions: aRMR in patients with lipedema calculated with predictive equations was significantly lower than aRMR measured with other methods. This study found the agreement of predictive equations compared to IC is low (<60%). Fat-free mass (FFM) is a stronger determinant of RMR in patients with lipedema than fat mass.

Attention has been drawn to the role of changes in visceral adipose tissue rather than subcutaneous adipose tissue in the relationship between adipokines and dysfunctional adipose tissue. Especially in lipedema in which subcutaneous adipose tissue is affected, information about adipokines is insufficient. In this study, it was aimed to investigate adiponectin, ghrelin, resistin and visfatin levels and their relationship with adipose tissue thickness in patients with lipedema. For this purpose, subcutaneous adipose tissue thickness was evaluated objectively by ultrasonography. A total of 19 female patients diagnosed with lipedema and 15 healthy women with no age difference were included in the study. Skin and subcutaneous adipose tissue thickness were measured ultrasonographically. Serum levels of adiponectin, ghrein, resistin and visfatin of all subjects were measured using sandwich ELISA protocol. In patients with lipedema, subcutaneous subcutaneous tissue thickness and total skin-subcutaneous thickness were significantly increased in the thigh and calf, excluding skin thickness in the thigh, compared to controls (P0.05). No significant correlation was found between adiponectin, ghrelin, resistin and visfatin and skin, subcutaneous and total thickness measurements by ultrasound in patients with lipedema and controls (P>0.05). Although not statistically significant, when examined in detail, positive or negative correlations were observed between the groups in the relationship between adipokines and ultrasound measurements. According to our findings, although no significant relationship was found between serum levels of adipokines and subcutaneous adipose tissue thickness, it is controversial that they are completely unrelated. Further studies in larger series will shed light on the relationship between adipokines and subcutaneous tissue thickness and the importance of ultrasonography. , Adipokinler ve disfonksiyonel yağ dokusu arasındaki ilişkide subkutan yağ dokusundan ziyade viseral yağ dokusundaki değişikliklerin rolüne dikkat çekilmiştir. Özellikle cilt altı yağ dokusunun etkilendiği lipödemde adipokinler hakkında bilgi yetersizdir. Bu çalışmada lipödemli hastalarda adiponektin, ghrelin, resistin ve visfatin düzeylerinin ve bunların yağ doku kalınlığı ile ilişkisinin araştırılması amaçlandı. Bu amaçla cilt altı yağ dokusu kalınlığı ultrasonografi ile objektif olarak değerlendirildi. Lipödem tanısı almış toplam 19 kadın hasta ve yaş farkı olmayan 15 sağlıklı kadın çalışmaya dahil edildi. Deri ve deri altı yağ dokusu kalınlıkları ultrasonografik olarak ölçüldü. Tüm deneklerin serum adiponektin, ghrein, resistin ve visfatin seviyeleri sandviç ELISA protokolü kullanılarak ölçüldü. Lipödemli hastalarda, uyluk ve baldırda subkutan subkutan doku kalınlığı ve toplam deri-subkutan kalınlığı kontrollere kıyasla, uyluktaki deri kalınlığı dışında önemli ölçüde arttı (P0.05). Lipödemli hastalarda ve kontrollerde ultrason ile adiponektin, ghrelin, resistin ve visfatin ile deri, deri altı ve toplam kalınlık ölçümleri arasında anlamlı bir ilişki bulunmadı (P>0.05). İstatistiksel olarak anlamlı olmasa da detaylı incelendiğinde adipokinler ve ultrason ölçümleri arasındaki ilişkide gruplar arasında pozitif veya negatif korelasyonlar gözlendi. Bulgularımıza göre, serum adipokin düzeyleri ile deri altı yağ dokusu kalınlığı arasında anlamlı bir ilişki bulunmamakla birlikte, tamamen ilgisiz oldukları tartışmalıdır. Daha geniş serilerde yapılacak çalışmalar adipokinlerin cilt altı doku kalınlığı ile ilişkisine ve ultrasonografinin önemine ışık tutacaktır.

Lower extremity edema is a common complaint of patients across all medical specialties. This is a wide group of conditions, ranging from relatively minor conditions such as false swelling in lipedema to life-threatening conditions such as heart failure and nephrotic syndrome. The most common cause of chronic edema is chronic venous disease. High-quality differential diagnosis aims to determine the etiology of edema and initiate targeted treatment.

Lipoedema has received increased attention in recent years. Overlaps with obesity sometimes make it difficult to differentiate. However, this is important for a differentiated targeted therapy. Definition and clinic Lipoedema is a painful, genetic, exces sive increase in adipose tissue on the extremities in women. This leads to a disproportion of the body. The first symptoms often manifest themselves in puberty, the course is usually progressive. Characteristic symptoms are pain at rest and pressure, tendency to hematoma, feelings of tension and swelling, rapid fatigue of the muscles and edema, which are inconsistent depending on the stage. 25–88 % of lipoedema patients suffer from obesity at the same time. Prevalence Depending on the study, 5–9.7 %, corresponding to 2–4 million women in Germany. Etiology Family disposition is obvious. Hormonal changes are trigger factors and suggest hormonal influences. In the tissue there is a slight chronic inflammation (silent inflammation), which explains the symptoms. Diagnosis The diagnosis is made clinically and must be distin guished from other fat distribution disorders. The BMI is not suitable. The waist circumference-size quotient (BCG = WHtR Waist to Height-Ratio) should be used. Therapy interdisciplinary therapeutic approach,which inaddi tion to conservative decongestion therapy, surgical therapy by liposuction also includes nutrition, exercise and psychotherapy.

PURPOSE OF REVIEW: The regulation of blood pressure is conventionally conceptualised into the product of "circulating blood volume" and "vasoconstriction components". Over the last few years, however, demonstration of tissue sodium storage challenged this dichotomous view. RECENT FINDINGS: We review the available evidence pertaining to this phenomenon and the early association made with blood pressure; we discuss open questions regarding its originally proposed hypertonic nature, recently challenged by the suggestion of a systemic, isotonic, water paralleled accumulation that mirrors absolute or relative extracellular volume expansion; we present the established and speculate on the putative implications of this extravascular sodium excess, in either volume-associated or -independent form, on blood pressure regulation; finally, we highlight the prevalence of high tissue sodium in cardiovascular, metabolic and inflammatory conditions other than hypertension. We conclude on approaches to reduce sodium excess and on the potential of emerging imaging technologies in hypertension and other conditions.