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Purpose To evaluate the use of inframalleolar access for endovenous ablation when treating advanced venous disease with nonthermal nontumescent (NTNT) techniques. Methods This single-center retrospective study included 109 patients with advanced venous disease, treated using inframalleolar access between May 2018 and March 2020. NTNT techniques included ClariVein (Merit Medical Systems, South Jordan, Utah) and ScleroSafe (VVT Medical, Kefar Sava, Israel). Outcomes measured were postprocedure pain, leg edema, ulcer healing and recurrence rates, and venous insufficiency recurrence. Results Seventy-seven patients (70%) were treated with ClariVein and 32 (30%) with ScleroSafe. Postprocedure pain score (range, 0-10) after 1 week decreased from a preprocedure median of 5 (interquartile range, 3-6) to 1 ((interqartiel range, 0-2) (P = .0001). Complete wound healing was achieved in 38 patients (43.7%) after 30 days and in 71 patients (81.6%) after 90 days. One patient developed an ulcer recurrence and six developed venous insufficiency recurrence. There was no reported nerve or skin injuries. Conclusions NTNT ablation techniques using inframalleolar access are effective and safe without risk of nerve damage. Their use facilitates ulcer healing and limits pain in patients with advanced disease.

We evaluated the effect of first-visit foam sclerotherapy compared with scheduled treatment for patients with venous ulceration.The study design was a retrospective comparative study. From December 2009 to October 2019, a total of 245 venous ulcers in 214 patients (including recurrent ulcers) were treated at Oulu University Hospital. Of these 245 venous ulcers, 143 were treated with first-visit foam sclerotherapy (group A) and 102 with scheduled treatment (group B). All patients received endovenous ablation (foam sclerotherapy and/or endothermal ablation) and compression therapy to promote venous ulcer healing. The primary outcome was the interval to ulcer healing, determined by Kaplan-Meier survival analysis. The secondary outcomes included the time to ulcer healing from the receipt of referral and ulcer recurrence.The median time to ulcer healing was 2.3 months for group A and 3.2 months for group B (P = .002). The estimated median ulcer healing times after referral for a first session of endovenous ablation were 2.7 months with a delay of 1 month from the referral, 3.3 months with a delay of 1 to 2 months, and 5.0 months with a delay of2 months (P = .002). In group A, recurrent ulcers were recorded for 11 patients (7.7%). In group B, recurrent ulcers were recorded for 12 patients (11.8%; P = .281).The results of the present retrospective comparative study support first-visit foam sclerotherapy as an effective method to initiate endovenous ablation to promote venous ulcer healing. In venous ulcers, delays to endovenous ablation should be avoided whenever possible.

Study design Systematic review and meta-analysis. Objectives To identify, critically appraise, and synthesize research findings on non-sensate versus sensate flaps among individuals with spinal cord disease and pelvic pressure ulcers, with pressure ulcer recurrence as primary outcome. Methods PubMed, EMBASE, and Cochrane CENTRAL were screened for relevant studies. Data on surgical characteristics, ulcer recurrence, and sensory outcomes were retrieved and tabulated. Risk of bias was assessed with MINORS. The level of evidence was evaluated with GRADE. Meta-analysis was performed when possible. Results Meta-analysis of 1794 non-sensate locoregional reconstructions indicated a recurrence rate of 34% within several years (95% CI, 27-42). Twenty-one articles provided data on 75 sensate reconstructions, performed in 74 individuals. Meta-analysis of the sensate reconstructions indicated a recurrence rate of 1% (95% CI, 0-8). Sensate reconstructions were not associated with an increase of wound complications (19%; 95% CI, 7-40) compared with non-sensate ones (34%; 95% CI, 27-42). A very low level of evidence was determined with use of GRADE. Conclusion Although of a very low-level, the present evidence suggests that restoration of sensory innervation may be an effective intervention for the prevention of pressure ulcer recurrence among individuals with spinal cord disease. A prospective RCT is needed to confirm or refute the results of this systematic review.

Although surgical offloading seems a more permanent solution for prevention and treatment of neuropathic plantar diabetic forefoot ulcers (DFUs), the evidence for this assumption is weak and needs further studies to be established. The aim of this retrospective study is to compare the healing efficacy, associated morbidity, and recurrence rates of surgical versus removable knee-high offloading for neuropathic plantar (DFUs) healing. From January 2016 to January 2018, 70 neuropathic plantar forefoot DFUs were nonrandomly assigned to either removable knee-high cam-walker (n = 35), or metatarsal head, or accessory bone resection (n = 35). The primary endpoints were the frequency and rate of complete healing, and the rate of ulcer area reduction within 4 months. The secondary endpoints were 4 months morbidity and ulcer recurrence within 12 months. After 4 months, complete healing was significantly inferior with cam-walker compared with surgical offloading; 24 (67.6%) versus 31 patients (88.6%), respectively, P = .015. Ulcer area reduction was 2.4 cm2 (66.7%) versus 2.6 cm2 (83.9%), P = .001, in the mechanical versus the surgical groups, respectively. The mean healing time was 3.6 ± 2.1 versus 2.8 ± 0.6 months in the mechanical versus the surgical groups, respectively, P = .012. Morbidity and recurrence show nonsignificant differences between both groups. Ulcer recurrence was noted in 5/35 (14.3%) versus 2/35 (5.7%), in mechanical versus surgical groups, respectively, P = .23. Therefore, metatarsal head/accessory bone resection offered improved healing efficacy but similar morbidity and recurrence to the removable cam-walker.

Metatarsal head resection (MHR) is an effective option for the treatment of nonhealing neuropathic diabetic foot ulcers. The present study aimed to identify factors that predict treatment success for neuropathic diabetic foot ulcers undergoing metatarsal head resection. In this prospective interventional case series, 30 consecutive diabetic patients with documented nonischemic neuropathic plantar diabetic foot ulcers beneath the metatarsal head who underwent MHR were included. The study endpoint was demographic indicators of early and late postoperative outcomes. Patients were followed up for 1 to 66 months (mean 37.6 months). Except for 1 patient, all subjects' wounds (96.6%) healed after metatarsal head resection within an average of 35 days. One of the operated patients (3.4%) suffered short-term complications; long-term complications occurred in 23.3% of the patients. One patient (3.4%) experienced ulcer recurrence, 3 patients (10%) developed wound infection, and transfer lesions occurred in 3 other patients (10%) during the follow-up period. Using 3 estimators including ordinary least squares (OLS), White's heteroscedastic standard errors, and bootstrapping procedure, we could not find any statistically significant demographic feature related to ulcer healing. Using regression modeling, we could not find any evidence for a role of age, sex, weight, height, BMI, duration of ulcer until MHR, and duration of diabetes mellitus (years since diabetes diagnosis) affecting the outcome of MHR. Hence, demographic features, duration of ulcer until MHR, and years with diabetes did not affect the outcome of MHR. In conclusion, the authors believe that MHR will have a high rate of success for neuropathic wound healing in this specific subset of patients regardless of demographic features, as long as there is no ischemia to impair healing by secondary intention.

Aim of the study To explore patient understanding of why they develop a venous leg ulcer and how they can prevent recurrence. Method The methodological framework of the hermeneutic phenomenological approach was used. Semi-structured interviews were conducted with seventeen participants living with a venous leg ulcer from May 2017 to November 2018. Data were analysed using Smith's interpretative hermeneutic analysis. Results The results are categorised into three main themes: “Trauma due to accident” (initial venous leg ulcer) and “Prevention of ulcer recurrence” (compression); “Trauma due to compression therapy” (venous leg ulcer recurrence). The findings demonstrate active venous leg ulcers are often caused by acute incidents while carrying out an activity in people with underlying chronic venous insufficiency. After a complete healing, preventive measures, such a compression stockings are initiated by the patient or health care provider. Trauma due to adherence to compression stockings caused skin breakdown beneath compression that caused subsequent ulcer recurrence. Conclusion This study contributes to understanding the lived experience of patients with venous leg ulcers who develop a venous leg ulcer and their understanding of how they can prevent recurrence. Patients with VLUs would benefit from early preventive strategies, such as such a compression stockings fitting and application, integrated into daily care plan of primary care and community settings.

Chronic leg ulceration affects 1–2% of the population and is associated with poor healing, frequent ulcer recurrence, and significant morbidity. Venous reflux can be identified in more than 70% of ulcerated legs. Coexistent arterial disease may be a factor in up to 20% of patients, but the clinical significance is poorly understood. We describe a patient who presented with a lower-limb ulcer, which was treated as a misdiagnosed case of venous ulcer for 12 years, following femoral pseudoaneurysm ligation.

BackgroundRecurrence after the healing of a foot ulcer is very common among patients with diabetes mellitus. Novel diabetic therapeutic footwear consisted of merino wool, vibration chip, and orthopedic insoles is designed to influence multifaceted mechanisms of foot ulcer occurrence. The aim of this study is to examine the effect of the optimally designed therapeutic footwear on preventing ulcer recurrence in patients with a history of diabetic foot ulcers (DFU).Methods/designThe trial is designed as a two arms, parallel-group, open-label randomized controlled intervention study. The Log-rank Test was used for calculating sample size based on the latest national multicenter survey data of DFU in China. Three hundred and twenty participants will be recruited from the Diabetic Foot Care Center, West China Hospital, Sichuan University. Adults with diabetic peripheral neuropathy, healed foot ulceration in the 3 months prior to randomization, and aged ≥18 years, will be recruited. Participants will be randomized to receive novel diabetic therapeutic footwear (n = 160) or their own footwear (n = 160). The primary outcome will be the incidence of ulcer recurrence. The secondary outcome will be measurements of barefoot dynamic plantar pressures, the influence of footwear adherence on ulcer recurrence, and the incidence of cardiovascular events. Assessment visits and data collection will be obtained at baseline, 1, 3, 6, 9, and 12 months. The intention-to-treat principle will be applied. A cox regression model will be used to calculate the hazard ratio for the incidence of ulcer recurrence. The change of barefoot dynamic plantar pressures will be assessed using repeated measures ANOVA. The study protocol has been approved by the Ethics Committee of The Biomedical Research Ethics Committee of West China Hospital, Sichuan University (Reference No. 2019(96)).DiscussionThis clinical trial will give information on the ability of novel diabetic footwear on preventing ulcer recurrence in patients with a history of diabetic foot ulceration. If the optimally designed therapeutic footwear does work well, the findings will contribute to the development of innovative treatment devices for preventing foot ulcer recurrence in high-risk patients.Trial registrationChinese Clinical Trial RegistryChiCTR1900025538. Registered on 31 August 2019.

PURPOSE: The purpose of this study was to test our MUSTCOOL cooling patch intervention on the incidence of venous leg (VLU) and diabetic foot ulcer (DFU) recurrence over a previously healed wound. DESIGN: 6-month randomized controlled trial. SUBJECTS AND SETTING: The target population was individuals with previously healed ulcers receiving care in outpatient wound centers in the Southeastern region of the U.S. participated in the trial. The sample comprised 140 individuals with recently healed ulcers, their average age was 62.4 years (SD 12 yrs.); 86 (61.4%) were male; and 47 (33.6%) were Black or African American. METHODS: Participants were randomized to the MUSTCOOL or placebo patch. Both groups received instructions to apply the patch 3 times per week, and engage in standard of care including compression and leg elevation (VLU) or therapeutic footwear and hygiene (DFU). Demographic data were collected at baseline, and incidence measures taken at 1, 3, and 6 months. We also studied whether new ulcers developed on the adjacent leg or foot. Data were reported in frequencies/percentages. RESULTS: One hundred seventeen participants (84%) were analyzed who completed 6 months of study participation. Thirteen percent (9/69) and 17% (12/69) developed a recurrent or new VLU, respectively; 29% (14/48) and 13% (6/48) developed a recurrent or new DFU, respectively. One person in the DFU group developed both a recurrent and new ulcer. For 9 recurrent VLUs, 6 (66.7%) recurred in the MUSTCOOL group and 3 (33.3%) receiving the placebo. Of the 15 recurrent DFUs (includes individual that developed both a recurrent and new ulcer), 10 (66.7%) recurred in the MUSTCOOL group and 5 (33.3%) receiving the placebo. CONCLUSIONS: While the incidence of ulcer recurrent was slightly higher in the MUSTCOOL group, this finding was not considered clinically relevant. Overall ulcer recurrence during the 6-month study period was lower than reports in the literature, the time frame in which recurrence rates are highest. TRIAL REGISTRATION: The study was prospectively registered with ClinicalTrials.gov on December 10, 2015 (Identifier: NCT02626156) https://clinicaltrials.gov/ct2/show/NCT02626156.

STUDY DESIGN: This is a retrospective, non-randomized cohort study, with data collected during the regular annual visits between 2001 and 2019. OBJECTIVES: The aim of this study was to evaluate the efficacy of coccygectomy for coccygeal pressure ulcers in individuals with paraplegia due to spinal cord injury or other neurological causes and to evaluate its role in the prophylaxis of ulcer recurrence. SETTINGS: This study included inpatients and outpatients with a coccygeal pressure ulcer who were treated surgically at our Institution REHAB Basel and were followed with regular annual check-ups. METHODS: Individuals with category 3 or 4 acute or chronic coccygeal pressure ulcer (classification according European Pressure Ulcer Advisory Panel (EPUAP)) received coccygectomy in addition to rotation flap surgery. The operative care was provided exclusively by the head of the plastic surgery department at REHAB Basel. Standardized follow-up treatment was carried out according to the “Basel Decubitus Concept” and thus allowed continuous and usually lifelong, regular follow-up care. RESULTS: Forty-nine individuals underwent coccygectomy from 2001 to 2019 due to coccygeal category 3 or 4 pressure ulcers. The observation period was between 1.5 and 18.3 years. In 86% of the individuals, no relapse occurred during the first year. Over the next 5 years 78% remained relapse free. CONCLUSIONS: In coccygeal pressure ulcer category 3 or 4, coccygectomy, in addition to sufficient rotation flap surgery, is a suitable method for recurrence prevention of pressure ulcer in this anatomic area.

Composite frontal scalp defects involving the frontal bone and full thickness scalp can pose a reconstructive challenge. Often, they necessitate the use of microsurgical free tissue transfer, which can be physiologically demanding in high-risk patients with multiple comorbidities, with exposure to prolonged general anesthesia time and increased surgical morbidity. The experience of a single surgeon was reviewed with reconstruction of composite frontal scalp wounds in 4 patients with structural framework and a bipedicled scalp advancement (ie, "bucket handle") flap, thus obviating the need for free tissue transfer. All 4 patients demonstrated complete wound healing by final follow-up, without need for further reoperations or ulcer recurrence. In face of composite frontal scalp defects in less than ideal candidates for lengthy microsurgical flap procedures, the bucket-handle flap can provide a simple and reliable reconstructive option.

A medial plantar flap is superior as a sensory flap with regard to tissue wear, prevention of ulcer recurrence, and other such factors. However, a wound at a plantar weight-bearing site is likely to lead to abnormal hyperkeratosis that can cause pain and fissures. In addition, the development of a scar contracture in infant patients can cause failure of normal foot development. To overcome these issues, we developed a method in which an island flap from a non-weight-bearing site is used as a step-ladder advancement plantar flap for moderate-sized tissue loss at a plantar weight-bearing site, followed by primary closure of the flap donor site with suturing to prevent scar contracture and abnormal hyperkeratosis. This technique showed good functional and cosmetic outcomes, as the step-ladder-like suture lines were unlikely to cause scar contracture and abnormal hyperkeratosis owing to the staggered scar, leading to pain prevention.

Toe deformities are common in people with diabetes and are often associated with toe ulcers. Operative procedures have been used to reduce toe deformities, because these were proposed to be beneficial in the management of toe ulcers. The present systematic review investigated the effect of flexor tenotomy to address toe deformity for healing and preventing diabetes-related toe ulcers. Four electronic databases were searched in January 2016. Studies were included if they had reported the effects of flexor tenotomy for healing and/or preventing diabetes-related toe ulcers. Six studies with a total of 264 flexor tenotomies performed on toes with ulcers and 57 performed as a prophylactic procedure were included. The mean duration of preoperative ulceration was 207.9 (range 7 to 1825) days. The mean duration to postoperative ulcer healing was 29.5 days, with an overall healing rate of 97%. The rate of ulcer recurrence was 6%. All the toes that had undergone prophylactic flexor tenotomy remained free of ulceration. Overall, the rate of complications was low. Flexor tenotomy to address toe deformity is relatively safe and effective in healing and preventing diabetes-related toe ulcers. Flexor tenotomy should be considered in the management of diabetes-related toe ulcers in the presence of toe deformities.

Objective: This study aimed to identify, in the literature, noninvasive measures for prevention of venous ulcer recurrence (VUs). Methods: An integrative review was carried out in the databases of the Biblioteca Virtual em Saúde (BVS), Public Medline (PubMed), Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Excerpta Medica Database (Embase) in the period from 2015 to 2017. the search was performed using the controlled descriptors «varicose ulcer» and «recurrence» and the Boolean operator AND between them in all databases described, in Portuguese, English, and Spanish. After the searches, two reviewers carried out the pre-selection by titles and summary of the articles followed by the full reading of the pre-selected studies. Results: 210 studies were identified, of which 188 were excluded because they did not attend to the guiding question. Two reviewers read in full the 22 pre-selected articles and included in this review nine that were part of the discussion of this paper. Conclusion: Studies in this review suggest that adherence and correct use of compressive therapy with socks associated with education and self-care measures are effective in preventing recurrence of VU. The association of acetylsalicylic acid with standard measures of treatment still lacks conclusive results and new studies to prove efficacy are suggested.

Nonostante i recenti progressi in tema di wound care, le ulcere varicose degli arti inferiori restano un problema frequente, con un alto tasso di recidiva. In questo lavoro abbiamo esaminato la storia clinica, la storia chirurgica e le patologie associate di 133 pazienti affetti da ulcera varicosa degli arti inferiori, di cui 56 da ulcera recidiva o plurirecidiva. L’analisi dei fattori di rischio potenziale per recidiva ha evidenziato come la presenza di varici recidive, una pregressa trombosi venosa profonda, problemi ortopedici, interventi ortopedici, l’obesità e un’età inferiore a 60 anni siano fattori di rischio potenziale per una recidiva dell’ulcera. La combinazione di uno più fattori di rischio assume significatività per la possibilità di una recidiva; si passa dal 22,7% in assenza di fattori di rischio al 33% per i pazienti che ne presentano due, fino al 57,5% in presenza di tre fattori di rischio e all’81,3% per quattro o più. L’ulcera varicosa richiede un follow-up stretto del paziente e una terapia elastocompressiva continua, che deve vedere una stretta collaborazione del paziente e un’attenzione specifica ai fattori di rischio. Despite recent advances in wound care, varicose ulcers of lower limbs remain frequent and display a high rate of recurrence. In this paper, we examined the clinical, surgical histories and associated diseases of 133 patients with venous ulcers of the lower limbs, which were recurrent in 56 cases. The analysis of potential risk factors for recurrence showed that the presence of recurrent varicose veins, a previous deep venous thrombosis, orthopedic problems, previous orthopedic procedures, obesity and age lower than 60 are potential risk factors for ulcer recurrence. Furthermore, the association of one or more risk factors increased the likelihood of relapse, from 22.7% with no risk factors to 33% with 2 risk factors, up to 57.5% with 3 risk factors, and up to 81.3% with 4 risk factors or more. Venous ulcers require close follow-up and continuous elastic compression, close collaboration by the patient and specific focus on risk factors.

Background: Split-thickness skin grafting (STSG) is an effective coverage method for chronic foot ulcers. Many of these ulcers develop on the plantar aspect of the foot. Split-thickness skin grafting may be a high-risk operation in such a high wear area. However, outcomes data is lacking for patients receiving STSG to the plantar aspect of the foot, especially in terms of recurrence. The purpose of this study is to retrospectively compare outcomes of STSG to plantar and non-plantar chronic ulcers. Methods: Medical records for all patients receiving STSG from 2014-2016 at our institution were reviewed under IRB approval. Major outcome measures included time to healing and time to ulcer recurrence. Results: There were 158 patients with 182 STSGs identified. Fifty-two STSGs were located on the plantar surface of the foot and 130 STSGs on a non-plantar surface. Percent take at 30 days was not significant between the two groups (56% plantar vs. 60% non-plantar, p=0.199). However, plantar surface STSGs were significantly less likely to be healed at 60, 90, and 365 days (p Conclusions: Split-thickness skin grafting to the plantar surface of the foot is more likely to experience complications and take longer to heal than on non-plantar surfaces but the durability of the graft approximates that of non-plantar surface grafts. This suggests that STSG to the plantar surface of the foot may require more upfront investment from the patient and the surgeon but remains a viable wound coverage option. Disclosure E. Walters: None. M. Pandya: None. N. Rajpal: None. M.M. Abboud: None. C. Attinger: Consultant; Self; Acelity, Integra LifeSciences. P.J. Kim: Consultant; Self; Acelity, Integra LifeSciences.

Background/Aims The purpose of this study is to investigate the recurrence rate of peptic ulcer disease (PUD) over a long follow-up period with PUD patients without Helicobacter pylori. Methods We retrospectively reviewed patients diagnosed with PUD on endoscopy and divided them into two groups: a H. pylori-negative group (HP-negative group), and a group of patients with untreated H. pylori (HP noneradicated group). We compared the recurrence rates of PUD in these two groups and analyzed the factors that affected ulcer recurrence. Results Total of nine hospitals in Korea participated, and a total of 1,761 patients were retrospectively reviewed. The HP-negative group included 553 patients, and the HP noneradicated group included 372 patients. The 5-year cumulative probabilities of PUD recurrence were 36.4% in the HP-negative group and 43.8% in the HP noneradicated group (p=0.113). The factors that were found to affect recurrence in the HP-negative group were elder, male, and comorbid chronic kidney disease. Conclusions The 5-year cumulative probability of PUD recurrence without H. pylori infection after a long-term follow-up was 36.4% and the factors that affected recurrence were elder, male, and comorbid chronic kidney disease.

Background The aim of the study was to provide a literature review of thoracic endovascular aortic repair (TEVAR) outcomes for penetrating ulcer of the aorta. Methods Relevant articles in the Embase, Medline, and Cochrane databases reporting the results of endovascular repair for penetrating ulcers of the thoracic aorta were systematically searched and reviewed. Results Thirty-one articles were integrated after a literature review, and 310 patients treated by TEVAR for penetrating ulcers of the aorta were identified. In this cohort, most patients were male (65.8%), had a history of smoking (60.4%), and systemic hypertension (90%). Only 9% were asymptomatic at initial presentation. Most cases (76%) occurred among patients with a single ulcer, located in the descending thoracic aorta (81%), with associated intramural hematoma in 45%. The technical success of TEVAR was 98.3%. Surgical conversion during the postoperative period with stent-graft explantation was required in 1 patient. The overall 30-day mortality was 4.8% (15 of 310). The most frequent complications were endoleaks (8%, 25 of 310) and access problems (16.1%, 26 of 161). After a mean follow-up of 17.7 months (range, 1 to 52), the all-cause mortality was 22.9% (71 of 310), and the aortic-related mortality was 4.1% (13 of 310). During follow-up, new endoleak and ulcer recurrence were observed in 5.4% (n = 15 of 274) and 4.5% (n = 5 of 110), respectively, requiring a new aortic endovascular procedure in 50% (n = 10). Conclusions Thoracic endovascular aortic repair of penetrating ulcer has excellent short-term and midterms results. The endovascular approach should be the first line management for aortic ulcer when intervention is indicated.

With the aim to improve the outcomes for spinal cord-injured patients undergoing surgery for pressure ulcers, a structured treatment programme regulating pre- and postoperative care and rehabilitation was introduced in 2002 in Stockholm. Fifty-one consecutive patients operated on between 2002 and 2007 were included in a 10-year follow-up to evaluate the programme regarding initial healing results and long-term ulcer and health status. At one month postoperatively, 49 out of 51 (96%) patients were completely healed. Five patients (5/44, 11%) developed recurrent or new ulcers within 3 years of surgery. Two patients were re-operated on (2/44, 5%). Between 3 and 10 years after surgery, 9 patients (9/33, 27%) had a history of recurrent ulcers, and 6 (6/33, 18%) had a history of new ulcers, a total of 15 patients (15/33, 45%). Of these, three needed re-operation (3/33, 9 %). The health status values using a visual analogue rating scale were 70 (median) at 3 and 10 years compared with 30 (median) preoperatively. The good initial healing, the low ulcer recurrence rate and the raise in health status indicate the value of a structured treatment programme, especially for the first few postoperative years.

Helicobacter pylori eradication therapy has a role in minimizing the complications of peptic ulcer disease, namely, bleeding, perforation, and obstruction. However, the precise role of H. pylori eradication therapy in the complicated ulcers remains inconclusive, especially in perforation and gastric outlet obstruction. The prevalence of H. pylori in peptic ulcer bleeding patients has been widely underestimated owing to the differences in diagnostic tests and patient characteristics, and hence, it is recommended that an initial negative test should be followed up by a delayed repeat testing to rule out false negativity. It is well established now that eradication of H. pylori in patients with bleeding ulcers reduces rebleeding and ulcer recurrence. Multiple studies have attributed high recurrence rates of duodenal ulcer following simple closure to a high prevalence of H. pylori infection. Eradication therapy decreases the recurrence rate of perforated ulcers, thus justifying the role of H. pylori eradication therapy following the primary surgical management of perforated ulcers. The role of H. pylori in duodenal ulcer with gastric outlet obstruction is yet to be evaluated clearly. There are some reports of resolution of gastric outlet obstruction following therapy for H. pylori, obviating the need for surgery. Clarithromycin-containing regimens are recommended as first-line in areas of low resistance, whereas bismuth-containing quadruple therapy is the first-line empirical treatment in areas of high clarithromycin resistance. Treatment of H. pylori is beneficial in most of the patients with complicated peptic ulcer disease, especially in reducing recurrence of ulcer with or without complications.

Objective To explore the therapeutic and recurrence-preventing effects of Qi-Replenishing and Blood-Activating Formula in rats with acetic acid-induced gastric ulcer. Methods A total of 138 SD rats were selected to make rat models with gastric ulcer induced by acetic acid (24 rats with sham operation served as sham operation group), and were randomly divided into model group ( n = 30), western medicine group ( n = 30), traditional Chinese medicine (TCM) group ( n = 24) and combination group (combined western medicine and TCM group, n = 30). Western medicine group was gavaged with omeprazole in the morning and with iso-volumetric distilled water in the afternoon; TCM group and TCM sham operation group were gavaged with iso-volumetric distilled water in the morning and with Qi-Replenishing and Blood-Activating Formula in the afternoon; combination group was gavaged with omeprazole in the morning and with Qi-Replenishing and Blood-Activating Formula in the afternoon; sham operation group and model group were gavaged with iso-volumetric distilled water both in the morning and afternoon. Ulcer indexes and degree of mucosal degree in rats at different time points after gavage were observed. Twenty-eight days after gavage, interleukin (IL)-1β was given to induce ulcer recurrence so as to observe the recurrent severity and rate of ulcer in each group. Results Compared with model group and western medicine group, treatment in combination group could prominently reduce the ulcer index of rats with peptic ulcer, and increase the healing rate and inhibition rate of peptic ulcer. After IL-1β-induced ulcer recurrence, combination group was significantly superior to model group and western medicine group in ulcer recurrent rate [50% (3/6) vs . 100% (6/6)] and severity. Conclusions Basic acid-suppression therapy combined with Qi-Replenishing and Blood-Activating Formula can effectually improve the ulcer healing quality and reduce ulcer recurrence.

A retrospective analysis for the pressure ulcer in our burns center in northeast China was taken in order to find the prognostic factors for ulcer recurrence.We collected the clinical data of hospitalized patients with pressure ulcer ranging from September 2013 to September 2018 involving initial hospitalized data, follow up visit data and recurrent hospitalized data, further univariable and multivariable Cox regression analysis were taken for searching the prognostic factors of recurrent ulcer.The recurrent rate was 8.02%, and in the result of univariable and multivariable Cox regression analysis, blood albumin level on admission below 25 g/dl contributed to the strongest predicting factor for recurrence, with HR = 32.745(95%CI = 8.061-133.022, P 0.001). Multiple ulcers showed the second significant importance for predicting recurrence, with HR = 24.226(95%CI = 3.855-152.231, P = 0.001 0.05). Single caregiver contributed to the third prognostic factor, with HR = 0.016(95%CI = 0.004-0.076, P 0.001).In a conclusion, multiple ulcers, blood albumin level below 25 g/dl on admission and single caregiver were the three prognostic factors for recurrent pressure ulcer and the shortages of medical care out of hospital in northeast China need more attention urgently. Flap treatment may not be a protective factor for ulcer recurrence, but considered the advantages on the closure of deep wounds, it was still an effective treatment for pressure ulcer nowadays.

Home monitoring of foot temperatures in high-risk diabetes patients proves to be a promising approach for early recognition and treatment of pre-signs of ulceration, and thereby ulcer prevention. Despite previous studies demonstrating its efficacy, it is currently not widely applied in (Dutch) health care. In a multicenter, outcome-assessor-blinded, randomized controlled trial, 304 patients with diabetes mellitus types I or II, loss of protective sensation based on peripheral neuropathy, and a history of foot ulceration in the preceding 4 years or a diagnosis of Charcot neuro-osteoarthropathy will be included. Enhanced therapy will consist of usual care and additional at-home daily measurement of foot temperatures at six to eight predefined locations on the foot. If a contralateral foot temperature difference of > 2.2 °C is found on two consecutive days, the participant is instructed to contact their podiatrist for further foot diagnosis or treatment, and to reduce ambulatory activity by 50% until temperatures are normalized. Enhanced therapy will be compared to usual care. The primary outcomes are the cost (savings) per patient without a foot ulcer (i.e., cost-effectiveness) and per quality-adjusted life year gained (i.e., cost-utility). The primary clinical outcome in the study is the proportion of patients with foot ulcer recurrence on the plantar foot, apical surfaces of the toes, the interdigital spaces or medial and lateral forefoot surfaces during 18-month follow-up. Confirmation of the efficacy of at-home foot temperature monitoring in ulcer prevention, together with assessing its usability, cost-effectiveness and cost-utility, could lead to implementation in Dutch health care, and in many settings across the world. Netherlands Trial Registration: NTR5403 . Registered on 8 September 2015.

Background: The aim of this paper was to create an updated Australian guideline on footwear for people with diabetes.Methods: We reviewed new footwear publications, (international guidelines, and consensus expert opinion alongside the 2013 Australian footwear guideline to formulate updated recommendations.Result: We recommend health professionals managing people with diabetes should: (1) Advise people with diabetes to wear footwear that fits, protects and accommodates the shape of their feet. (2) Advise people with diabetes to always wear socks within their footwear, in order to reduce shear and friction. (3) Educate people with diabetes, their relatives and caregivers on the importance of wearing appropriate footwear to prevent foot ulceration. (4) Instruct people with diabetes at intermediate-or high-risk of foot ulceration to obtain footwear from an appropriately trained professional to ensure it fits, protects and accommodates the shape of their feet. (5) Motivate people with diabetes at intermediate-or high-risk of foot ulceration to wear their footwear at all times, both indoors and outdoors. (6) Motivate people with diabetes at intermediate-or high-risk of foot ulceration (or their relatives and caregivers) to check their footwear, each time before wearing, to ensure that there are no foreign objects in, or penetrating, the footwear; and check their feet, each time their footwear is removed, to ensure there are no signs of abnormal pressure, trauma or ulceration. (7) For people with a foot deformity or pre-ulcerative lesion, consider prescribing medical grade footwear, which may include custom-made in-shoe orthoses or insoles. (8) For people with a healed plantar foot ulcer, prescribe medical grade footwear with custom-made in-shoe orthoses or insoles with a demonstrated plantar pressure relieving effect at high-risk areas. (9) Review prescribed footwear every three months to ensure it still fits adequately, protects, and supports the foot. (10) For people with a plantar diabetic foot ulcer, footwear is not specifically recommended for treatment; prescribe appropriate offloading devices to heal these ulcers.Conclusions: This guideline contains 10 key recommendations to guide health professionals in selecting the most appropriate footwear to meet the specific foot risk needs of an individual with diabetes.

ObjectivesTo clarify the surgical methods and the clinical results of subfascial endoscopic perforator surgery in Japan.MethodsThis study included 1287 limbs of 1091 patients who underwent subfascial endoscopic perforator surgery in 14 hospitals. Simultaneous saphenous vein treatment was performed in 1079 limbs (83.8%), and 118 limbs (9.2%) had deep venous lesions. The venous clinical severity score was calculated before and 6 to 12 months after surgery. The ulcer healing rate and ulcer recurrence rate were calculated cumulatively.ResultsPreoperative venous clinical severity score was significantly decreased from 10.0 ± 6.6 to 3.1 ± 3.4 ( P ConclusionThese results indicate that subfascial endoscopic perforator surgery is an alternative to improve the long-lasting disease severity and/or clinical outcome.

The etiology of chronic venous insufficiency is typically neglected or misunderstood when treating lower-extremity edema and venous ulcerations. Despite the high prevalence of venous compression syndromes, it is rarely considered when treating venous ulcers and unresolved venous disease. We report a case of bilateral iliac vein outflow obstruction that prohibited venous ulcer healing until properly treated. This case highlights the importance of properly identifying and treating venous compression syndromes to enhance ulcer healing and decrease the risk of venous ulcer recurrence.

Compression therapy is a standard use in patients with an advanced chronic venous insufficiency in order to aid venous ulcers or to prevent ulcer recurrence. Nevertheless, there exists only low evidence for the use of compression therapy in patients with uncomplicated varicose veins even though there has been reported a high recommendation. Especially the duration of time remains unclear. The article gives an overview about the actual literature. Overall it seems that a compression therapy after phlebolgical interventions has a benefit. Nevertheless, the evidence is very low and the postoperative use is based on experience. Especially for patients with symptoms and oedema the application of compression stockings may have an advantage.

Patients with chronic diabetes can develop plantar hallux ulcerations secondary to neuropathy, increased pressure, and deformity. The present retrospective study evaluated the efficacy of hallux interphalangeal joint (HIPJ) arthroplasty to address recalcitrant ulceration. Two groups of patients with diabetes were compared: a surgical group of 13 patients and a nonsurgical standard therapy group of 13 patients. The patients in the surgical group underwent HIPJ arthroplasty. All the patients in the standard therapy group received local wound care and offloading. The mean duration of follow-up was 19.5 (range 1.2 to 47.9) months, and the mean age was 55 ± 13.0 years. Statistical significance was found in the surgical group for faster time to healing (3.5 weeks [2.5, 4.25] vs 9 weeks [2, 17.29], p = .033) and lower incidence of ulcer recurrence (8% ± 7.69 vs 54% ± 53.85, p = .031). There were also fewer amputations in the surgical group (0% ± 0 vs 38% ± 38.6, p = .063). To our knowledge, only 1 other published study has evaluated HIPJ arthroplasty as a treatment of recalcitrant hallux ulceration. The present study adds comparison data from a nonoperative standard therapy group and found that HIPJ arthroplasty is an effective curative treatment option to address chronic plantar hallux ulcerations in diabetic patients with neuropathy.

Purpose To investigate risk factors, clinical features, and treatment outcomes of recurrent Mooren ulcers in China. Methods Medical records of 139 patients (173 eyes) with Mooren ulcers, including 37 patients (38 eyes) with recurrence, were retrospectively reviewed. Clinical features and treatment outcomes were evaluated. The risk factors for ulcer recurrence were analyzed with logistic regression; the cumulative risk of recurrence was assessed with Kaplan-Meier analysis. Results The ratio of males to females with Mooren ulcers was 1.62:1. As to age, 32 of 106 patients aged >35 years and 5 of 33 younger patients (28 males and 9 females) had recurrence. Forty-one patients had bilateral disease (7 eyes removed before their visit to our hospital were excluded) and 98 patients had unilateral disease, with recurrence in 10 and 27 patients, respectively. Thirty eyes had recurrence around the primary lesion; 27 eyes had recurrence within 12 months after treatment. Of all eyes, 97.7% were saved and 81.5% retained vision better than 0.05. The cumulative risk of first recurrence at 6, 12, 24, 36, and 48 months was 10.4%, 17.1%, 22.5%, 27.2%, and 28.6%, respectively. Male sex (P = 0.043) and surgical treatment (P = 0.035) were significantly associated with an increased risk of recurrence. Conclusions This study provided the clinical characteristics and treatment outcomes of patients with recurrent Mooren ulcers in China. The cumulative risk of first recurrence at 4 years after treatment was 28.6%. Male patients and patients with severe ulcers that required surgery had an increased risk of recurrence.

Chronic wound care is a growing medical problem, reaching epidemic proportions worldwide. Even after the wound has healed, wound recurrence remains a significant issue, with rates approximating 40% in 6 months after healing. The authors evaluate a retrospective analysis of their wound care clinics healing and recurrence rates. The authors evaluate the efficacy of varying physical modalities on preventing recurrence of wounds after their healing. The authors take their evaluation out to one year.

It Is essential for nurses to develop their skills in the education of patients with leg ulcers. No ulcer will be healed, or prevented, unless the patient co-operates with, and participates in, the treatment. Full compliance is more likely if the patient understands what is being done, and why. Teaching patients the self-help skills which they should practise for the rest of their lives to promote healing and prevent ulcer recurrence requires patience, skill and an understanding of the individual's personal circumstances1.

OBJECTIVE To evaluate the efficacy, safety and long-term outcome of TIPP for the adjunct therapy of superficial venous reflux-related VLUs. METHODS A total of 93 consecutive patients (104 legs) with superficial venous insufficiency-related VLUs who underwent TIPP (53 legs) or conventional phlebectomy (51 legs) between January 2010 and December 2013 were retrospectively studied. RESULTS Compared to patients in the conventional phlebectomy group, TIPP patients had larger ulcer areas before surgery (P

Summary Background Leg ulceration caused by chronic venous disease occurs in 1% of the adult Western population. A majority of these patients is successfully treated in the outpatient setting. A minority of patients is hospitalized, most frequently because of the lack of healing tendency. The literature provides recurrence rates for ulcer disease, but lacks specific data on recurrence rates after in-hospital treatment of recalcitrant venous leg ulcers. Objectives To investigate time to ulcer recurrence after in-hospital treatment of venous leg ulceration. Methods A multicentre, retrospective cohort study of patients admitted for leg ulceration between 1996 and 2007 was conducted. Results Data could be collected for 107 of the patients. Of these, 27 had conservative treatment (bed rest, local wound care, pain management) and 48 patients underwent surgical ulcer treatment with (n = 19) or without (n = 29) initial vacuum-assisted closure (VAC) treatment. The treatment method was ‘miscellaneous’ in the remaining 32 patients. Median admission time was 30 days, median percentage of closure at discharge was 95%, and median time to ulcer recurrence 60 days. The Mann–Whitney U-test showed significant differences between the conservative group and the surgery group, the latter having a longer length of hospital stay (P

Lower extremity ulcers in diabetic patients are difficult to treat. Recently, the use of human blood platelet-derived components in this indication has been raising interest. In this study, we have evaluated the safety and efficacy of the combination of autologous platelet gel (PG) and skin graft for treating large size recalcitrant ulcers. Eight consecutive diabetic patients aged 25 to 82 with nine nonhealing lower extremity ulcers (median size of 50 cm2; range 15–150 cm2) were treated. Skin ulcer was debrided, and the wound was sprayed after 7 to 10 days with autologous platelet-rich plasma and thrombin. Thin split-thickness skin graft with multiple slits was then applied on the wound bed and fixed with staples or cat-gut sutures. There were no adverse reactions observed during the study. Eight out of 9 skin grafts took well. The interval between skin graft and complete wound healing ranged from 2 to 3 weeks in the 8 successful cases. No ulcer recurrence was noted in those patients during the follow-up period of 2 to 19 months. In this study, the combination of autologous platelet gel and skin grafting has proven beneficial to heal large-size recalcitrant ulcers.

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm 2 , and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.

The aim of this study was to determine the rate of venous ulcer recurrence and the level of compliance in patients wearing European class 1 or class 2 compression stockings. A total of 100 patients with healed venous leg ulcers were recruited, and were randomised to either class 1 (n = 50) or class 2 (n = 50) compression stockings. Follow‐up was at 1 week, 3, 6, 9 and 12 months to monitor ulcer recurrence and compliance. Patients had a duplex scan to identify the source of venous incompetence. The rate of ulcer recurrence after 12 months was 16·1%, and the difference in recurrence rate between classes was not statistically significant (P = 0·287) although greater numbers in class 1 developed a recurrence. Participants (88·9%) were compliant; non‐compliant patients were at a significantly greater risk of recurrence (P≤ 0·0001). Thirteen patients had both superficial and deep incompetence; those randomised to class 1 stockings (n = 4) developed ulcer recurrence. Patients with a history of multiple episodes of ulceration were more likely to develop a recurrence (P = 0·001). The lowest venous ulcer recurrence rates were seen in patients who were compliant with hosiery regardless of the compression level. Patients with both superficial and deep incompetence had a lower rate of recurrence with class 2 compression.

Few studies have examined factors associated with diabetic foot ulcer (DFU) recurrence. Using data from patients enrolled in the prospective Eurodiale DFU study, we investigated the frequency of and risk factors for DFU recurrence after healing during a 3‐year follow‐up period. At our site, 93 Eurodiale‐enrolled patients had a healed DFU. Among these, 14 were not alive; of the remaining 79 patients we enrolled 73 in this study. On entry to the Eurodiale study, we assessed demographic factors (age, sex and distance from hospital); diabetes‐related factors [duration, and glycated haemoglobin (HbA1c) levels]; comorbidities (obesity, renal failure, smoking and alcohol abuse) and DFU‐related factors [peripheral arterial disease, ulcer infection, C‐reactive protein (CRP) and; foot deformities]. During the 3‐year follow‐up period, a DFU had recurred in 42 patients (57·5%). By stepwise logistic regression of findings at initial DFU presentation, the significant independent predictors for recurrence were plantar ulcer location [odds ratio (OR) 8·62, 95% confidence interval (CI) 2·2–33·2]; presence of osteomyelitis (OR 5·17, 95% CI 1·4–18·7); HbA1c > 7·5% ([DCCT], OR 4·07, 95% CI 1·1–15·6) and CRP > 5 mg/l (OR 4·27, 95% CI 1·2–15·7). In these patients with a healed DFU, the majority had a recurrence of DFU during a 3‐year follow‐up period, despite intensive foot care. The findings at diagnosis of the initial DFU were independent risk factors associated with ulcer recurrence (plantar location, bone infection, poor diabetes control and elevated CRP) and define those at high risk for recurrence, but may be amenable to targeted interventions.

Eleven perforator-sparing gluteal fasciocutaneous rotation flaps were used for coverage of pressure sores in 10 patients with mean age 38.4 years. Nine patients were paraplegic, and one patient was ambulatory. All pressure ulcers were classified as grade 4. The pressure sores were sacral in five patients, unilateral ischial in five patients, and unilateral trochantric in one patient. Seven ulcers were recurrent and four were primary. The flap sizes ranged from 7 × 7 cm to 15 × 13 cm. In a total of 11 flaps, nine flaps included two perforators, one flap included three perforators, and one flap included single perforator. Skin incision is the same as that for the conventional gluteal rotation flap. The flap is elevated subfascially until at least two dominant musculocutaneous perforators of the superior or inferior gluteal arteries are encountered. In the recurrent ischial sores, the inferior part of gluteus maximus was used to fill dead space at the base of the ulcer as a separate muscle flap. Eight of 11 flaps healed uneventfully without complications. Mean follow-up period was 18.6 months (range 37–5 months). The recurrence rate in the same region was 0% during follow-up period. The appearances of pressure sores in other sites occurred in two patients that healed with conservative treatment. There was no major complication such as total flap necrosis. Only minor complications occurred which were treated without surgical intervention. The perforator-sparing gluteal rotation fasciocutaneous flap is a versatile and reliable flap for coverage of all gluteal pressure sores. This is an ideal flap for patients in whom the risk of ulcer recurrence is high as the rerotation is possible in case of recurrence.

Background: The use of medicinal plants or their active components is becoming an increasingly attractive approach for the treatment of various disorders including Peptic ulcers (a group of gastrointestinal erosions with increasing prevalence all over the world). One of these natural derivatives is Curcumin. It proved to have a potent anti-inflammatory and antioxidant capacities at both neutral and acidic pH. Hence, it can be used in treatment of peptic ulcers. Aim of the Work: The use of Curcumin for the treatment of acute and chronic ulcers still needs further investigations to validate its clinical application. So, this research was planned to clarify the role of Curcumin in both prevention and treatment of Indomethacin- induced gastric ulcer in male albino rats by using the light and scanning electron microscopes. Material and Methods: Thirty adult male albino rats were used in the present study. They were divided into 5 groups: A control group and a group in which experimental gastric ulcer was induced using the nonsteroidal anti-inflammatory drug (NSAID) Indomethacin. This group was further subdivided into group (a) without protection and group (b) receiving Curcumin protection prior to Indomethacin administration. The last group was the healing group in which the rats were further subdivided into: group (a) auto-healing group and group (b) receiving Curcumin for ten days following Indomethacin administration. Results: In the experimental Indomethacin gastric ulcer induction group, acute forms of gastric ulceration were seen, destruction of the gastric mucosa and loss of mucosal cellular architecture were detected. In the group receiving protection with Curcumin, less severe forms of gastric ulceration either in size or extent were observed; decrease in mucosal congestion was also detected. These findings were analyzed statistically and proved to be significant (p

Objectives To assess differences in clinical outcomes between patients with traumatic and spontaneous leg ulcers. Methods Consecutive leg ulcer follow-up patients seen between April 2004 and October 2005 in a specialist leg ulcer clinic were asked about the mechanism of the original ulceration. Twenty-four-week healing and 12-month recurrence rates were calculated using Kaplan-Meier analysis and outcomes were compared between groups with traumatic and spontaneous ulcers. Results Of the 300 patients assessed, 38 were excluded (incomplete data). In the remaining 262 patients, cause of ulceration was traumatic in 116/262 (44%) and spontaneous in 146/262 (56%). Age, ankle brachial pressure index Conclusion Approximately half of all leg ulcer patients recall a traumatic event. When managed in leg ulcer clinic, traumatic ulcers heal faster and recur less frequently than spontaneous ulcers.

The purpose of the study was to review the incidence rate of new and recurrent ulcerations in transmetatarsal amputations after original ulcers healed with percutaneous Achilles' tendon lengthening as an isolated procedure. We reviewed 35 charts from period of January 1995 to March 2007, and 28 were included for the final review. Twenty-four ulcers were grade 1A, 2 were 0A and 1B, and 1 was 1C using the University of Texas Grading System. Time to heal of ulceration post-TAL was 9.4 weeks (range 3-72 weeks). For statistical analysis, we used binomial distribution for dichotomous variables. Results demonstrated 4 limbs did not heal, 10 patients had an ulcer recurrence (p0.001), and 6 developed new ulcers. Of the 28 patients in which TAL was performed, 16 developed new neuropathic ulcers (including recurrent ulcers; p=0.0099). High recurrence and new ulcers formation exist after TAL in patients with an unbalanced metatarsal amputation, and extrinsic/ intrinsic factors may need to be addressed to prevent recurrence.4.

The first 15 years' experience with vagotomy and drainage for duodenal ulcer at the Royal Prince Alfred Hospital, Sydney, is summarized in a retrospective study. Proved ulcer recurrence in 16% of patients, a mortality rate of 2–6%, and a postoperative complication rate of 32% suggest that vagotomy and drainage as the procedure of choice in all patients with chronic and complicated duodenal ulcer sjiould be reconsidered. The delay in recognition of ulcer recurrence and the increase in the number of patients with longer follow-up show disturbing similarities to the recurrence of ulcer after gastroenterostomy alone.

Diagnosing Charcot neuroarthropathy requires a heightened index of suspicion. Early recognition and intervention can limit deformity. Aggressive conservative management should be initiated early in the treatment plan to minimize the devastating effects often seen with this condition. Any delay in therapy can result in severe foot and ankle deformity in which traditional nonoperative methods alone may be inadequate. These deformities may lead to ulcerations and ultimately progress to amputation of the lower extremity. Surgical correction and stabilization is an effective method to prevent further deformity and ulcer recurrence. If performed in the appropriate setting and for the right indications, Charcot foot reconstruction is a better alternative to lower limb amputation.

Background. The use of external banding during transcommissural external valvuloplasty has the theoretical advantage of increasing the durability of surgical procedure. The aim of this study was to assess the durability of this combined approach and compare its long-term results with those of external valvuloplasty procedure applied alone. Methods. We retrospectively reviewed data on 144 patients with combined superficial and deep venous reflux who underwent transcommissural external valvuloplasty procedure alone or transcommissural external valvuloplasty plus external banding procedure over a 7-year period from September 1998 to November 2005. The clinical study included only the patients who have completed at least 48 months of follow-up period. Seventy-six patients who have completed the necessary follow-up period were divided into 2 groups according to the surgical procedure performed. Group A consists of 40 patients in whom transcommissural external valvuloplasty was the procedure of choice and Group B consists of 36 patients in whom an external banding has been added to external valvuloplasty repair. The outcomes assessed are venous clinical severity scores of patients, ulcer recurrence and competency rates. Results. In both groups, median preoperative Venous Clinical Severity Scores were 3. The severity scores improved in both groups during the postoperative follow-up period. However, although the scores of Group B patients at 12 and 24 months were lower than those of Group A, the difference was not statistically significantly at these time points; but, reached a statistical significance at the end of 36 months. Ulcer-freedom rates at 48 months for groups A and B were 72% and 96%, respectively. The cumulative competency rates of 40 Group A patients were 85% at 6 months, 77.5% at 12 months, 69% at 24 months, 58% at 36 months, 55% at 48 months, and 48.5% at 60 months. The cumulative competency rates of 36 patients in Group B were 88% at 6 months, 80% at 12 months, 75% at 24 months, 71.5% at 36 months, 69% at 48 months, and 69% at 60 months. Conclusions. Although external valvuloplasty procedure is an acceptable technique that can be used in patients with deep venous reflux, our study revealed that its durability may be limited and decreases over time. The addition of external banding provides more durable results with a lesser incidences of ulcer recurrence and valve incompetence.

Four hundred and sixty-four patients with duodenal ulcer disease received continuous maintenance treatment with ranitidine for up to 9 years. Treatment failure was defined as either the first symptomatic recurrence of ulcer or the first ulcer recurrence accompanied by haemorrhage. Life tables were constructed using the Kaplan-Meier product-limit method; comparisons of survival curves were performed using the log-rank test; and multivariate analysis was carried out using the Cox proportional hazards model. Results. The proportion of patients remaining free from symptomatic recurrence of ulcer during maintenance treatment with either 150 mg/day or 300 mg/day ranitidine was: 95% at 1 year; 88% at 3 years; 86% at 5 years; and 81% at 7 and 9 years (95% C.I. 76-86%). Young age and the absence of exposure to non-steroidal anti-inflammatory drugs (NSAIDs) at the time of diagnosis of ulcer were shown to increase the likelihood of developing ulcer recurrence. The rate of ulcer recurrence after 9 years of maintenance treatment (17%) was significantly less than that after 5 years without active anti-ulcer therapy (80%), P = 0.0001. The proportion of patients who remained free from ulcer haemorrhage during maintenance treatment was: 99.1% at 1 year and 98.1% at 5 and 9 years (95% C.I. 96.7-99.6%). The risk of haemorrhage was significantly greater in patients who were not receiving active treatment (12.4% at 5 years) than in patients receiving maintenance treatment (less than 2% at 9 years), P = 0.0001 (log-rank test). Patients who had originally presented with haemorrhage had an increased risk of further ulcer bleeding compared with patients who presented with pain (P = 0.0013). A significantly greater proportion of patients with NSAID-associated duodenal ulcers remained free from ulcer recurrence during maintenance treatment compared with patients suffering from 'idiopathic' ulcers (P = 0.0238), although there was no difference between the two groups in respect of haemorrhage during maintenance treatment. Conclusions. (a) Continuous maintenance treatment with ranitidine for up to nine years successfully prevents ulcer recurrence in more than 80% of patients with duodenal ulcer disease. (b) Young age increases the risk of ulcer recurrence during maintenance treatment with ranitidine. Ulcers associated with NSAID-intake at the time of diagnosis have a lesser risk of recurrence during maintenance treatment. (c) The risk of haemorrhage in patients with ulcer disease receiving maintenance treatment with ranitidine for nine years was less than 2% compared with greater than 12% in untreated patients observed for 5 years.(ABSTRACT TRUNCATED AT 400 WORDS)

In a randomly allocated, double-blind, endoscopically controlled study, 98 patients with gastric ulcers were treated with either (a synthetic prostaglandin of E2-like structure) enprostil 70 micrograms b.d. or 150 mg ranitidine b.d. The healing rates at 4, 8 and 12 weeks were enprostil 57, 91 and 94% and for ranitidine 55, 88 and 98%, respectively. Following ulcer healing, half the patients were followed for 1 year without treatment and the others were given 70 micrograms enprostil nocte. Endoscopy was repeated in both groups after 6 and 12 months or if dyspeptic symptoms returned. The recurrence rate without maintenance at 6 and 12 months, following ranitidine therapy, was 67 and 75%, and after enprostil therapy 50 and 61%, respectively. On maintenance enprostil, the recurrence rates were 28 and 40%. Forty-seven per cent of patients who completed maintenance treatment had a proven ulcer recurrence within 6 months of stopping therapy. Diarrhoea was a common side-effect of enprostil therapy. Seven patients were withdrawn because of diarrhoea or abdominal pain.

This paper is a sequel to the article ‘How often should patients in compression have ABPI recorded?’ ( Furlong, 2013 ). Monitoring ankle brachial pressure index (ABPI) is essential, especially in those patients wearing compression hosiery, as it can change over time ( Simon et al, 1994 ; Pankhurst, 2004 ), particularly in the presence of peripheral arterial disease (PAD). Leg ulceration caused by venous disease requires graduated compression ( Wounds UK, 2002 ; Anderson, 2008). Once healed, compression hosiery is required to help prevent ulcer recurrence ( Vandongen and Stacey, 2000 ). The Royal College of Nursing ( RCN, 2006 ) guidelines suggest 3-monthly reviews, including ABPI, with no further guidance. Wounds UK (2002) suggests that patients who have ABPI