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The appropriateness of long-term cimetidine prescribing was evaluated retrospectively in 243 outpatients. Criteria defining appropriate indications for the use of cimetidine for longer than eight weeks were established. Of the 243 patients surveyed, 115 (47 percent) were considered to be inappropriately receiving long-term cimetidine, either because they had never been objectively studied radiographically or endoscopically (23 percent) or had negative results before initiation of therapy (24 percent). Risk factors known to be associated with recurrent peptic ulcer disease were reviewed. Patients fulfilling criteria for appropriate long-term cimetidine usage had a greater prevalence of risk factors compared to the nonjustifiable group. Of particular interest, individuals considered appropriate for long-term therapy were very likely to have had a gastrointestinal bleeding episode prior to beginning therapy (52 percent for gastric ulcer, 8 percent for the nonjustifiable group). This increased prevalence of gastrointestinal hemorrhage may be due to the inherent nature of peptic ulcer disease or a result of physicians selecting affected individuals who may benefit from long-term treatment. Eliminating inappropriate usage of long-term cimetidine in conjunction with a thorough evaluation of risk factors for recurrent ulcer disease can be useful in selecting those individuals most likely to benefit from long-term cimetidine therapy.

In one surgical unit, 241 patients have undergone anterior gastric seromyotomy and posterior truncal vagotomy for chronic duodenal ulcer. The postoperative mortality rate was 0·4 per cent. Four patients (1·6 per cent) required a drainage procedure for gastric stasis. The first 66 patients (Group A) were followed prospectively and 58 were available for assessment at 5 years. Eight patients (14 per cent) had developed a recurrent ulcer. In seven of these patients this responded to conservative treatment with H2 receptor antagonists. One patient has required Polya partial gastrectomy for recurrent ulceration. At 5 years 47 patients (81 per cent) were placed in the Visick I or II categories. In the next 175 patients (Group B), the ulcer recurrence rate was 3 per cent, suggesting a learning curve in mastering the procedure. We conclude that the immediate and 5-year results of the first 66 patients are at least comparable with those of highly selective vagotomy. Anterior gastric seromyotomy with posterior truncal vagotomy is an easy and rapid procedure and may be more widely applicable than highly selective vagotomy.

We measured serum group I pepsinogen (PG I) levels in subjects with endoscopically normal gastric and duodenal mucosa and patients with peptic ulcer. The release mechanism of PG I into blood stream was also investigated. The mean (+/- S.E.) serum PG I level in 136 subjects with endoscopically normal mucosa was 61 +/- 2 ng/ml and the normal range was calculated to be 30-109 ng/ml from the frequency distribution. In the patients with unoperated recurrent duodenal ulcer, the serum PG I levels remained high with the healing process of the ulcer. On the other hand, in the patients with non-recurrent duodenal ulcer and those with recurrent or non-recurrent gastric ulcer, the serum PG I levels decreased with the healing process of the ulcer gradually and significantly from the value in the active stage. These findings suggest that duodenal ulcer patients with high levels of serum PG I throughout the healing process of the ulcer tend to have the recurrence. Therefore, the serial measurements of serum PG I with the healing process will be helpful for the prediction of ulcer recurrence. Administration of atropine caused a significant decrease in serum PG I in the patients with duodenal ulcer, which suggests the vagal control of PG I release in duodenal ulcer patients.

The amount of sick-listing in 75 patients operated on with highly selective vagotomy (HSV) was studied during two periods, the first consisting of 12 months and ending 1 year before operation and the second period, also consisting of 12 months, starting 1 year after operation. Patients with suspected ulcer recurrences were excluded and only patients who, at the 1-year postoperative follow-up study, were without symptoms suggestive of ulcer recurrence are included. The median amount of sick days was 31.3 for the period preceding and 37.2 (NS) after the operation. Before operation 60% of all sick-leave diagnoses were ulcer or gastritis, compared with 20% after operation. A 50% increase in infectious diseases and lumbago occurred. Psychiatric disorders rose from 1 to 16 occasions. We therefore conclude that patients apparently cured of chronic ulcer disease change target and develop symptoms elsewhere. The study shows no potential economic benefits of HSV, at least not with regard to a diminishing amount of sick days after operation.

We describe a modification of the biceps femoris myocutaneous flap for reconstruction of ischial pressure ulcer defects. In this modification, all neural and vascular pedicles are preserved and the flap is advanced into the ischial defect rather than transposed as described in the literature. With this method, no transferred tissue is lost. Besides ensuring good tissue survival, the flap preserves a maximum number of reconstructive options in the event of ischial pressure ulcer recurrence. These advantages make the biceps femoris myocutaneous advancement flap our first choice for reconstruction of ischial pressure ulcer defects.

Due to fear of duodenal ulcer recurrence, PGV is not yet accepted by most surgeons in the United States as a satisfactory operation for treatment of intractable duodenal ulcer. Currently PGV has a 30 day operative mortality of 0.3 percent, a severe morbidity of 1 percent, and a long-term ulcer recurrence rate of about 11 percent. Truncal vagotomy and pyloroplasty has a mortality of 0.7 percent, a morbidity of 5 percent, and a recurrence rate of about 10 percent. Truncal vagotomy and antrectomy has a mortality of 1 percent, a morbidity of 5 percent, and a recurrence rate of about 2 percent. Thus, PGV is preferable to vagotomy and pyloroplasty since vagotomy and pyloroplasty has higher mortality and morbidity rates. The recurrence rate is similar. Furthermore, since postoperative morbidity is more difficult to manage than ulcer recurrence, a cogent argument can be made that PGV is superior to vagotomy and antrectomy as an operation for intractable duodenal ulcer.

Tri-potassium di-citrato bismuthate is a complex bismuth salt stable in colloidal form advocated for the treatment of peptic ulcer. Preliminary placebo-controlled trials in small numbers of ambulant patients with endoscopically proven peptic ulcer, strongly suggest that the compound accelerates the rate of healing of gastric and duodenal ulcer within 4 weeks of treatment. However, trials involving larger numbers of patients followed-up for longer periods are required before a clear verdict on the efficacy of tripotassium di-citrato bismuthate in gastric and duodenal ulcer can be given. There are no reliable data on the effect of the drug on ulcer recurrence rate. Side-effects are negligible and the drug could become an important therapeutic agent in peptic ulcer therapy if results of further study are conclusive. The drug causes dark discolouration of the stools and this should be borne in mind when considering the possibility of the presence of intestinal bleeding.

Subtotal gastrectomy has proved to be a good procedure for control of complications of duodenal ulcer. It is not uniformly effective, however, as 2%-4% of patients so treated ultimately develop recurrence. Also, this procedure is associated with the development of postgastrectomy sequelae which may be disabling. These limitations of gastrectomy have led many surgeons to search for a more effective procedure, with a lower incidence of postoperative sequelae. During recent years a trend toward more conservative operative procedures has emerged. Some, such as vagotomy and gastrojejunostomy, are associated with a higher incidence of recurrent ulceration but a lower incidence of postoperative physiologic disturbance. One procedure, hemigastrectomy and vagotomy, has been reported to reduce the incidence of ulcer recurrence without an increase in postgastrectomy sequelae. 2,9,12 Palumbo et al, who have utilized antrectomy and vagotomy, report a lowered incidence of both recurrent ulceration and the dumping syndrome. 10 Our experience with

Thirty-one operations have been performed on 28 patients for refractory postphlebitic stasis ulcers during the past 15 years. Venous insufficiency had been present 1 to 35 years. The average duration between ulceration and definitive surgery was five years. The ulcers had recurred after ligation and stripping of varicose veins in ten patients and after excision and split-thickness grafting of the ulcer in five patients. Eighteen patients have been followed up for at least five years. The ulcer recurrence rate is approximately 10%.

Adequate therapy of duodenal ulcer should not only accomplish healing of the ulcer but should prevent its recurrence. Since the advent of vagotomy as a surgical treatment of duodenal ulcer the question of its effect on ulcer recurrence has been raised repeatedly. The literature on this subject is inadequate, and in most of the reports the data are inconclusive. For example, a report by Weber, Goldblum, and Gregg 1 cites three cases of gastric ulceration following vagotomy. No insulin tests were done in two of these cases, and in the third case the insulin test would be considered by us to be inadequate, since the blood sugar level attained was only 58 mg. per hundred cubic centimeters. In addition, this patient had a gastroenterostomy, which in our experience frequently causes false negative results in insulin tests. Dragstedt 2 states that persistence or recurrence of duodenal or gastrojejunal ulcer is almost

One hundred and seventy-one patients were treated by vagotomy and drainage for duodenal ulcer. When performed electively, the mortality was low (0.9%). For massive, continuing hemorrhage the mortality was high (22.2%). There was an 11.1% overall incidence of ulcer recurrence. The number of vagal trunks resected did not establish the completeness of vagotomy. Insulin testing was performed postoperatively in 60 patients. Of these, 22 (37%) were positive. A positive insulin test was associated with a high incidence of recurrent ulcer (60%). There were no recurrences in those patients with negative or equivocal Hollander tests. We believe that routine postoperative insulin tests are a valuable prognostic guide.

The results of antrectomy for recurrent ulcer after parietal cell vagotomy are reviewed. Eighteen patients underwent precise antrectomy between 6 months and 7 years after their primary operation. Fourteen patients were reconstructed with a gastroduodenostomy and 4 with a gastrojejunostomy. Eighteen patients were available for follow-up of between 18 months and 10 years. One patient (6·25 per cent) developed a recurrent ulcer 1 year after antrectomy. There was no operative mortality. Six patients (33 per cent) had minor complications in the immediate postoperative period, and one (5·5 per cent) had a major complication. According to Visick grading, 75 per cent had good or excellent results and 25 per cent poor results. Antrectomy following parietal cell vagotomy can be achieved with a low operative mortality, a low ulcer recurrence rate and a satisfactorily low incidence of post-gastrectomy problems.

Apligraf™ is full thickness manufactured living skin equivalent indicated for the treatment of venous leg ulcers (VLU). OBJECTIVE: To undertake a model-based retrospective cost-effectiveness analysis (CEA), from a societal and health care perspective, of the outpatient treatment of VLU with the 4-layer high-compression bandage system with and without one application of Apligraf™. METHODS: Because no prospective head-to-head study of this comparison had yet been undertaken, a computer-based model was developed. The model represented the clinical consequences of the two approaches (ulcers healed, time to heal, ulcer recurrence, infections, complications) and the costs associated with these consequences over two analytic horizons, 3 months and 6 months. Data for the 3-month model was estimated based on two published studies and clinical experience by a panel of seven physicians from across Canada. The panel used an interactive modified Delphi approach culminating in a facilitated group meeting. Data for the 6-month model was extrapolated from the shorter model using several different plausible assumptions. RESULTS: Over 3 months the use of Apligraf increased costs by $304 and $316 from the societal and the health care perspectives, respectively, provided clinical benefits of 22 ulcer days averted (UDA), and a C/E ratio of $14/UDA for each perspective. Over 6 months the C/E ratio was below $5/UDA for the societal and health care perspectives. Sensitivity analysis indicated that the model was relatively robust. Subgroup analyses suggested that Apligraf is particularly cost-effective in patients with long-standing ulcers. CONCLUSION: The model suggests that Apligraf is cost-effective in treating VLU, particularly when longer analytic horizons are considered. Confirmation of this finding in a prospective study is encouraged.

Information is limited concerning the long term prognosis for paediatric peptic ulcer disease. We traced 19 individuals in whom this diagnosis had been made 14 to 27 years earlier. All had been diagnosed using strict criteria. Each completed a postal questionnaire and where necessary further information was obtained by direct interview or by discussion with the general practitioner. Hospital case notes, from adult life, were studied where these were available. At follow up the subjects ranged from 25 to 38 (median 30) years old. A high incidence of morbidity persisting into adult life was found. Nine (47%) had had a proven ulcer recurrence since entering adult life. Ten (53%) were no longer prone to recurring episodes of abdominal pain, but 40% of these had undergone vagotcmy and pyloroplasty for intractable symptoms. Thus only six patients (31%) had made a lasting and spontaneous recovery. Complications such as haemorrhage, penetrating ulcer, severe pyloric stenosis or perforation had occurred in 10 (53%). Seven (37%) had undergone surgery, and in two of these cases more than one operation had been performed. Fifty-eight percent of ccmplications suffered and 89% of surgical operations performed involved patients of 21 years or older. These findings firmly reinforce the opinion that the disorder frequently persists into adult life. The impact of the newer means of medical therapy, such as the H2 receptor antagonists remains to be evaluated.

Although modern medicine therapy reliably heals peptic ulcers, relapse is the rule and remains a major challenge to investigators and practitioners alike. Several factors associated with ulcer recurrence have been identified but pathogenetic mechanisms are obscure. Some recent studies suggest that the type of treatment used to heal the initial ulcer influences the propensity to recurrence. Although there is circumstantial evidence that relapse may be accelerated after initial treatment with H2-receptor antagonists, overall it appears that differences in recurrence rates are more likely due to the influence of colloidal bismuth subcitrate in reducing recurrence rates. Several mucosal abnormalities have been identified in patients with peptic ulcer disease in remission. These include defective gastric mucus, reduced duodenal bicarbonate secretion and altered synthesis of certain prostaglandins, particularly of the E series. Decreased salivary secretion of epidermal growth factor and gastric Campylobacter pylori infections have also received much attention recently. It is postulated that the cause of recurrent ulceration, like that of initial ulceration, is multifactorial, and that local factors caused by the initial ulcer may contribute to the propensity of recurrence.

Thirteen eyes with sterile marginal corneal ulcers were treated with cryotherapy and conjunctival recession or resection. Ulcer progression was ultimately controlled in all cases (mean follow-up of 21 months). One eye with Mooren's ulcer required reoperation to achieve a quiescent state, and two other eyes needed conservative therapy after surgery in order to heal. The eyes required careful observation for ulcer recurrence or problems associated with the original systemic diseases, such as Sjogren's syndrome. In the majority of cases, visual acuity was not affected by the procedure. Light microscopy of the conjunctiva adjacent to the ulcer showed lymphocytes and plasma cells.

The patients working in a ship yard, who suffered from gastric ulcer, were examined to study the influence of their life environmental factors on the gastric ulcer recurrence and recrudescence. The results obtained were as the followings; 1. In the gastroscopic demonstration of gastric ulcer, the cases of recurrent ulcer could not clearly be differed from those of not recurrent. 2. In the studies of their life environment and the analysis of both mecholyland C.M.I.~test, the results from a group followed by recurrent ulcer fail to be distinguished from the other not followed. 3. Night duty, overwork, taking adrenal steroid hormone, severe emotional strain about work and so on may play a important role in the factors of ulcer recurrence. 4. As the complete healing of gastric ulcer has unlikely taken place during the determination of redness by gastroscopic studies, the medical treatment should be continued for about more 6 months and the patients should be kept away from both night duty and overwork.

Surgical management of patients with islet-cell, duodenal wall tumors (DWT), and the Zollinger-Ellison syndrome (ZES) is controversial. Complete tumor excision or total gastrectomy has been advocated. Duodenal wall tumors were identified in 13% (103 of 800) of patients in the Z-E Tumor Registry. The characteristics of ZES patients with DWTs and results of surgery were studied. Less than half of the patients with DWTs had solitary lesions. Four subgroups were identified: group 1, 48 patients with localized DWTs; group 2, 26 patients with DWTs and lymph node metastasis; group 3, 24 patients with duodenal wall and pancreatic tumors; and group 4, five patients with DWTs and islet-cell hyperplasia. Total gastrectomy resulted in the best survival when the DWTs were associated with pancreatic or metastatic lesions or both. Attempts at local tumor excision resulted in a 51% ulcer recurrence rate. Local excision of DWTs with less than total gastrectomy was successful in only 20 patients.

Background A clinical history of peptic ulcer has been reported to be associated with a high rate of ulcer recurrence in nonsteroidal anti-inflammatory drug (NSAID) users. Therefore, it is a very important issue to precisely know the previous history prior to NSAIDs administration. To clarify the possible difficulty to identify the history, we determined the sensitivity and diagnostic concordance of endoscopy for the identification of ulcer scars indicative of previous clinical history of peptic ulcer diseases. Methods The first study enrolled 200 consecutive patients with a clinical history of gastric or duodenal ulcers previously confirmed by esophagogastroduodenoscopy. The sensitivity of endoscopy for identifying scars was determined for these patients. In the second study, the extent of interobserver agreement was determined for 47 endoscopists who identified ulcer scars in endoscopic photographs of 30 sites of previous active gastric ulcers and 30 sites of previous active duodenal ulcers. The kappa coefficient of reliability was calculated to measure the interobserver agreement on the diagnosis of ulcer scars. Results Out of 190 patients eligible for analysis, 104 (54.7%) were found to have gastric or duodenal ulcer scars on endoscopy; there were no gastric or duodenal ulcer scars seen in the remaining patients (45%). In the second study, the kappa values for endoscopic diagnosis of gastric and duodenal ulcer scars were 0.14 (95% CI 0.13-0.16) and 0.29 (95% CI 0.27-0.32), respectively. The addition of indigo-carmine chromoendoscopy did not provide a statistically significant improvement in diagnostic concordance in patients with gastric ulcer scar since the kappa value for chromoendoscopic diagnosis was 0.15; 95% CI 0.13-0.17 as low as for un-contrasted scars. Conclusions The sensitivity and concordance of endoscopic diagnosis of gastric and duodenal ulcer scars are not satisfactory for the use of endoscopy only to identify previous ulcer disease. To avoid the overlooking the previous clinical history of peptic ulcer diseases, the diagnosis of peptic ulcer scar has to be carefully done prior to NSAIDs administration.

Results Overall, 2,034 people presented with a foot ulcer in 2012. Mean age was 63(±14) years and 67.8% were male. Co-morbidities included 85% had diabetes, 49.7% hypertension, 39.2% dyslipidaemia, 25.6% cardiovascular disease, 13.7% kidney disease and 12.2% smoking. Foot ulcer types included 51.6% neuropathic, 17.8% neuroischaemic, 7.2% ischaemic, 6.6% post-surgical and 16.8% other; whilst 31% were infected. Clinical indicator results revealed 98% had their wound categorised, 51% received non-removable offloading, median ulcer healing time was 6-weeks and 37% had ulcer recurrence. Conclusion This paper details the largest foot ulcer database reported in Australia. People presenting with foot ulcers appear predominantly older, male with several co-morbidities. Encouragingly it appears most patients are receiving best practice care. These results may be a factor in the significant reduction of Queensland diabetes foot-related hospitalisations and amputations recently reported.

Objective This was a systematic review of the literature to determine which compression method is superior in promoting ulcer healing and reducing recurrence in patients with lower extremity venous ulcer disease. Methods We conducted a comprehensive search of multiple databases for randomized and nonrandomized comparative studies from 1990 to December 2013. Results We identified 36 studies and two Cochrane systematic reviews. Many studies had moderate risk of bias. We found no overall difference between compression stockings vs compression bandages with respect to ulcer healing, time to ulcer healing, or ulcer recurrence outcomes. When we compared stockings vs short stretch bandages, stockings were superior with respect to ulcer healing. However, stockings compared with four-layer systems showed no difference in ulcer healing outcomes. When four-layer systems were compared with compression with less than four layers, there was also no significant difference in ulcer healing outcomes. Similarly, short stretch bandages were not superior to long stretch bandages with respect to ulcer healing, time to ulcer healing, or ulcer recurrence. One Cochrane review presented many additional comparisons and reported increased wound healing with compression compared with no compression, with multicomponent systems over single component systems, and compression systems with an elastic component over no elastic component. Another Cochrane review demonstrated a reduction in recurrence with compression in patients with healed ulcers. Conclusions At least moderate-quality evidence supports compression over no compression, multicomponent systems over single component systems, and systems with an elastic component over those without. We did not find significant differences with respect to ulcer healing outcomes for other comparisons. Low-quality evidence supports the effect of compression on ulcer recurrence.