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The current study aimed at identifying the risk factors and initial diagnostic aids for abomasal ulcers. The risk factor analysis confirmed a significant association (P < 0.05) of abomasal ulcers with concentrate-rich diets (OR, 4.795; CI, 1.212-15.974) and concurrent disorders (OR, 2.978; CI, 0.987-8.980), while the buffaloes in early lactation (OR, 2.777; CI, 0.703-10.972) showed a higher tendency (P = 0.078) for the disorder. The depressed demeanour, dark or black manure (melena), anemia, tachycardia, decreased milk production, anorexia, tachypnea, absence of rumination, abdominal guarding, kyphosis, and tachypnea were the most frequent clinical signs. Subjecting the abomasal fluid for cultural isolation, gram staining, and stormy clot fermentation test identified the presence of clostridium perfringes, while screening through uniplex PCR detected cpa toxin. The buffaloes affected with type-3 and 4 abomasal ulcers exhibited a higher peritoneal fluid to serum ratio of total protein, albumin, and glucose with a low (P < 0.01) serum-ascites albumin gradient (SAAG) concentration compared to reference values of healthy buffaloes. The first two principal components of PCA explained 54.50% of the total variances with lymphocytes, creatine kinase, and rumen chloride levels as the top contributors to dimension I, and albumin, total protein, sodium, and methylene blue reduction time (MBRT) for rumen liquor as the major contributors to dimension II. The vector plot revealed lymphocytopenia, decreased hemoglobin, hypoalbuminemia, hypokalemia, decreased rumen pH, neutrophilia, eosinophilia, leucocytosis, greater MBRT, and higher rumen chloride, serum creatine kinase, and blood urea nitrogen as the major indicators for abomasal ulcers. Histopathological studies revealed infiltration of inflammatory cells in the mucosa along with multifocal areas of necrosis, degeneration, and eroded muscle structure. The study projected a few high-scored clinical signs and extremely variable clinical indicators as initial diagnostic aids of abomasal ulcers, which can be confirmed by ultrasonography and peritoneal fluid examination., (© 2023. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Guidelines for the management of upper gastrointestinal bleeding (UGIB) are regularly published, yet little is known concerning adherence to recommendations in practice., Objectives: We aimed to assess adherence to European Society of Gastrointestinal Endoscopy (ESGE) recommendations in patients with non-variceal UGIB., Materials and Methods: All hospitalized patients with an esophagogastroduodenoscopy (EGD) performed due to suspected non-variceal UGIB at our department were included in a prospective registry. Data between 2018-2020 from this registry were retrospectively analyzed. Adherence to the 2015 ESGE bleeding and propofol sedation guidelines was assessed. Adherence to recommendations concerning preendoscopic (risk) evaluation, preendoscopic PPI, transfusion management, and endoscopic management of peptic ulcers was analyzed., Results: Among 1005 patients (mean age 70.4 years, 42.1% women) the most common bleeding etiologies were gastric or duodenal ulcers (16.8%), esophagitis/GERD (11.1%), and angiodysplasia (9.9%); mortality was 7.6%. Adherence to preendosopic risk evaluation was low, in 0% a Mallampati classification and in 37.5% an ASA scoring was documented. Preendoscopic PPI was started at 58.6%, and adherence to recommended transfusion management was >98%. Peptic ulcers were Forrest-graded in 72.8%. High-risk ulcers were treated appropriately in 77.9% and low-risk ulcers were not treated in 73.6%. Especially Forrest Ib ulcers were undertreated, with an adherence of 59.6%. Only 22/179 (12.3%) patients with peptic ulcers and early endoscopy were consistently managed according to ESGE recommendations., Conclusions: Adherence to ESGE guidelines in patients with non-variceal UGIB is moderate to low, even at a tertiary university hospital. Strategies must be devised for guidelines to reach patients in everyday practice.

Goals: The aim was to systematically evaluate risks and benefits of proton pump inhibitor (PPI) use for stress ulcer prophylaxis in the critically ill patient., Background: Whether PPIs increase mortality in the critically ill patient remains controversial., Study: Systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies with trial sequential analysis, Bayesian sensitivity analysis, and fragility index analysis., Results: A total of 31 studies in 78,009 critically ill adults receiving PPIs versus any comparator were included. PPI use was associated with an increased mortality risk in all studies [19.6% PPI vs. 17.5% comparator; RR: 1.10; 95% confidence interval (CI): 1.02-1.20; P =0.01], in the subgroup of RCTs (19.4% vs. 18.7%; RR: 1.05; 95% CI: 1.0-1.09, P =0.04), but not cohort studies (19.9% vs. 16.7%; RR: 1.12; 95% CI: 0.98-1.28, P =0.09). Results were maintained with a Bayesian sensitivity analysis (RR: 1.13; 95% credible interval: 1.035-1.227) and a fragility index analysis, but not sequential analysis ( P =0.16). RCTs with a higher baseline severity of illness revealed the greatest mortality risk with PPI use (32.1% PPI vs. 29.4% comparator; RR: 1.09; 95% CI: 1.04-1.14; P <0.001). PPI use reduced clinically important bleeding in RCTs (1.4% PPI vs. 2.1% comparator; RR: 0.67; 95% CI: 0.5-0.9; P =0.009) but increased bleeding in cohort studies (2.7% PPI vs. 1.2% comparator; RR: 2.05; 95% CI: 1.2-3.52; P =0.009). PPI use was not associated with a lower incidence of clinically important bleeding when compared with histamine-2 receptor antagonists (1.3% vs. 1.9%; RR: 0.59; 95% CI: 0.28-1.25, P =0.09)., Conclusions: This meta-analysis demonstrated an association between PPI use and an increased risk of mortality., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess the value of multiplanar computed tomography (CT) in the diagnosis of nonperforated duodenal bulb ulcer (NPDBU)., Method: We retrospectively analyzed data from 135 patients with NPDBU (ulcer group) and 150 patients with a normal duodenal bulb (control group) who underwent contrast-enhanced abdominal CT and were diagnosed via upper endoscopy from January 2018 to February 2022. The clinical and CT features were compared between the two groups. Independent prognostic factors for diagnosing NPDBU were determined using binary logistic regression analysis. An external validation cohort to determine the model's efficiency comprised 80 patients from another center., Results: Gastrointestinal bleeding was more frequent in patients with NPDBU than in those without (p < 0.001). No significant differences in age and sex were observed between the groups (all p > 0.05). The duodenal bulbar wall was significantly thicker in the ulcer group than in the control group, as determined using CT (p < 0.001). Irregular mucosal surface, layered enhancement, and blurred fat space around the duodenal bulb were more common in the ulcer group than in the control group (all p < 0.001). Binary logistic regression analysis revealed that gastrointestinal bleeding, wall thickness of ≥ 4.85 mm, irregular mucosal surface, and blurred peripheral fat space were the most significant variations associated with NPDBU, with an area under the curve (AUC) of 0.974. The external validation cohort had an AUC of 0.916., Conclusions: Careful multiplanar CT interpretation suggests the underlying presence of NPDBU and allows timely endoscopic verification and appropriate treatment., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: Dubowitz syndrome is a rare genetic disease with only a few cases reported in the literature. It is characterized by growth retardation, microcephaly, facial dysmorphism and higher risk of developing cancer and cardiomyopathies. PG is an autoinflammatory disorder that causes painful ulcers to develop on the skin and has not been previously associated with Dubowitz syndrome., Case Presentation: The authors report the case of a 50-year-old female with Dubowitz syndrome who developed painful ulcerative lesions. An incisional biopsy was performed to rule out other diagnoses, and a subsequent clinical diagnosis of PG was made. The patient was treated with specialized wound dressings and oral glucocorticoids. The clinical picture improved consistently after 7 weeks of therapy., Conclusions: This case report, to the authors' knowledge, is the first to suggest a possible association between Dubowitz syndrome and PG and also to indicate an effective treatment.

Background: One of the most important problems associated with the treatment of Rheumatoid Arthritis (RA) is erosive-ulcerative lesions (EUL) of the gastroduodenal zone, which is associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs)., Aims: Our research aims to study the clinical and histo-morphological criteria for forming the EUL of the gastroduodenal zone in patients with RA., Methods: Patients were divided into 3 groups, depending on the presence of an EUL, according to Fibrogastroduodenoscopy (FGDS) data with a negative test for H. pylori. Group 1 included RA patients without EUL (n = 18), group 2 RA patients with erosive lesions of the gastroduodenal zone (n = 57), and group 3 consisted of RA patients with ulcerative lesions (n = 17). As a norm, we used data from a survey of 18 healthy donors corresponding to RA patient's age and sex distribution, where no somatic pathology was revealed. GSRS questionnaire was used for assessment of subjective symptoms. For histomorphological studies, biopsy specimens were taken during FGDS using an Olympus Evis Exera II digital video endoscope., Results: Patients of RA with EUL in the gastro-duodenal zone were significantly different from the group of healthy donors and patients of group 1 by the severity of 5 symptoms related to the upper gastrointestinal tract according to the GSRS questionnaire, including abdominal pain, heartburn, belching acid, a feeling of sucking and burning in epigastria, nausea and vomiting. In general, there were no clinically significant differences between the frequency of occurrence and the severity of symptoms on the GSRS scale between group 2 and group 3, except for complaints of heartburn. So, RA patients of group 3 had a higher rate of heartburn feeling of 3.0 (2.0-3.0) points than patients of group 2 with 2.0 (1.0-2.0) points., Conclusion: The development of a EUL of the gastroduodenal zone in patients with RA is associated with low activity of inflammation in all studied slides, regardless of structurally destructive changes in the stomach and duodenum and compensatory hyperplastic reactions in the superficial layer of mucosa membrane, which can be determined by minimal subjective sensations or even complete absence of clinical manifestations with the formation of "silent ulcers", complicated by bleeding and perforation., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Significance: Due to the persistence of chronic wounds, a second surgical intervention is often necessary for patients with peripheral arterial disease (PAD) within a year of the first intervention. The dynamic vascular optical spectroscopy system (DVOS) may assist physicians in determining patient prognosis only a month after the first surgical intervention., Aim: We aim to assess the DVOS utility in characterizing wound healing in PAD patients after endovascular intervention., Approach: The DVOS used near-infrared light ( 670 < λ < 850    nm ) to record hemodynamic response to a cuff inflation in 14 PAD patients with lower limb ulcers immediately before, immediately after, and at a first follow-up 3 to 4 weeks after intervention. Ankle-brachial index (ABI) and arterial duplex ultrasound (A-DUS) measurements were obtained when possible., Results: The total hemoglobin plateau time differed significantly between patients with ulcers that reduced in size ( N = 9 ) and patients with ulcers that did not ( N = 5 ) 3 to 4 weeks after intervention ( p  value < 0.001 ). Data correlated strongly (89% sensitivity, 100% specificity, and AUC = 0.96 ) with long-term wound healing. ABI and A-DUS measurements were not statistically associated with wound healing., Conclusions: This pilot study demonstrates the potential of the DVOS to aid physicians in giving accurate long-term wound healing prognoses 1 month after intervention., (© 2022 The Authors.)

To compare the safety and efficacy of thoracic endovascular aortic repair (TEVAR) and optimal medical treatment (OMT) for type B penetrating aortic ulcer (PAU) associated with intramural hematoma (IMH). From January 2015 to December 2018, 68 consecutive patients with acute type B PAU associated with IMH were enrolled in the study. TEVAR was performed following initially OMT in 30 patients (group A), and OMT was performed in 38 patients (group B). Primary outcome was aortic-related mortality. Secondary outcomes included all-cause mortality, aortic-related adverse events, and complete aortic remodeling. There was no significant difference in the baseline characteristics of patients among the 2 groups except for the depth of PAU and the thickness of IMH. Patients in group B had a significant higher risk of aortic-related mortality (13.3% vs 0%, P = .045), as the same to aortic-related adverse events during follow-up. Compared to OMT, TEVAR contributed to the favorable aortic remodeling more significantly during the mid-term follow-up (85.7% vs 18.2%, P < .001). Comparing with optimal medical repair, TEVAR for patients with PAU associated with IMH could promote the favorable aortic remolding more significantly and result in lower aortic-related mortality during mid-term follow-up. It should be considered as the first-line therapeutic option when intervention is required., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Rectal foreign bodies (RFB) are quite uncommon except in very busy hospitals. Because of their rarity, it is seldom that the treating physicians have a standard approach to the diagnosis, technique of extraction, and post-extraction evaluation. This can be further complicated by the rather extreme variability of size, shape, and texture of the foreign bodies, as well as the potential extent of trauma to the rectum or distal colon., Aim: The objectives of this study were to delineate the demographics, classification of cause, and injury patterns of RFB and to present the results of the transanal surgical management of a large series of RFB., Methods: We retrospectively collected extensive data from the hospital medical records of the 291 patients who presented with RFB to the emergency department of Shenyang Proctological Hospital (Shenyang, China) from 2012 July to 2020 December. Specifically, demographics, origins and circumstance of the RFB, complications, injuries, anesthesia method, and the results of the transanal surgical management were recorded and analyzed., Results: Of the 291 RFB cases, 225 (77.3%) were male and 66 (22.7%) were female, with a mean age of 53.8 ± 15.5 years (range, 1 ~ 88 years). The circumstances of the RFB were categorized as swallowed, 199 cases (68.4%); self-inserted, 87 (29.9%); and iatrogenic, 5 (1.7%). The proportion of males in the self-inserted RFB group was significantly greater than the swallowed RFB group (t = 31.114, p = 0.000). In the swallowed RFB group, the most common anorectal injuries and pathological changes were the following: penetration into the mucosa (75 cases, 37.7%), perianal or submucosal abscess (27 cases, 13.6%), and penetration into the anal canal (18 cases, 9.0%). In the self-inserted RFB group, 64 (73.6%) of the 87 cases had an intact rectum, whereas 8 (9.2%) had rectal mucosal ulcers and bleeding, and 7 (8%) had rectal lacerations. In the iatrogenic RFB group, 3 cases (60%) had rectal mucosal ulcers and bleeding, and 2 cases (40%) had inflammation of the rectal mucosa. Regarding extraction procedures, in the swallowed group, 187(187/199; 94%) patients underwent a transanal surgical procedure, and all were successful. In the self-inserted group, 82 patients underwent the transanal surgical procedure, and 74 (74/82; 90.2%) were successful whereas it was unsuccessful in the remaining 8 patients (8/82, 9.8%). Three (3/4, 75%) patients with iatrogenic RFB were resolved by the transanal surgical procedure., Conclusion: Men were markedly more likely than women to have swallowed RFBs and self-inserted RFBs. No serious damage to the rectum and anus was found in cases of swallowed RFB. Moreover, most surgical operations to remove foreign bodies via the anus were successful in this category of RFB. In contrast, rectal injury was more severe in patients with self-inserted RFB, such as rectal laceration, rectal mucosal ulcer, and bleeding. Moreover, the transanal removal operation in patients with self-inserted RFB had a failure rate of nearly 10%. Thick, long, hard foreign bodies did present a great challenge to the operator. Therefore, if necessary, patients with foreign bodies may need to be promptly referred for transabdominal removal., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Charcot arthropathy (CN) can ultimately lead to limb loss despite appropriate treatment. Initial conservative treatment is the accepted treatment in case of a plantigrade foot. The aim of this retrospective study was to investigate the mid- to long-term clinical course of CN initially being treated conservatively, and to identify risk factors for reactivation and contralateral development of CN as well as common complications in CN., Methods: A total of 184 Charcot feet in 159 patients (median age 60.0 (interquartile range (IQR) 15.5) years, 49 (30.1%) women) were retrospectively analyzed by patient chart review. Rates of limb salvage, reactivation, contralateral development and common complications were recorded. Statistical analysis was performed to identify possible risk factors for limb loss, CN reactivation, contralateral CN development, and ulcer development., Results: Major amputation-free survival could be achieved in 92.9% feet after a median follow-up of 5.2 (IQR 4.25, range 2.2-11.25) years. CN recurrence occurred in 13.6%. 32.1% had bilateral CN involvement. Ulcers were present in 72.3%. 88.1% patients were ambulating in orthopaedic footwear without any further aids. Presence of Diabetes mellitus was associated with reactivation of CN, major amputation and ulcer recurrence. Smoking was associated with ulcer development and necessity of amputations., Conclusions: With consistent conservative treatment of CN with orthopaedic footwear or orthoses, limb preservation can be achieved in 92.9% after a median follow-up of 5.2 years. Patients with diabetic CN are at an increased risk of developing complications and CN reactivation. To prevent ulcers and amputations, every effort should be made to make patients stop smoking., Level of Evidence: III, long-term retrospective cohort study., (© 2021. The Author(s).)

Background: Data on severe and extensive burns in China are limited, as is data on the prevalence of a range of related gastrointestinal (GI) disorders [such as stress ulcers, delayed defecation, opioid-related bowel immotility, and abdominal compartment syndrome (ACS)]. We present a multicentre analysis of coincident GI dysfunction and its effect on burn-related mortality., Methods: This retrospective analysis was conducted on patients with severe [≥ 20% total burn surface area (TBSA)] and extensive (> 50% TBSA or > 25% full-thickness TBSA) burns admitted to three university teaching institutions in China between January 1, 2011 and December 31, 2020. Both 30- and 90-day mortality were assessed by collating demographic data, burn causes, admission TBSA, % full-thickness TBSA, Baux score, Abbreviated Burn Severity Index (ABSI) score, and Sequential Organ Failure Assessment (SOFA) score, shock at admission and the presence of an inhalation injury. GI dysfunction included abdominal distension, nausea/vomiting, diarrhoea/constipation, GI ulcer/haemorrhage, paralytic ileus, feeding intolerance and ACS. Surgeries, length of intensive care unit (ICU) stay, pain control [in morphine milligram equivalents (MME)] and overall length of hospital stay (LOHS) were recorded., Results: We analyzed 328 patients [75.6% male, mean age: (41.6 ± 13.6) years] with a median TBSA of 62.0% (41.0-80.0%); 256 (78.0%) patients presented with extensive burns. The 90-day mortality was 23.2% (76/328), with 64 (84.2%) of these deaths occurring within 30 d and 25 (32.9%) occurring within 7 d. GI dysfunction was experienced by 45.4% of patients and had a significant effect on 90-day mortality [odds ratio (OR) = 14.070, 95% confidence interval (CI) 5.886-38.290, P < 0.001]. Multivariate analysis showed that GI dysfunction was associated with admission SOFA score and % full-thickness TBSA. Overall, 88.2% (67/76) of deceased patients had GI dysfunction [hazard ratio (HR) for death of GI dysfunction = 5.951], with a survival advantage for functional disorders (diarrhoea, constipation, or nausea/vomiting) over GI ulcer/haemorrhage (P < 0.001)., Conclusion: Patients with severe burns have an unfavourable prognosis, as nearly one-fifth died within 90 d. Half of our patients had comorbidities related to GI dysfunction, among which GI ulcers and haemorrhages were independently correlated with 90-day mortality. More attention should be given to severe burn patients with GI dysfunction., (© 2022. The Author(s).)

Studies have shown that autoimmune disease (AID)-related ulcers are disease complications that lead to serious poor prognosis such as infection and disability. It is difficult to make a clear diagnosis and there are contradictions between the applications of immunosuppressive therapy and anti-infectious therapy. Improper diagnosis and immunosuppressive therapy can easily delay the timing of anti-infectious therapy and surgery for patients, which bring adverse effects on the prognosis of patients. This paper reviews the concept, clinical characteristics and treatment suggestions of each subtype of AID-related ulcers, in order to provide more ideas for AID-related ulcers' clinical diagnosis and treatment.

Background: Systemic sclerosis (SSc) is a rare connective tissue disease characterised by immune dysfunction, vasculopathy, cellular inflammation, fibrosis of the skin associated with multiple internal organs involvement. Ischaemic digital ulcers (IDU) of the hands commonly occur in patients with SSc adversely affecting functional independence., Purpose: Aim of the study is to investigate the effectiveness of a rehabilitation protocol based on the combined use of ultrasound (US) therapy and therapeutic exercise in terms of ulcers healing, pain relief, and hand functioning in patients affected by SSc with IDUs. Moreover, we also investigated the safety of the proposed intervention., Study Design: Prospective before-after study., Methods: We included 20 patients with IDUs secondary to SSc. All patients were treated with US combined with manual therapy, including McMennel joint manipulation, pompage mobilization technique and connective tissue massage, for 10 sessions. We evaluated softness, dyschromia, pain, and hand mobility using the Pressure Sore Status Tool (PSST), the Numerical Rating Scale (NRS), and the Duruoz Hand Index (DHI) at T0 and at the end of the treatment (T1)., Results: Treatment with US combined with manual therapy significantly reduced ulcers depth, improved ulcers margins, and reduced periwound skin damage (median PSST score 16 at T1, p<0.0001). Moreover, significant benefits were reported in terms of pain relief (NRS 3 at T1; p<0.0005), and hand function (DHI score 19 at T1; p<0.0005). Finally, this approach seems to be safe, without side effects reported at the end of treatment, along with an optimal compliance., Conclusion: Therapeutic US combined with manual therapy should be used as additional intervention to manage IDUs in SSc patients., (© 2022. The Author(s).)

Acute hemorrhagic rectal ulcer is a relatively rare cause of lower gastrointestinal bleeding. It most commonly occurs in bedridden elderly patients with multiple comorbidities. While the diagnosis can be confirmed on colonoscopy, achieving hemostasis may be difficult due to the poor visual field resulting from severe bleeding and stool remaining in the rectum, the stiffness of ulcers which may preclude effective clipping, the poor tolerability of patients for the procedure, and high risk of recurrence. Here, we present 4 cases of acute hemorrhagic rectal ulcer, where hemostasis could not be achieved through traditional methods. In each case, the assistant introduced his finger into the rectal lumen and digitally compressed the bleeding vessel under endoscopic guidance. Once hemostasis was achieved, the responsible vessel could be visualized and traditional hemostatic measures were taken. No recurrence was observed in any of the cases during follow-up. This simple maneuver can be applied safely and effectively even by assistants attempting the maneuver for the first time. The technique was effective with the endoscope in retroflexed position and could be combined with gel immersion endoscopy to first identify the location of hemorrhage. We also review the existing literature on acute hemorrhagic rectal ulcers.

Background and Aim: Solitary rectal ulcer syndrome (SRUS) is an uncommon benign disorder of defecation. Management of ulcers is usually unsatisfactory with conventional treatment (laxatives, behavioral therapy, biofeedback, topical treatments, and surgery). Studies on the effectiveness of argon plasma coagulation (APC) for SRUS refractory to conventional treatment is lacking. The aim of the study was to examine the effect of APC with conventional therapy in controlling bleeding and healing of refractory SRUS., Methods: Fourteen patients of refractory SRUS diagnosed on clinical, colonoscopic, and histological findings, refractory to conventional therapy, were offered multiple sessions of APC in addition to conventional treatment. All patients were followed up to determine bleeding control and ulcer healing., Results: Fourteen patients with a mean duration of symptoms of 9.21 ± 6.94 months were included. All the patients were advised to have a high intake of fluids and laxatives and to undergo biofeedback in addition to the APC. Lesions were located anteriorly (66%), circumferentially (25%), and posteriorly (9%). Mean follow-up duration was 7 months (3 to 12 months). APC enabled bleeding control in all the patients (100%), complete healing of ulcer in 71% (10 patients), and reduction in ulcer size to less than 50% of the initial size in the remaining 29% patients. None of the patients had any procedure-related complications like bowel perforation, infections, or fistula formation., Conclusions: APC with conventional therapy is effective in controlling bleeding and healing in SRUS refractory to conventional treatment.

Objective: The aim of this study was to determine the interaction of full thickness excisional wounds and tumors in vivo., Summary of Background Data: Tumors have been described as wounds that do not heal due to similarities in stromal composition. On the basis of observations of slowed tumor growth after ulceration, we hypothesized that full thickness excisional wounds would inhibit tumor progression in vivo., Methods: To determine the interaction of tumors and wounds, we developed a tumor xenograft/allograft (human head and neck squamous cell carcinoma SAS/mouse breast carcinoma 4T1) wound mouse model. We examined tumor growth with varying temporospatial placement of tumors and wounds or ischemic flap. In addition, we developed a tumor/wound parabiosis model to understand the ability of tumors and wounds to recruit circulating progenitor cells., Results: Tumor growth inhibition by full thickness excisional wounds was dose-dependent, maintained by sequential wounding, and relative to distance. This effect was recapitulated by placement of an ischemic flap directly adjacent to a xenograft tumor. Using a parabiosis model, we demonstrated that a healing wound was able to recruit significantly more circulating progenitor cells than a growing tumor. Tumor inhibition by wound was unaffected by presence of an immune response in an immunocompetent model using a mammary carcinoma. Utilizing functional proteomics, we identified 100 proteins differentially expressed in tumors and wounds., Conclusion: Full thickness excisional wounds have the ability to inhibit tumor growth in vivo. Further research may provide an exact mechanism for this remarkable finding and new advances in wound healing and tumor biology., Competing Interests: The authors have declared that no conflict of interest exists., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Systemic sclerosis is a disease where microcirculation damage is critical in their beginning and vascular complications have similar pathogenic findings. Digital ulcers are a frequent complication in systemic sclerosis patients and pulmonary hypertension is one of the leading causes of death. The use of bosentan has been shown to be useful for the treatment of pulmonary arterial hypertension and to prevent new digital ulcers. However, is unknown if bosentan can prevent pulmonary hypertension. Our objective was to determine if bosentan is useful to prevent pulmonary hypertension in SSc patients. A retrospective study in 237 systemic sclerosis patients with digital ulcers history treated or not with bosentan to prevent it was made. We analyzed the occurrence of pulmonary hypertension defined by an echocardiogram pulmonary arterial pressure > 40 mmHg in the entire cohort. Demographic, clinical, and treatment variables were recorded for all patients. Statistical significance was denoted by p values < 0.05. Fifty-nine patients were treated with bosentan a median of 34 months. 13.8% of treated patients had pulmonary hypertension vs 23.7% of untreated patients (p 0.13) during the follow up. In multivariate analysis patients not treated with bosentan had 3.9fold-increased risk of pulmonary hypertension compared with patients under bosentan treatment (p < 0.02). Moreover the percentage carbon monoxide diffusing capacity (DLCO) in bosentan treated patients did not decrease from baseline to the end of follow-up (61.8±14% vs 57±20.1%, p = 0.89). We concluded that Systemic sclerosis patients with digital ulcers treated with bosentan seems to have less risk to develop pulmonary hypertension and to stabilize DLCO., Competing Interests: The authors have declared that no competing interests exist.

Purpose: To compare the accuracy of non-electrocardiogram (ECG)-gated CT angiography (CTA), single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA in detecting the intimal tear (IT) in aortic dissection (AD) and ulcer-like projection (ULP) in intramural hematoma (IMH)., Materials and Methods: A total of 81 consecutive patients with AD and IMH of the thoracic aorta were included in this single-center retrospective study. Non-ECG-gated CTA, single-diastolic-phase ECG-gated CTA, and full-phase ECG-gated CTA were used to detect the presence of the IT and ULP in thoracic aortic regions including the ascending aorta, aortic arch, and proximal and distal descending aorta., Results: The accuracy of detecting the IT and ULP was significantly greater using full-phase ECG-gated CTA (88% [95% CI: 100%, 75%]) than non-ECG-gated CTA (72% [95% CI: 90%, 54%], P = 0.001) and single-diastolic-phase ECG-gated CTA (76% [95% CI: 93%, 60%], P = 0.008)., Conclusion: Full-phase ECG-gated CTA is more accurate in detecting the IT in AD and ULP in IMH, than non-ECG-gated CTA and single-diastolic-phase ECG-gated CTA.

Background: Penetrating ulcers of aorta, aortic dissections and intramural hematomas all come under acute aortic syndromes and have important similarities and differences., Case Report: We report a 67 year old man with rupture of a large penetrating ulcer of the distal ascending aorta with hemopericardium and left hemothorax. He underwent interposition graft replacement of ascending aorta and hemi-arch with a 30 mm Gelweave Vascutek graft but represented 6 months later with development of a penetrating ulcer which ruptured into a huge 14 cm pseudoaneurysm. This was repaired with a 28 mm Vascutek Gelseal graft replacement of arch and interposition graft reconstruction of innominate and left common carotid arteries. 6 weeks later, however, he ruptured his proximal descending aorta and underwent TEVAR satisfactorily. Unfortunately, 2 days later, he developed a pathological fracture of left proximal tibia with metastasis from a primary renal cell carcinoma. He died 3 weeks later from respiratory failure. We shall briefly outline the similarities and differences in presentation and management of penetrating aortic ulcers, aortic dissections and intramural haematomas. We shall discuss, in greater detail, penetrating ulcers of thoracic aorta, their natural history, location, complications and management., Conclusion: This case report is unique on account of initial successful surgical redressal following rupture of penetrating ulcer of distal ascending aorta into left pleural and pericardial cavities, normally associated with instant death. The haemodynamic effects of the rupture were staggered due to initial contained rupture into a smaller pseudoaneurysm, followed by a further rupture into a false aneurysmal sac followed eventually by generalised rupture into the pleural and pericardial cavities - a unique way of aortic rupture. Further development of another penetrating ulcer and a small pseudoaneurysm in the distal arch 6 months later which further ruptured into a larger 14 cm false aneurysmal sac, which again did not result in exsanguination, is again extraordinarily rare. Thereafter he underwent emergency thoracic endovascular aortic repair (TEVAR) for a further rupture of descending thoracic aorta. All three ruptures were managed successfully and would usually be associated with near-certain death, only for the patient to succumb eventually to the complications of metastatic renal cell carcinoma.

Background Acute penetrating aortic ulcers (PAUs) are reported to dynamically evolve into different clinical outcomes ranging from regression to aortic rupture, but no practice guidelines are available in China. Methods and Results All 109 patients with acute PAUs were monitored clinically. At 30 days follow-up, 31 patients (28.44%) suffered from aortic-related adverse events, a composite of aortic-related mortality, aortic dissection, or an enlarged ulcer. In addition, 7 (6.42%) patients had clinically related adverse events, including all-cause mortality, cerebral stroke, nonfatal myocardial infarction, acute heart failure alone or acute exacerbation of chronic heart failure, acute renal failure, arrhythmia, and bleeding events. In the present study, the intervention criteria for the Chinese PAU population included a PAU diameter of 12.5 mm and depth of 9.5 mm. The multivariate analysis showed that an ulcer diameter >12.5 mm (hazard ratio [HR], 3.846; 95% CI, 1.561-9.476; P =0.003) and an ulcer depth >9.5 mm (HR, 3.359; 95% CI, 1.505-7.494; P =0.003) were each independent predictors of aortic-related events. Conclusions Patients with acute PAUs were at high risk for aortic-related adverse events and clinically related adverse events within 30 days after onset. Patients with an ulcer diameter >12.5 mm or an ulcer depth >9.5 mm have a higher risk for disease progression, and early intervention may be recommended.

Ulcerative colitis, a chronic and recurrent inflammatory disease, is localized to the colonic mucosa but can affect other organs and lead to various complications. Gastroduodenitis associated with ulcerative colitis has been reported. However, little is known about esophageal ulcers. We herein report two rare cases of esophageal ulcers associated with ulcerative colitis. Furthermore, the clinical and histological characteristics of 18 previously reported cases are summarized. This case series and literature review will encourage the accurate diagnosis and treatment of esophageal ulcers associated with ulcerative colitis.

Rationale: Tetanus is usually caused by wound infection with Clostridium tetani after acute injuries. Skin cancer wound is a rarely reported cause of tetani infection. It is difficult to be diagnosed and mistaken for other brain lesions., Patient Concerns: A 49-year-old man presenting with the only symptom of repeated convulsions was admitted to our department. He had an ulcerated skin cancer on the right buttock that had been excised in another hospital 1 month before admission, leaving the wound unhealed. He was suspected of having a metastatic brain tumor early, but exhibited a negative cranial CT-scan., Diagnosis: Tetanus was diagnosed when he was observed to have sudden convulsions after sensory stimulation such as noise, light, or touch., Interventions: Despite administration of a high dose of diazepam and phenobarbitone, continuous generalized rigidity with laryngospasm still occurred. Instead, when propofol was intravenously infused, the spastic convulsion completely stopped. Tracheotomy and mechanical ventilation were performed., Outcomes: The patient gradually recovered in 2 weeks., Lessons: Tetanus is rarely infected through the wound of an ulcerated skin cancer. Early diagnosis can only be based on accurate assessment of clinical manifestations, and propofol infusion appears to be more effective in anti-convulsion management for patients with tetanus. Routine vaccination to prevent tetanus in patients with ulcerated skin cancer should be considered in the future clinical work.

Long-term abuse of ketamine causes ketamine-induced cystitis. The functional alterations of bladder epithelial cells in microenvironment during cystitis remain poorly understood. Here, we explored extracellular vesicles (EV) alteration in ketamine-induced toxicity. To simulate the high-concentration ketamine environment in vivo, we established an in vitro model of high ketamine using human uroepithelial cells (SV-HUC-1). Cell viability and proliferation were assessed to evaluate the effects of various concentrations (0, 0.25, 0.5, 1, 2, 4 and 8 mmol/L) of ketamine on SV-HUC-1 cells. The cell supernatant cultured at a concentration (0, 1, 2, 4 mmol/L) of ketamine was selected for EV extraction and identified. Subsequently, we assessed different groups (ketamine, ketamine plus EV blocker, EV, EV plus extracellular vesicles blocker) of oxidative stress and expression of inflammation. Last, luciferase reporter assay was performed to study the transcriptional regulation of EV on the NF-kB and P38 pathway. The results of our study suggested that treatment with 0, 1, 2 or 4 mmol/L ketamine altered the morphology and secretion capacity of extracellular vesicles. As the concentration of ketamine increased, the average particle size of EV decreased, but the crest size, particle concentration and EV protein increased. Moreover, after the addition of EV blocker, EV secreted at different concentrations were blocked outside the cell membrane, and the degree of oxidative stress decreased. Our study provided evidence that ketamine alters the secretion of EV by directly stimulating cells in inflammation microenvironment and EV play significant roles in intercellular signal communication and the formation of KIC.EV., (© 2020 Guangxi Medical University First Affiliated Hospital. Journal of Cellular and Molecular Medicine published by Foundation for Cellular and Molecular Medicine and John Wiley & Sons Ltd.)

BACKGROUND Initially presumed as nonpathogenic, the bacterial genus aerococcus now includes 7 distinct virulent and avirulent species. Aerococcus urinae first isolated in 1992 is an uncommon cause of urinary tract infection (UTI) and is seen in only 0.15% to 0.8% of cases. A. urinae associated invasive bacteremia and systemic infection are extremely rare entities. Less than 50 cases of A. urinae associated with infective endocarditis (IE) have been reported in the literature, with the prevalence being 3 per 1 million. CASE REPORT A 59-year-old male presented to our hospital with exertional dyspnea and new-onset atrial flutter. Prior to his current admission patient was treated for A. urinae associated UTI with levofloxacin for 10 days. A transthoracic echocardiogram revealed severe aortic regurgitation with aortic valve endocarditis, which was subsequently confirmed on transesophageal echocardiogram. Blood cultures displayed gram-positive cocci in clusters, ultimately identified as A. urinae. The patient was treated with intravenous vancomycin and underwent surgical aortic valve replacement along with patch repair for underlying aortic wall ulcer. CONCLUSIONS To the best of our knowledge, this is the first-ever reported case of A. urinae associated IE complicated by an aortic wall ulcer. Male gender, age >65 years, and preexisting urinary tract pathology have all been implicated as risk factors for aerococcus infection. A. urinae is almost always sensitive to penicillin, carbapenem, and aminoglycosides.

On January 1st, 2019, one male patient, aged 55 years, with chronic ulcer in right lower extremity was admitted to Northern Jiangsu People's Hospital. After admission, ulcer debridement and vacuum sealing drainage (VSD) surgery was performed in lower right extremity. Two pieces of bone-like tissue was removed from the lateral space between the Achilles tendon and fibula in the right leg, which was confirmed as ossification tissue by histopathological sections after surgery. The wounds were treated with VSD technique and dressing changes. On the 49th day after surgery, split-thickness skin graft was taken from the lateral left thigh and grafted to the wound area, which was then treated with VSD. The skin graft of patient survived well. The wound healed completely and the patient was discharged from hospital on day 77 post hospitalization. This case suggests that the patients with chronic ulcer should complete all related examinations in time, and improving the blood circulation of the wound and clearing the ectopic ossification in the wound are critical for wound healing.

Introduction: Arterial ulcers develop as a complication of tissue hypoperfusion, ordinarily from atherosclerotic disease, but sometimes due to other medical conditions or trauma. While people with spinal cord injury (SCI) may be predisposed to resting hypotension, and, hence, to inadequate peripheral circulation, there are no reports of arterial ulcers as a secondary effect of SCI., Case Presentation: A 54-year-old woman with long standing cervical SCI presented with a nonhealing lateral malleolar ulcer that was complicated by osteomyelitis and unresponsive to biweekly debridement. On examination, she was hypotensive with cool extremities and non-palpable pedal pulses but had no evidence of atherosclerotic disease, cardio-metabolic derangement, or vasculopathy. We treated her with Midodrine with improvement in her peripheral circulation then referred her for surgical intervention., Discussion: To our knowledge, this is the first reported case of an arterial ulcer in a person living with SCI that was most likely caused by resting hypotension. It is possible that individuals with SCI-particularly those with higher-level injuries-are at risk for this condition. Clinicians must be alert to arterial ulcers as a potential complication of SCI with concomitant hypotension.

Invasive tracheobronchial aspergillosis (ITBA) complicated by nontuberculous mycobacteria (NTM) is rare. An 88-year-old man was admitted for hemoptysis. Bronchoscopy revealed bronchial ulcers, and a tissue biopsy showed Aspergillus fumigatus. He was diagnosed with ITBA, which improved with voriconazole. During treatment, infiltrative shadows appeared in his lungs, and bronchoscopy was performed once again. A non-necrotic epithelioid granuloma and Mycobacterium intracellulare were detected in the biopsy specimen. He was diagnosed with NTM disease. It is important to note that tracheobronchial ulcers may cause hemoptysis and to identify the etiology and treat it appropriately when multiple bacteria are found.

More and more evidence advises that circular RNAs (circRNAs) function critically in regulating different disease microenvironments. Our previous study found that autotransplantation of adipose-derived mesenchymal stem cells (ADSCs) promotes diabetes wound healing. Exosomes derived in ADSCs play an important regulatory role. This study aimed to characterize if mmu&#95;circ&#95;0000250 played a role in ADSC-exosome-mediated full-thickness skin wound repair in diabetic rats. Endothelial progenitor cells (EPCs) were selected to study the therapeutic mechanism of exosomes in high-glucose (HG)-induced cell damage and dysfunction. Analysis and luciferase reporter assay were utilized to explore the interaction among mmu&#95;circ&#95;0000250, miRNA (miR)-128-3p, and sirtuin (SIRT)1. The diabetic rats were used to confirm the therapeutic effect of mmu&#95;circ&#95;0000250 against exosome-mediated wound healing. Exosomes containing a high concentration of mmu&#95;circ&#95;0000250 had a greater therapeutic effect on restoration of the function of EPCs by promotion autophagy activation under HG conditions. Expression of mmu&#95;circ&#95;0000250 promoted SIRT1 expression by miR-128-3p adsorption, which was confirmed via luciferase reporter assay and bioinformatics analysis. In vivo, exosomes containing a high concentration of mmu&#95;circ&#95;0000250 had a more therapeutic effect on wound healing when compared with wild-type exosomes from ADSCs. Immunohistochemistry and immunofluorescence detection showed that mmu&#95;circ&#95;0000250 increased angiopoiesis with exosome treatment in wound skin and suppressed apoptosis by autophagy activation. In conclusion, we verified that mmu&#95;circ&#95;0000250 enhanced the therapeutic effect of ADSC-exosomes to promote wound healing in diabetes by absorption of miR-128-3p and upregulation of SIRT1. Therefore, these findings advocate targeting the mmu&#95;circ&#95;0000250/miR-128-3p/SIRT1 axis as a candidate therapeutic option for diabetic ulcers.

Background: Aortic intramural hematoma (IMH) is a subset of acute aortic syndrome, and its prognosis may differ between races. This study aimed to study the prognosis of Chinese type B IMH patients and to find out risk factors., Methods: A total of 71 type B IMH patients with or without penetrating atherosclerosis ulcer (PAU) administrated in our center between September 2013 and October 2017 were retrospectively studied. Both clinical and imaging data were collected and analyzed. The primary end point was aorta-related death, and the secondary end point was progression, which was defined as enlargement of aorta, increased aortic wall thickness, and aortic dissection or aneurysm formation. Kaplan-Meier survival analysis and Cox regression analysis were used for prognostic analysis., Results: Among these 71 patients, 21 had simple type B IMH, when 50 had type B IMH in association with PAU. Twenty-five patients received optimal medical therapy (OMT) alone, while 46 patients received surgery and OMT. The mean follow-up time was 27.5 ± 13.5 months. For type B IMH patients, association with PAU indicated poor prognosis and required more intensive management (HR = 16.68, 1.96~141.87), while maximum aortic diameter (MAD) was an independent risk factor (HR = 1.096, 1.016~1.182). For patients with PAU-IMH, MAD was an independent risk factor (HR = 1.04, 1.021~1.194), while surgical treatment was independent protective factor (HR = 0.172, 0.042~0.696)., Conclusion: Association with PAU and MAD were independent risk factors for type B IMH patients. Surgery may improve the outcomes for type B IMH in association with PAU.

Background: Epstein-Barr virus-positive mucocutaneous ulcer (EBV-MCU) is a new category of mature B-cell neoplasms. Ulcers occur in the oropharyngeal mucosa, skin, and gastrointestinal tract. The onset of EBV-MCU is suggested to be related to the decreased immunity of the patient, the causes of which include the use of immunosuppressive agents and aging. EBV-MCU may regress spontaneously and it often has a benign course after the dose reduction or discontinuation of immunosuppressive agents or during follow-up. Here, we report the case of a patient who required surgical resection for the intestinal obstruction arising from EBV-MCU., Case Presentation: A Japanese elderly male visited our hospital with chief complaints of a palpable mass and dull pain in the left upper quadrant, loss of appetite, and weight loss. Although abdominal computed tomography and total colonoscopy (TCS) revealed a tumor with circumferential ulcer in the transverse colon, histopathological analysis of a biopsy specimen of this lesion showed only nonspecific inflammation. Because the tumor spontaneously regressed during the time he underwent tests to obtain a second opinion from another hospital, TCS was reperformed on the patient. TCS revealed that the tumor decreased in size and the inflammatory changes in the surrounding mucosa tended to improve; however, tightening of the surrounding mucosa due to scarring was observed. Another histopathological analysis of a biopsy specimen showed widespread erosion of the mucosa and the formation of granulation tissue with marked infiltration of various inflammatory cells into the mucosal tissue of the large intestine. Moreover, some of the B-lymphocyte antigen CD20-positive B cells were also positive for EBV-encoded small RNA-1, suggesting the possibility of EBV-MCU. Later, the tumor developed into an intestinal obstruction; thus, the transverse colon was resected. Histopathological analysis of the resected specimen demonstrated scattered Hodgkin and Reed-Sternberg-like multinucleated large B cells in addition to EBER-1-positive cells. The patient was finally diagnosed as having EBV-MCU., Conclusions: This is the first report of a case of EBV-MCU that developed into an intestinal obstruction requiring surgical resection. It is necessary to consider the possibility of EBV-MCU when examining an ulcerative or tumorous lesion in the gastrointestinal tract.

Objectives: Ulcerative laryngitis (UL) is challenging in terms of treatment and patient counseling, with few reports in the literature. This study describes UL patients and their clinical course including detailed voice and stroboscopic outcomes after treatment which have not been described in previous literature., Methods: Single-institution, retrospective review of 23 UL patients. Demographics, historical factors, disease course, treatment, and outcomes are presented. Treatment results were compared to prior studies., Results: Seventy four percent had inflammatory/infectious precipitating event. Average presenting Voice-Handicap-Index-10 (VHI-10) was 25 (range: 6-38) and average final VHI-10 was 9 (range: 0-26). Ninty five percent had improvement in VHI-10 (average decrease of 15). Only 50% had final VHI-10 within "normal" limits. Treatment comprised reflux medications (85%), antibiotics (22%), antifungals (39%), antivirals (52%) steroids (52%), and/or voice rest (65%). Average symptom duration before evaluation was 42 days; average follow-up was 6.8 months. Final laryngovideostroboscopy revealed no ulcers in 78%, but 65% had persistently decreased mucosal wave vibration. Average time to ulcer resolution was 2.25 months but resolution or plateau of voice symptoms occurred later, average 2.7 months. Multiple regression analyses revealed that younger age, shorter symptom duration, and antireflux treatment were significant predictors of decrease in VHI-10 (P < 0.05)., Conclusions: Most patients have good voice outcomes following resolution of UL, although vocal fold mucosal wave abnormalities may persist. This study provides the most detailed report of UL, disease course and treatment outcomes to date. Additionally, this study is also the first to suggest that earlier initiation of treatment may improve voice outcome after UL., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Ulceration in the bronchial mucosa is noted rarely in bronchoscopy. In the past, it was frequently encountered in endobronchial tuberculosis. Deep necrotic bronchial ulcers are seen very rarely in clinical practice. Here we are reporting a first-ever case report of malignant bronchial ulcer presenting as necrotic deep bronchial ulcer, in a 70-year-old male, chronic smoker, who complained of breathlessness for 3 months, cough for 3 months, loss of weight and of appetite for 1 month. Bronchoscopy showed a large necrotic ulcer with dense anthracotic pigmentation which bleeds in touch with forceps. Bronchial washings, brushings, endobronchial biopsy were taken from the ulcer which was suggestive of poorly differentiated bronchogenic carcinoma. TBNA from the mediastinal nodes showed the features of caseous necrosis with granulomatous inflammation. Consequently, with the diagnosis of poorly differentiated carcinoma with pulmonary tuberculosis and COPD, the patient was started on anti-tuberculosis drugs, inhaled bronchodilators and referred to an oncologist for chemotherapy.

Blind pouch syndrome-associated anastomotic ulcer is rare, and its endoscopic features remain poorly described. A 79-year-old man was referred to our hospital for melena. Capsule endoscopy revealed multiple ulcers in the small intestine. Double-balloon endoscopy (DBE) and a gastrografin examination through DBE revealed a potential anastomotic ulcer, a blind pouch, and a side-to-side anastomosis in the middle of the small intestine. Laparoscopic partial resection of the small intestine with anastomosis was performed on the suspected blind pouch syndrome-associated anastomotic ulcer. To our knowledge, this is the first report describing the endoscopic features of a blind pouch syndrome-associated anastomotic ulcer.

Objective: To describe a stepwise management of patients with interstitial cystitis/bladder pain syndrome (IC/BPS) with Hunner's lesions and present single institution long-term outcomes., Methods: This is a retrospective review of a single tertiary center experience with management of patients with Hunner's lesions from January 2005 to January of 2015. Patients who met the diagnostic criteria for IC/BPS were included. Systematic approach to treatment of patients with Hunner's lesions is proposed based on our results., Results: Fifty-five patients with IC/BPS and Hunner's lesions were included. Mean age was 65.0 ±12.7 years, 76.4% (42/55) were female, and median symptom duration was 2 years (interquartile range [IQR] 1.7). All patients had a biopsy to rule out malignancy with therapeutic fulguration which resulted in subjective symptom improvement in 81.8% (45/55) and median time to repeat procedures was 12 months (IQR 621). Triamcinolone injection into the lesion was done in 35 patients and 91.4% (32/35) reported subjective improvement. Repeat injections were done for 74% (26/35) and median time between injections was 8 months (IQR 4, 13). AUA symptom scores and quality of life improved significantly with both treatment modalities. Adjunctive treatment with cyclosporine was used in 47.2% (26/55), and 7.2% (4/55) went on to have a cystectomy., Conclusion: Patients with Hunner's lesions benefit from early progression from conservative treatments to endoscopic management. Excellent symptom control can be achieved with biopsy/fulguration and triamcinolone injections but recurrence is common and repeat treatments are needed for most patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In the Stress Ulcer Prophylaxis in the Intensive Care Unit (SUP-ICU) trial, 3291 adult ICU patients at risk for gastrointestinal (GI) bleeding were randomly allocated to intravenous pantoprazole 40 mg or placebo once daily in the ICU. No difference was observed between the groups in the primary outcome 90-day mortality or the secondary outcomes, except for clinically important gastrointestinal bleeding. However, heterogeneity of treatment effect (HTE) not detected by conventional subgroup analyses could be present., Methods: This is a protocol and statistical analysis plan for a secondary, post hoc, exploratory analysis of the SUP-ICU trial. We will explore HTE in one set of subgroups based on severity of illness (using the Simplified Acute Physiology Score [SAPS] II) and another set of subgroups based on the total number of risk factors for GI bleeding in each patient using Bayesian hierarchical models. We will summarise posterior probability distributions using medians and 95% credible intervals and present probabilities for different levels of benefit and harm of the intervention in each subgroup. Finally, we will assess if the treatment effect interacts with SAPS II and the number of risk factors separately on the continuous scale using marginal effects plots., Conclusions: The outlined post hoc analysis will explore whether HTE was present in the SUP-ICU trial and may help answer some of the remaining questions regarding the balance between benefits and harms of pantoprazole in ICU patients at risk of GI bleeding. CLINICALTRIALS., Gov Registration: NCT02467621., (© 2019 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd.)

Background: Pleomorphic dermal sarcomas (PDS) are frequent UV-induced sarcomas of the skin of intermediate grade malignant potential. Despite the fact that PDS have a noteworthy potential to recur (up to 28%) as well as to metastasize (up to 20%), there are no specific clinical guidelines with respect to follow-up these patients. Moreover, little is known about clinical, histological or molecular prognostic factors in PDS., Objective: The aim of the present study was to identify risk factors to predict relapse in a large multicentre sample cohort of PDS which could aid to optimize personalized treatment recommendations regarding surgical safety margins and adjuvant radiotherapy., Methods: Patients with a diagnosis of PDS were selected from nine European institutions based on the histopathologic criteria described by Fletcher. Clinicopathologic and follow-up data were collected and statistically analysed calculating univariate hazard ratios with 95% confidence intervals by use of the Cox proportional-hazards model and a significance level of P < 0.05. Patients with an incomplete excision of the tumour were excluded., Results: Univariate Cox regression analysis of possible prognostic factors for progression-free survival (PFS) performed in 92 patients revealed that an excision margin of <2 cm is significantly associated with relapse of PDS [hazard ratio 4.478 (95% CI 1.536-13.055), P = 0.006]. Ulceration of the tumour was associated with a significantly better prognosis [0.396 (0.174-0.904), P = 0.028] whereas adjuvant radiotherapy did not reach statistical significance to improve prognosis in patients with PDS [0.775 (0.231-2.593), P = 0.679]. Gender, age, immunosuppression, intratumoural necrosis, tumour location, vertical thickness or horizontal diameter did not significantly influence PFS in PDS., Conclusion: We identified surgical safety margins of <2 cm and absence of ulceration as risk factors for relapse in patients with PDS. These findings may be implemented into both the primary treatment as well as the further monitoring of patients with PDS., (© 2019 European Academy of Dermatology and Venereology.)

Cardiovascular injuries represent the second most common cause of death among trauma victims in the United States. Motor vehicle collisions account for more than 80% of all blunt thoracic trauma. Given the nonspecific nature and variable severity of presenting symptoms, such as chest pain and shortness of breath, as well as confounding and overlapping clinical presentations in the setting of additional injuries, diagnosis of cardiovascular injuries can be challenging. This article reviews the clinical entities of acute aortic syndrome and pulmonary embolism, their imaging findings, and diagnostic challenges., (Copyright © 2019 Elsevier Inc. All rights reserved.)