Persistent Ulcers Research Articles

Plunging ranula presenting as a giant retroauricular mass: A case report

Plunging ranula is rare and manifests as the submandibular or submental cystic mass, without intra-oral abnormality. It usually causes misdiagnosis and malpractice. This article reported a case of plunging ranula that appeared as a massive mass located behind the left ear. A 6-year-old child presented with recurrent left retroauricular swelling over six months without obvious inducement. The mass showed repeatedly swelling and persistent skin ulcers. Physical examinations described a fluctuant, nontender mass behind the left ear whose size was about 5 cm×5 cm×3 cm. The skin upon the surface of the mass was thin and red, and overflowed yellow slimelike contents. Computed tomography (CT) showed an extensive cystic lesion in the left neck. After local incision and drainage the mass was shrink. With the primary clinical diagnosis of branchial cyst, the patient underwent mass resection through postauricular incision. During the operation, the fistula was traced to the area around the sublingual gland, and the postoperative pathology report demonstrated cystic spaces occurring in soft tissue without lymphoid tissue. One month postoperatively, the patient presented the "egg-white", wire-drawing transparent viscous fluid outflowing from the left external auditory canal, indicating that the fluid in the external auditory canal originated from the sublingual gland and the disease was the plunging ranula presenting as a giant left retroauricular mass. We readmitted the patient to the hospital and the ipsilateral sublingual gland was completely removed in the mouth under general anesthesia. No clinical evidence of recurrence was found at the end of 9 months follow-up. So far, there is no literature reporting plunging ranula behind ear. This case report describes the clinical manifestation, diagnosis, and differential diagnosis and treatment of a case of plunging ranula, and reveals that, other than the submandibular or submental, plunging ranula also could be found in retroauricular region. The plunging ranula is difficult to fully confirm through a clinical character, and usually easy to be misdiagnosed as other tumors, like lymphatic malformation, venous malformations, etc. Radiographic examination and/or puncture fluid observation are required for identification. "Egg-white", wire-drawing mucous secretion is the most important characteristic in clinical diagnosis of sublingual gland cyst. However, if sublingual gland resection, i.e. removal of the source of cyst fluid is performed, a good prognosis can be achieved.

P084 DEEP REMISSION WITH DOUBLE BIOLOGIC THERAPY: A SUCCESSFUL CASE OF COMBINATION USTEKINUMAB AND VEDOLIZUMAB FOR SEVERE REFRACTORY CROHN’S DISEASE

Abstract Background Stricturing Crohn’s disease (CD) constitutes a severe phenotype often associated with a high degree of morbidity (3). Surgical resection is first-line therapy for symptomatic strictures, but most patients relapse without subsequent medical therapy (4–5). Biologics are the mainstay for inducing and maintaining remission, but some cases are refractory despite maximum dosage of therapy. Reports of dual biological therapy (DBT) in refractory, stricturing CD are sparse, and prior case reports document only clinical remission (1). To contribute further knowledge regarding the use of DBT in stricturing CD, we present the case of a refractory CD patient who achieved deep remission with ustekinumab and vedolizumab. Case Presentation A 35 year old non-smoking, Caucasian male was referred to our clinic in 2014 for refractory CD complicated by multiple strictures. Prior to establishing care with us, he received two jejunal resections and a sigmoid resection. Previously failed therapies included azathioprine with infliximab, adalimumab, and certolizumab. He continued to progress under our care despite combination methotrexate/certolizumab, as well as methotrexate/golimumab. He underwent proctocolectomy with end ileostomy in 2015 and initiated vedolizumab q8weeks post-operatively. He reoccurred in 2018, when he presented with an ulcerated ileal stricture. He was switched from vedolizumab to ustekinumab q8weeks and placed on prednisone, but continued to progress, developing significant hematochezia requiring hospitalization and blood transfusions. Ileoscopy performed during hospital admission confirmed severe, ulcerating disease in the ileum with stricture. Ustekinumab dosing was increased to q4weeks, azathioprine was initiated, and he underwent stricturoplasty. Follow-up ileoscopy three months later revealed two ulcers in the neo- TI (Figure 1). Vedolizumab q8weeks was initiated in addition to ustekinumab q4weeks and azathioprine 125mg. After four months on this regimen the patient felt better, but follow-up ileoscopy showed two persistent ulcers in the neo-TI. Vedolizumab dosing interval was increased to q4weeks. After four months, subsequent ileoscopy demonstrated normal neo-TI (Figure 2). Histologic evaluation of biopsies confirmed deep remission of crohn’s disease. No adverse side effects have occurred with maximum doses of both ustekinumab and vedolizumab combination therapy. Discussion This case supports both the safety and efficacy of ustekinumab and vedolizumab dual biologic therapy for treatment of severe, refractory Crohn’s disease. While there are reports of DBT inducing clinical remission, this case supports efficacy for vedolizumab and ustekinumab combination therapy to induce deep histologic remission. Large practical clinical trials are needed to better investigate the safety and efficacy of DBT with vedolizumab and ustekinumab, but our case suggests this combination may be a safe and efficacious therapy for refractory CD patients.

Trigeminal Trophic Syndrome: A Cause of Dysesthesia and Persistent Facial Ulceration

A woman in her 70s presented with a nonpainful, enlarging lesion on the left cheek of 6 months’ duration. She described the initial lesion as a “fever blister” that did not heal after application of triple antibiotic ointment. She reported a history of trigeminal neuralgia with nerve ablation approximately 8 years prior and admitted to frequently manipulating the lesion because of a sensation of having to blow her nose. Numbness of the affected area was present.

Case report: leg ulcers resolving after discontinuation of clozapine for schizophrenia

There is a high prevalence of skin conditions and metabolic disturbances in patients with schizophrenia. Skin ulcers, in particular those of the lower extremities, mostly arise from arterial and/or venous pathology. Diabetes is considered a prominent risk factor. Atypical antipsychotics carry an increased risk for cardiometabolic side effects, clozapine being among those with the highest risk. We explore the case of a 57-year-old female patient with refractory schizophrenia who received a combination of clozapine and haloperidol. She soon developed type 2 diabetes mellitus and persistent malleolar ulcerations shortly thereafter. We discontinued clozapine and the ulcerations resolved definitively. We discuss underlying ulcer pathophysiology and review the literature for metabolic and cutaneous side effects of antipsychotics. To our knowledge, this is the first report of a patient developing leg ulcers upon treatment with clozapine.

Progenitor Biological Bandages: An Authentic Swiss Tool for Safe Therapeutic Management of Burns, Ulcers, and Donor Site Grafts.

Clinical experience gathered over two decades around therapeutic use of primary human dermal progenitor fibroblasts in burn patient populations has been at the forefront of regenerative medicine in Switzerland. Relative technical simplicity, ease of extensive serial multitiered banking, and high stability are major advantages of such cell types, assorted to ease of safety and traceability demonstration. Stringent optimization of cell source selection and standardization of biobanking protocols enables the safe and efficient harnessing of the considerable allogenic therapeutic potential yielded by primary progenitor cells. Swiss legal and regulatory requirements have led to the procurement of fetal tissues within a devised Fetal Progenitor Cell Transplantation Program in the Lausanne University Hospital. Proprietary nonenzymatic isolation of primary musculoskeletal cell types and subsequent establishment of progeny tiered cell banks under cGMP standards have enabled safe and effective management of acute and chronic cutaneous affections in various patient populations. Direct off-the-freezer seeding of viable dermal progenitor fibroblasts on a CE marked equine collagen scaffold is the current standard for delivery of the therapeutic biological materials to patients suffering from extensive and deep burns. Diversification in the clinical indications and delivery methods for these progenitor cells has produced excellent results for treatment of persistent ulcers, autograft donor site wounds, or chronic cutaneous affections such as eczema. Herein we describe the standard operating procedures for preparation and therapeutic deployment of the progenitor biological bandages within our translational musculoskeletal regenerative medicine program, as they are routinely used as adjuvants in our Burn Center to treat critically ailing patients.

LEUKEMIC INFILTRATION IN TONGUE

Soft tissue changes in the oral cavity associated with leukemia such as oral bleeding, mucosal petechiae, mucosal ulceration, and infection are commonly described. Leukemic cells may infiltrate the oral cavity as leukemic infiltration to the gingival tissue but rarely involve other areas. The objective of this report is to describe a case of leukemic infiltration (myeloid sarcoma) in the oral cavity. A 48-year-old male patient was admitted to our service complaining of malaise, fever, and gingival bleeding. At clinical examination, beyond the gingival bleeding involvement, a rare clinical presentation characterized by the development of a persistent ulceration on the lateral border of the tongue was observed, which biopsy results showed the presence of infiltration of immature cells with scarce cytoplasm and hyperchromatic nucleus. Blood test revealed 119.000/mm3 leukocytes, whereas the myelogram demonstrated 87% of blasts carrying a myeloid differentiation confirmed by flow cytometry positivity confirming the diagnosis of acute myeloid leukemia.

Circumferential constriction ischaemic syndrome (CCIS): A potentially reversible ischaemic condition of lower limb

Circumferential constriction in limb will lead to distal limb ischaemia. This is a potentially reversible condition but it has a drastic consequence if undiagnosed. We described a patient with underlying diabetes mellitus presented with persistent lower limb linear circumferential ulcer and developing subacute limb ischaemia distal to the ulcer. During further wound dressing, a rubber band was detected in the wound. Surgical exploration removed the rubber band and its circumferential constriction effect. As a result, the ulcer healed uneventfully and the distal limb perfusion improved clinically. A scoring index consisted of contributing risk factors was proposed to facilitate the diagnosis. A flow chart was proposed to serve as a treatment protocol to ensure logical and comprehensive management. We hope the proposal of the new term and flow chart can help improve the threshold of recognition and for salvage of potentially devastating limb ischaemia.

P041 An Interesting Case of Refractory Immune-Mediated Esophageal Stricture Following Immunotherapy With Nivolumab Treated With Esophageal Dilation

INTRODUCTION: Immune checkpoint-inhibitors (ICIs) are a type of immunotherapy that targets proteins expressed by T-lymphocytes which stimulate the immune system to attack cancer cells. ICIs have gained popularity due to their effective action against several metastatic malignancies. There have been a few well-described immune-related adverse events (irAEs) which include dermatitis, uveitis, hepatitis, and colitis. The incidence of immune-mediated stomatitis and mucositis has been reported in 5–9% of patients treated with Nivolumab or Pembrolizumab therapy. Furthermore, gastroesophagitis remains an under recognized irAE which is associated with stricturing of the esophageal mucosa. Here we describe an interesting case of steroid-refractory immune-mediated ulcerative esophagitis complicated by an esophageal stricture, following immunotherapy with Nivolumab. CASE DESCRIPTION: A 68 year-old female with stage IIIA melanoma of the right foot, underwent wide excision followed by adjuvant Nivolumab therapy. She later presented with a three month duration of significant odynophagia and dysphagia to both solids and liquids, associated with regurgitation of undigested food particles. Initial upper esophagogastroduodenoscopy (EGD) demonstrated circumferential ulceration 35 cm from the incisors. Pathology revealed inflamed granulation tissue with ulceration and fibrinopurulent exudate, negative for herpes simplex virus, cytomegalovirus and fungal stains. There was no evidence of Helicobacter Pylori infection. Nivolumab was discontinued and the patient was started on an empiric trial of proton-pump inhibitor (PPI) and Carafate with no symptomatic improvement. A follow-up EGD eight months later, was notable for scattered islands of salmon-colored mucosa with no active inflammation and a moderately severe stenosis 25 cm from the incisors, which could not be traversed with an adult upper endoscope. A biopsy of the esophageal stricture exhibited evidence of granulation tissue, marked ulceration, and both acute and chronic inflammation. Due to recurrence of her symptoms with steroid tapering, she was given three induction doses of Infliximab. A follow-up EGD four weeks later was remarkable for post-esophagitis scarring and a decreased vascular pattern, with persistent ulceration in the esophagus despite treatment with steroids and Infliximab. There was a benign-appearing severe esophageal stenosis 15 cm from the incisors, measuring 25 cm in length with an 8-mm inner diameter. The stricture was effectively dilated to 12 mm with a favorable clinical response thereafter. CONCLUSION: There is a wide spectrum of irAEs which clinicians need to be aware of as ICI therapy becomes more prevalent. Close surveillance is warranted in patients suspected of developing irAEs. Ulcerative esophagitis is a rare side effect of immunotherapy that can quickly progress to stricturing disease. It is important to highlight that management of immune-mediated ulcerative esophagitis includes cessation of immunotherapy, followed by a trial of PPI and corticosteroid therapy. For refractory cases complicated by an esophageal stricture, endoscopic dilation is often the treatment of choice. Our case is unique in that the patient demonstrated a favorable clinical response following esophageal dilation. To date, there has only been one case reported in the literature of a radiation-induced esophageal stricture which was successfully treated with serial esophageal dilation.

2749 Looks Like a GI Bleed, Think Like a Gastroenterologist: A Case of Recurrent Bleeding in a Patient With Billroth II Operation

INTRODUCTION: Anastomotic gastric adenocarcinoma (GAC) following distal gastrectomy Billroth II for peptic ulcer disease (PUD) has long been recognized but remains poorly studied. CASE DESCRIPTION/METHODS: A 65-year-old male with history of PUD status post Billroth II in 1991 presented with multiple episodes of melena and abdominal pain. EGD revealed friable gastric mucosa with oozing ulcers on the gastric side of the gastrojejunal anastomosis (GJA) (Figure 1a–c) and severe bile reflux. Stomach biopsies were negative for H. pylori or other pathology. Patient was subsequently admitted four more times that year for similar symptoms, each time presenting with symptomatic anemia that resolves with therapy, and EGD showing superficial erosions near the GJA. It was suspected however, that the initial biopsies were likely taken from areas far from the actively bleeding sites. Therefore, the GI team insisted on an outpatient EGD when the patient was asymptomatic to accurately investigate the GJA. After multiple missed appointments, he had an outpatient EGD (Figure 1d) with biopsies of the friable mucosa positive for GAC, and eventually underwent Roux-en-Y gastrectomy with esophagojejunostomy. Biopsy of the mesenteric nodules confirmed the diagnosis of moderately differentiated Stage IIIA GAC. Chemoradiation therapy was initiated, but patient left against medical advice and ended up in hospice care eight months later. DISCUSSION: We present a patient with persistent bleeding ulcers and symptomatic anemia 25 years after a Billroth II procedure, who despite multiple endoscopic evaluations with stomach biopsies, was not diagnosed on time. Eventually, the correct diagnosis of Stage III primary GAC was made after an outpatient EGD with targeted biopsies of the area associated with recurrent bleeding. Given the negative biopsies, the persistent gastric ulcers were thought to be complications of Billroth II with a short limb leading to bile reflux, or due to patient’s poor compliance and follow up. However, it was recognized that the patient had a higher risk of GAC as he was 15-20 years after Billroth II, and more importantly, that the inpatient EGD biopsies were not of the actively bleeding area of interest. Our patient presented after a long asymptomatic interval with symptoms initially misinterpreted as benign. It is therefore imperative to maintain a high suspicion of gastric malignancy for these patients to encourage earlier diagnosis.

1665 A Baffling Case of Gastrocolitis

INTRODUCTION: Chronic mesenteric ischemia often has a subtle presentation requiring a high index of suspicion. Average time to diagnosis is 10.7 months, often delayed due to the vague nature of complaints. We present a challenging case of severe chronic mesenteric ischemia in a young woman. CASE DESCRIPTION/METHODS: A 42-year-old female smoker presented with abdominal pain, constipation, and >70-lb weight loss. She had developed black, watery stools one week prior. Vital signs were normal, BMI was 12.6. She was cachectic, had abdominal distention and tenderness worse in the right lower quadrant. A contrasted CT scan revealed a distended colon and large stool burden. She failed conservative management. Endoscopy revealed multiple Forrest III gastric ulcers (Figure 1) and deep cecal ulcerations (Figure 2) with normal TI. Biopsies showed inflammation with granulation tissue. Work up was negative for vasculitis and infection. She failed a steroid trial for a presumptive diagnosis of Crohn’s disease. CT enterography was normal. Repeat endoscopy showed persistent gastric ulcers. Biopsies revealed ischemic gastritis with associated ulceration and submucosal blood vessels with fibrin thrombi. A CT angiogram showed severe stenosis of the celiac artery and chronic occlusion of the superior mesenteric artery (Figure 3.) Endovascular celiac and SMA stenting failed requiring surgically-placed retrograde celiac and SMA stents. Her symptoms recurred due to celiac stent thrombosis and SMA stent migration to the left iliac artery. Finally, an antegrade supraceliac to celiac and SMA bypass was performed with excellent results. DISCUSSION: A high index of suspicion is required to diagnose chronic mesenteric ischemia. Risk factors include age > 60, female gender, history of PAD, CVD, or CAD. Typical symptoms include weight loss, postprandial pain, and diarrhea though most people are asymptomatic or present with atypical symptoms including nausea, vomiting, early satiety, or bleeding which often lead to misdiagnosis or delayed diagnosis. Management is aimed at preventing further bowel infarction via endovascular or open revascularization. Patients who fail stenting or angioplasty have a much higher risk of perioperative mortality during open repair (15% vs. 2%.) Our patient’s young age, normal initial CT abdomen, gastric and cecal ulcerations with lack of vascular disease history blurred the clinical picture. A high index of suspicion is required in patients with an initial negative work up.

2726 Dilemma of Hypercalcemia and Persistent Peptic Ulcer Disease: Case Report and Literature Review

INTRODUCTION: Hypercalcemia has been linked to peptic ulcer disease (PUD), but between the two is not well understood. We are presenting a case of PUD that did not respond to long term twice daily PPI but did improve when the hypercalcemia was corrected with parathyroidectomy. CASE DESCRIPTION/METHODS: A 48-year-old male patient underwent one yearlong evaluation for persistent abdominal pain. His evaluation included three CT scans, EGD as well as octreotide and parathyroid scans. Initially, it was believed that his symptoms were related to severe PUD that did not respond to prescribed medical treatment due to poor patient compliance. He presented to the ED complaining of epigastric pain. Abdominal imaging revealed inflammation and narrowing of the entire duodenum as well as non-obstructive nephrolithiasis. His Calcium level was 11 mg/dl. An EGD revealed many non-bleeding cratered duodenal ulcers in the entire duodenum. An acquired non-obstructing, benign-appearing, intrinsic stenosis was found in the third portion of the duodenum. Biopsies were negative for H. pylori infection. He denied NSAID use. He was discharged on oral PPI therapy twice daily. Two months later, he returned with recurrent abdominal pain after running out of his PPI. CT scan showed persistent inflammatory changes involving the entire duodenum to the jejunum. Serum gastrin level was 201 pg/ml. Calcium level was 10.4 mg/dL. He was treated symptomatically with plans for outpatient push enteroscopy. The patient’s clinical course was complicated by obstructive nephrolithiasis requiring bilateral ureteral stents. Almost one year later, he returned with abdominal pain. Another CT scan showed persistent duodenitis. His labs showed evidence of Hypercalcemia 12 mg/dl. Gastrin Level 382 pg/ml. Octreotide scan was performed and was negative for any active neuroendocrine tumor. Parathyroid scan revealed parathyroid adenoma. The patient underwent parathyroidectomy and did well. He was discharged home on PPI twice daily. He was seen in follow-up and denied any PUD symptoms. DISCUSSION: This patient with severe non-resolving peptic ulcers. Removal of the parathyroid adenoma resulted in complete resolution of his symptoms. The gastric secretory response to hypercalcemia may be responsible for the occurrence of peptic ulcer disease in patients with hyperparathyroidism. In conclusion, serum calcium level must be considered among the usual tests in patients with rare and/or non-specific abdominal symptoms and part of the workup for persistent PUD.

2787 Gastric Amyloidosis With Arteriovenous Malformation: A Rare Etiology of Upper GI Bleeding

INTRODUCTION: Amyloidosis refers to group of conditions caused by a build-up of amyloid fibrils in organs and tissues throughout the body. We present a very rare case of localized amyloidosis of the stomach presenting with an upper gastrointestinal bleeding (UGIB) due to arteriovenous malformation (AVM). CASE DESCRIPTION/METHODS: An 81-year-old female with past medical history significant for hypertension presented with hematemesis of one day duration. Vital signs were within normal limits. Physical exam was significant for epigastric tenderness. Initial lab work revealed hemoglobin 8.4 g/dL, mcv 83 fL, wbc 11.2 K/cm, platelets 513 K/cmm. Complete metabolic panel was within normal limits. Esophagogastroduodenoscopy (EGD) demonstrated oozing of blood on contact with air insufflation from the lesser curvature, body and fundus of the stomach with normal duodenum. Interventional radiology angiogram and computed tomography angiography were performed and were unable to localize source of bleeding. EGD was attempted four days later and recurrent oozing of blood on mucosal contact with air insufflation occurred. She was subsequently placed on total parenteral therapy (TPN) and sucralfate for ten days to help heal the cause of the inflammation. A third endoscopy showed similar findings. Thus, biopsies were taken. Hemoglobin remained stable with no recurrent hematemesis episodes and patient was discharged on PPI, sucralfate and liquid diet. CD34 staining on biopsy reveals dilated and congested blood vessels suggestive of AVM and special stain (Congo Red) portraying apple green birefringence confirming diagnosis of amyloidosis (Figures 1 and 2). Serum protein electrophoresis exhibited gamma globulin spike portraying AL amyloidosis. DISCUSSION: A single case of intraabdominal arteriovenous malformation and localized amyloidosis of an abdominal mass has been reported. This is the first reported case of localized gastric amyloidosis with AVM presenting with an UGIB. The association between AVM and amyloidosis is hypothesized to be due to amyloid proteins deposition predilection around leaky vasculatures, which was proven in mice. AVM causes amplified plasma flow and increased amyloid deposition leading to vessel friability and ischemia, ultimately resulting in mucosal ulcerations with delayed healing. This is our postulated mechanism as to why our patient had persistent gastric ulcer bleeding not amenable to multiple therapeutic/follow-up EGDs.

1454 Recurrent Isolated Colon Ischemia Secondary to Kayexlate. Kayexelate Helps History to Repeat Itself

INTRODUCTION: Kayexalate, sodium polystyrene sulfonate, is often used for treatment of hyperkalemia. This resin based medication has been associated with colon ischemia. CASE DESCRIPTION/METHODS: 69 y/o male with extensive past medical history of end stage renal disease (ESRD) on hemodialysis (HD), atrial fibrillation not on anticoagulation, stroke with right hemiparesis s/p trach and PEG dependent, and left colostomy for diversion. He was transferred from the HD clinic to the ED for acute anemia, hypotension and hematochezia from ostomy. He was admitted for hemorrhagic shock, received intravenous fluid resuscitation, blood transfusions and was started on inotropic support. Infectious workup was negative. Computed tomography angiography was negative for acute bleed. EGD was unremarkable. Colonoscopy revealed extensive circumferential ulceration and pseudomembrane in the cecum and proximal ascending colon. Biopsies were consistent with colon ischemia. He improved clinically with supportive care and discharged. Three months later he was admitted for parotitis and hyperkalemia. He was started on Kayexalate and then developed hematochezia from ostomy with hemodynamic stability a few days later. He underwent repeat colonoscopy revealing persistent ulcerations with erythematous friability in the same area previously seen in prior colonoscopy. Biopsies this time revealed acute reactive epithelial atypia with embedded polystyrene sulfonate crystals. DISCUSSION: It is well known patients with renal failure on dialysis have a higher risk of developing colon ischemia. Kayexalate has been seen to cause colitis, which can progress to necrosis in 1% and perforation. This is hypothesized to be due to the release of prostaglandins and mesenteric vasoconstriction, thus causing mucosal damage. This may explain why this patient with recent history of right colon ischemia had Kayexalate induced injury in the same area. Symptoms of this damage can be seen within days to weeks after administration of medication, as in this case. In conclusion, patients with ESRD presenting with hematochezia, careful review of medications should be done as Kayexalate may induce colon ischemia. ESRD patients with previous colon ischemia, urgent HD rather than Kayexalate may be preferred, as the latter may recur as colon ischemia in the setting of previously injured tissue.

Topical Recombinant Human Nerve Growth Factor (Cenegermin) for Neurotrophic Keratopathy: A Multicenter Randomized Vehicle-Controlled Pivotal Trial

To evaluate the efficacy and safety of topical cenegermin (recombinant human nerve growth factor) in patients with neurotrophic keratopathy. Multicenter, randomized, double-masked, vehicle-controlled trial. Patients with neurotrophic persistent epithelial defect with or without stromal thinning. The NGF0214 trial, conducted among 11 sites in the United States, randomized 48 patients 1:1 to cenegermin 20 μg/ml or vehicle eye drops, 6 drops daily for 8 weeks of masked treatment. Follow-up was 24 weeks. Safety was assessed in all patients who received study drug. Efficacy was assessed by intention to treat. The primary end point was healing of the neurotrophic lesion (persistent epithelial defect or corneal ulcer) after 8 weeks of masked treatment. Masked central readers measured neurotrophic lesions in randomized clinical pictures, then assessed healing status conventionally (<0.5 mm of fluorescein staining in the greatest dimension of the lesion area) and conservatively (0-mm lesion staining and no other residual staining). Secondary variables included corneal healing at 4 weeks of masked treatment (key secondary end point), overall changes in lesion size, rates of disease progression, and changes in visual acuity and corneal sensitivity from baseline to week8. Conventional assessment of corneal healing showed statistically significant differences at week 8: compared to 7 of 24 vehicle-treated patients (29.2%), 16 of 23 cenegermin-treated patients (69.6%) achieved less than 0.5 mm of lesion staining (+40.4%; 95% confidence interval [CI], 14.2%-66.6%; P= 0.006). Conservative assessment of corneal healing also reached statistical significance at week 8: compared to 4 of 24 vehicle-treated patients (16.7%), 15 of 23 cenegermin-treated patients (65.2%) achieved 0 mm of lesion staining and no other residual staining (+48.6%; 95% CI, 24.0%-73.1%; P < 0.001). Moreover, the conservative measure of corneal healing showed statistical significance at week 4 (key secondary end point). Compared to vehicle, cenegermin-treated patients showed statistically significant reductions in lesion size and disease progression rates during masked treatment. Cenegermin was well tolerated; adverse effects were mostly local, mild, and transient. Cenegermin treatment showed higher rates of corneal healing than vehicle in neurotrophic keratopathy associated with nonhealing corneal defects.

Anti-inflammatory effect of an eye drops solution based on liposomal ozonated oil in different corneal and anterior segment human diseases

The gaseous ozone can be effectively stabilized – for topical use – as ozonated oil, an organic analog of ozone, that has the same properties; the tolerability on the ocular surface has been further improved by means a specific formulation, developed for ophthalmic use, based on liposomal sunflower ozonated oil plus hypromellose (Ozodrop®, FB Vision, Ascoli Piceno, Italy), which is extremely biocompatible with the delicate ocular surface tissue. The use of ozone in certain eye anterior segment pathologies could be providential due to its anti-inflammatory and bactericidal activity, in addition to promoting tissue repair properties. Nowadays, the overuse of antibiotics in the treatment of infectious diseases, and the appearance of multidrug-resistant bacterial strains, has driven research towards the study of new resistance-free antimicrobial agents. In our experience, this new liposomal ozonated oil formulation was used to promote wound healing and treat some inflammatory and infectious pathologies of the anterior segment, such as vernal conjunctivities, granulomatous conjunctivities, persistent dystrophic corneal ulcer, i.e. diseases necessitating adequate anti-inflammatory and regenerative therapy. In these conditions, a topical dosage of one or two drops of collyrium every 4 h over 3-7 days is generally recommended, even though multiple and frequent instillations are often required to achieve clinical resolution. The use of ozone-based eye drops gave a faster resolution of the inflammatory and/or infectious process, healing of the wounded area, improvement of corneal deepithelization and resolution of the symptomatology (itching, soreness) and clinical sign. In conclusion, from our preliminary results, ozone-based eye drops represent a valid and suitable alternative therapy for the management of external ocular pathologies, both inflammatory and/or infective and traumatic.

Intralesional triamcinolone acetonide therapy for inflammatory oral ulcers

The aim of this study was to report on the clinical indications and treatment outcomes of intralesional steroid therapy (IST) for oral ulcerative conditions in an oral medicine practice. This was a retrospective single-center study of patients with oral ulcerative conditions treated with IST. Demographic data, clinical diagnosis of the oral condition, size of the ulcer, and pain were abstracted from patients' electronic medical records. Ninety-three patients (51 females [54.8%]) were treated for persistent traumatic oral ulcers (n = 38 [40.8%]), ulcers in oral chronic graft-versus-host disease (n = 23 [24.7%]), oral lichen planus (n = 19 [20.4%]), and other conditions (14%). Complete resolution was achieved in 81.7% of patients in a median of 96 days (range 10-357 days), with 80% fully healed in a median of 84 days (range 10-140 days). Overall, patients received a median of 2 injections (range 1-5 injections) and a median dose of 12 mg per injection (range 2-36 mg). Nearly half the patients were also treated with concomitant topical steroid therapy. After the first injection, the median pain score reduced from 5 (range 1-10) to 1 (range 0-10; P < .001) and the median size of ulcers reduced from 1 cm (range 0.1-5 cm) to 0.3 cm (range 0-2 cm; P < .001). IST may be an effective treatment for inflammatory and immune-mediated oral ulcers.

Clinical Aspects of Bacterial Corneal Ulcer Prolonged Course, the Role of Herpes Viruses in Its Pathogenesis, Treatment

Purpose: to study the role of human herpesviruses (HHV) in the pathogenesis of prolonged bacterial corneal ulcers. Patients and methods. 117 patients with bacterial corneal ulcer were examined. Two groups were identified: a favorable course-with duration of bacterial corneal ulcer epithelialization for 17 days (62 people) and a prolonged course with a persistent ulcer more than 17 days (55 people). Blood samples (n = 117) and scrapes from corneal ulcer (n = 117) were investigated in polymerase chain reaction (PCR) for the presence of deoxyribonucleic acid (DNA) of Herpes simplex virus (HSV1, 2), Epstein-Barr virus (EBV), Human herpesvirus type 6, 7 (HHV-6, HSV-7). Results. The HSV1, 2 and EBV genomes were detected in the cornea significantly more often in BCU of prolonged course compared with a favorable course (HSV1, 2 p = 0.012; EBV p = 0.012), and HHV-6 was detected not only in the cornea (p = 0.000), but also and in blood (p = 0.007). In patients with HHV DNA in corneal scarps and/or blood, after resorption of purulent infiltrate, corneal epithelialization was absent, and the use of antiherpetic drugs allowed to reduce the completion time of BCU epithelialization. Conclusion. The role of HHV-6, EBV, HSV 1, 2 in the pathogenesis of bacterial corneal ulcer of protracted course was revealed. The expediency of examination of patients with bacterial corneal ulcer on HHV is shown, a method of treatment is proposed, including antiherpetic therapy, which makes it possible to prevent the development of a protracted course.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Differentiated treatment of patients with diabetic foot syndrome at the stage of specialized surgical care

To assess 1-year results of differentiated treatment of patients with diabetic foot syndrome (DFS) who were included into 3-year register of diabetic foot outpatient practice (DFOP). It was performed retrospective analysis of 570 patients with DFS (2015-2017): group I - neuropathic form (n=285), group II - neuroischemic form (n=285). Patients were classified according to Texas grade. Group I - 107 (37.5%) patients (BI-III); 91 (31.9%) patients (AII+BII-III). Diabetic osteoarthropathy was diagnosed in 97 (34.0%) cases. Group II included 113 (45.2%) patients with DI-III and 171 (60.0%) patients with CII-II+DII-III. 308 patients received combined outpatient treatment (including limb off-loading in 88%), 195 patients - in-hospital surgical treatment (including endovascular procedures - 52), 67 patients - treatment at the place of residence. Postoperative follow-up was in diabetic foot outpatient practice. Statistical analysis of data was performed by using of Biostat software package. In group I 1-year results are unknown in 76 (26.7%) patients. Epitheliazation was noted in 101 (35.4%) cases, persistent diabetic ulcer - in 27 (12.9%), small amputations - 16 (7.7%), high amputations - 2 (0.95%). In group II results are unknown in 29 (10.2%) patients. Epitheliazation occurred in 121 (47.3%) cases, persistent diabetic ulcer - 53 (20.7%), small amputations - 47 (18.4%), high amputations - in 35 (13.7%) cases. DFOP is a key organizational unit of specialized medical care for patients with DFS. Regular follow-up of patients in DFOP and combined treatment at the stage of specialized surgical care allows to preserve limb in 99% of patients with neuropathic foot and in 86.3% of patients with neuroischemic foot.

Management of Post-Mastectomy Radio-Necrotic Ulcers &amp;amp; Osteoradionecrosis

Background: Breast cancer is still the most common indication for chest wall irradiation, despite the advances in RTH techniques complications still occur, and the time of its occurrence vary and could take few months to many years. ORN usually manifests with pain, exposed bone, fistulae and pathological fracture and the proper management needs proper debridement and coverage by thick musculocutaneous flaps. Objective: To evaluate different techniques of surgical management of post-irradiation persistent radio-necrotic ulcer & ORN with emphasis on the outcome of each technique. Patients and methods: A retrospective study from 2010 to 2015 reviewed 20 patients subjected to post-mastectomy radiotherapy as a treatment for breast cancer inNCICairo, and Minia oncology center Hospital, Egypt. Cases were biopsied to exclude local recurrence. The age, sex, type of ulcer, dose of radiotherapy received and the management done for these cases were recorded. Results: Only 4 patients responded to conservative treatment in the form of repeated dressings, and 16 patients needed surgical treatment; 5 of them were treated with debridement and coverage with split thickness graft with high rate of complications reaching 80%, the other 11 patients were reconstructed with musculocutanoeus flaps, of these 7 patients were reconstructed with LD flaps with 57.14% success rate and minor complications only, the other 4 cases were reconstructed with TRAM flap with 50% success and major loss of the flap in one case that needed salvage by LD flap. Pre-operative comorbidity was found in 6 patients and all of them experienced complications while only 3 of the other 14 who had no comorbidity had postoperative complications. Conclusion: Pedicled flaps provide a good choice for reconstruction and provide chest wall support without the use of synthetic mesh.