Small Ulcers Research Articles

S2389 The Odd Couple: Active H. pylori Infection Within Long Segment Barrett’s Esophagus

Introduction: Barrett’s esophagus (BE) is a consequence of poorly-controlled GERD leading to intestinal metaplasia, which predisposes to esophageal cancer. Similarly, there is a well-established link between Helicobacter pylori and development of gastric cancer. However, there is a negative association between H. pylori and risk of BE. Here, we present a rare case of H. pylori infection within Barrett's mucosa. Case Description/Methods: A 54-year-old woman was referred for one month of dysphagia to solids. She described food sticking in her mid-esophagus without difficulty swallowing pills or liquids. She also endorsed significant heartburn and belching but denied systemic symptoms, regurgitation, abdominal pain, or weight loss. EGD demonstrated a 5 cm segment of circumferential salmon-colored mucosa suspicious for Barrett’s esophagus, a small esophageal ulcer, and a normal stomach and duodenum. Gastric biopsies revealed mild gastritis with H. pylori organisms. Esophageal biopsies showed intestinal metaplasia consistent with Barrett’s esophagus as well as H. pylori organisms. Quadruple therapy was initiated with metronidazole, tetracycline, omeprazole, and bismuth (Figure). Discussion: We describe a rare case of H. pylori discovered within long-segment Barrett’s esophagus. Evidence suggests an inverse association between H. pylori and BE. However, a recent meta-analysis demonstrated that this association disappeared in patients with GERD. One proposed mechanism for H. pylori’s protectiveness against BE is decreased gastric acid production. Together, this suggests H. pylori protects against BE by preventing development of GERD but once GERD is present, H. pylori is no longer protective. Thus, our simultaneous diagnosis of BE and H. pylori could be explained by long-standing GERD and BE prior to H pylori infection. While it is uncommon to diagnose H. pylori and BE together, it is even rarer to see H. pylori within Barrett’s mucosa, given the organism’s proclivity for gastric epithelium. One potential explanation is that this patient’s significant GERD allowed reflux of H. pylori organisms into the esophagus, leading to colonization of the metaplastic epithelium. Furthermore, there may be microscopic satellites of gastric mucosa within the segment of BE, providing a friendlier environment in which the organisms could grow. More observation is needed to determine the significance and long-term effects of active H. pylori infection in Barrett's mucosa and if this facilitates progression to dysplasia or carcinoma.Figure 1.: 1. A. Esophagoduodenoscopy (EGD) image of 5 cm circumferential salmon mucosa consistent with Barrett’s esophagus. B. Hematoxylin and eosin (H&E) stain of esophageal mucosa demonstrating intestinal metaplasia and H pylori organisms.

S3582 Disguised as Post-Operative Ileus: A Case of a Giant Gastric Ulcer Causing Outlet Obstruction and Gastric Pneumatosis

Introduction: Giant gastric ulcers (GGU), defined as ulcers larger than 2-3cm, are relatively rare in the setting of widespread proton pump inhibitor (PPI) use. Though usually located in the lesser curvature, GGU may occur in any part of the stomach. Typical symptoms are similar to that of peptic ulcer disease (PUD), i.e. epigastric pain and gastrointestinal bleeding, however GGU are highly prone to perforation and are more likely to be malignant in the elderly. Overall, gastric outlet obstruction is the least common complication of PUD. Case Description/Methods: A 74-year-old obese male with history diabetes, sleep apnea, and prior laparoscopic gastric banding surgery was admitted for elective surgery for Charcot arthropathy. Post-operatively, he developed nausea, vomiting and abdominal bloating. Abdominal x-ray showed distention of the small bowel concerning for ileus. Exam showed a non-tender abdomen with distention and tympany on percussion. His emesis resolved with antiemetics, however distention persisted despite passing gas and stool. Three days after surgery, he developed acute anemia without overt bleeding requiring blood transfusions. Abdominal X-ray and CT was performed which showed marked gaseous distention of the stomach and gastric wall pneumatosis. Nasogastric tube was placed for decompression with subsequent resolution of his distention. Due to concern for gastric band erosion, Gastroenterology was consulted. Upper endoscopy was performed which revealed a 4cm clean-based ulcer with overlaying eschar along the greater curvature with surrounding erythema and edema. Biopsies of the ulcer border showed acute erosive gastropathy with focal clustering of eosinophils without evidence of dysplasia. He was started on PPI and sucralfate, and remained clinically stable without further gastrointestinal symptoms. (Figure) Discussion: Gastric pneumatosis due to gastric emphysema is caused by disruption of mucosa leading to air migrating into the gastric wall. Etiologies vary, including injury from instrumentation, severe vomiting, pulmonary pathology, penetrating gastric ulcers, or gastric outlet obstruction. Few cases reports have described gastric emphysema resulting from gastric band erosion, however there are no reports describing this occurring in the absence of full erosion. Overall, gastric emphysema is relatively rare, as is development of GGU. To our knowledge, this is the first reported case of unperforated giant gastric ulcer resulting in outlet obstruction with gastric pneumatosis.Figure 1.: CT abdomen showing marked gaseous distention of the stomach and gastric wall pneumatosis (Figure 1a). Upper endoscopy findings of a friable, erythematous giant ulcer with clean-base overlaying the greater curvature with significant surrounding erythema and edema in the fundus/cardia (Figure 1b and 1c), as well as multiple surrounding small ulcerations, some with clean-base and some with flat pigmented spots, throughout (not pictured). No evidence of active bleeding, visible vessel, or high-risk features for bleeding.

Self-Reported Prevalence of Recurrent Aphthous Stomatitis among UiTM Dental Students

Recurrent aphthous stomatitis (RAS) is a common mucosal disease characterized by multiple recurrent, small, round, or oval ulcers with circumscribed margins, erythematous haloes, and yellow grey base. Although the exact etiology is unknown, various factors can trigger RAS development. Objectives: This study aims to determine the prevalence of self-reported RAS and to evaluate the associated risk factors of RAS among dental students. Material and methods: A set of validated questionnaires was distributed among the dental students in the Faculty of Dentistry, UiTM. The questionnaire comprises socio-demographic characteristics, nature of ulcers, risk factors, and treatment modalities. Data obtained from the questionnaire were analyzed using Chi-square statistical test SPSS version 27. Results: A total of 299 dental students participated in the questionnaire survey. The prevalence of RAS among dental students was 90.3 %. There was no significant relationship between the socio-demographic background of participants with self-reported RAS. The most common site affected was the buccal mucosa 64.1%, followed by the lips 55.2%. Risk factors frequently associated with RAS are injury (trauma) and stress 47.8% and 28.1%, respectively. Most dental students (69.3%) do not get any treatment to treat their ulcers, and only 1.5% seek treatment from the dentist. Conclusions: This study highlights the high prevalence of self-reported RAS among dental students and common risk factors reported associated with the occurrence of RAS. Therefore, this data assists the clinician in identifying common associated risk factors of RAS and subsequently improve management and efficient therapeutics.

Endoscopic imaging in inflammatory bowel disease.

In inflammatory bowel disease, including Crohn's disease and ulcerative colitis, an excessive immune response due primarily to T-cell lymphocytes causes inflammation in the gastrointestinal tract. Lesions in Crohn's disease can occur anywhere in the gastrointestinal tract, i.e., from the oral cavity to the anus. Endoscopically, aphthoid lesions/ulcers believed to be initial lesions progress to discrete ulcers, which coalesce to form a longitudinal array and progress to longitudinal ulcers with a cobblestone appearance, which is a typical endoscopic finding. Before long, complications such as strictures, fistulas, and abscesses form. Lesions in ulcerative colitis generally extend continuously from the rectum and diffusely from a portion of the colon to the entire colon. Endoscopically, lack of vascular pattern, fine granular mucosa, erythema, aphthae, and small yellowish spots are seen in mild cases; coarse mucosa, erosions, small ulcers, bleeding (contact bleeding), and adhesion of mucous, bloody, and purulent discharge in moderate cases; and widespread ulcers and marked spontaneous bleeding in severe cases.

Metabolic Profiling of Heliotropium crispum Aerial Parts Using HPLC and FTIR and In Vivo Evaluation of Its Anti-Ulcer Activity Using an Ethanol Induced Acute Gastric Ulcer Model.

This study explored the antiulcer potential of methanol extract and fractions of Heliotropium crispum roots against the ethanol-induced gastric ulcer model in rats. Metabolic profiling of H. crispum aerial parts using Fourier-transform infrared spectroscopy (FTIR) revealed the presence of different metabolites with various functional groups. Meanwhile, High Performance Liquid Chromatography (HPLC) revealed the presence of three main peaks assigned to myricetin, quercetin, and kaempferol. In vivo, antiulcer activity results showed that the disease control group displayed five tiny ulcers less than 2 mm in diameter in addition to two hemorrhagic streaks. However, in the standard control group, only one small ulcer was visible for the total methanol extract. Gastric tissues and contents were evaluated to determine many parameters such as ulcer score, ulcer index, percentage inhibition of ulcer, gastric pH, gastric juice volume, and acidity. Results were endorsed by histopathological evaluation; gastric pH and mucus content were significantly increased, but gastric juice volume was significantly decreased. All fractions showed a significant decrease in ulcer index and % inhibition except the n-hexane fraction, whose results were insignificant compared to the disease control group. Thus, it was concluded that H. crispum shows an antiulcer effect by decreasing gastric juice volume and acidity, whereas gastric pH and mucus contents were increased that is attributed to the synergistic action of its detected polyphenolic compounds.

ORAL MANIFESTATION OF HERPES SIMPLEX CONCOMITANT TO GRAFT-VERSUS-HOST DISEASE POST HEMATOPOIETIC STEM CELL TRANSPLANTATION

A 29-year-old female patient, 90 days after hematopoietic stem cell transplantation (HSCT) due to severe aplastic anemia, presented with small ulcers spread over the hard palate and a painful ulcer of 1 cm in diameter in the region of the left lingual alveolar mucosa. The patient had cytomegalovirus viremia and had red blood cells and platelets transfused weekly. Cytology confirmed the diagnosis of herpes simplex virus (HSV) in the ulcer of alveolar mucosa and nonspecific inflammatory process in the palate, compatible with graft-versus-host disease (GVHD). Treatment with systemic acyclovir was initiated, with HSV ulcer remission in 7 days. After 3 days, new lesions appeared, and the treatment was extended. The treatment of viral manifestations concomitant with oral manifestation of GVHD is a challenge in patients post-HSCT. The correct diagnosis and the therapeutic choice are extremely important for a better evolution in these highly complex cases.

242 Peristomal ulcer as presenting feature of inflammatory bowel disease (IBD)

77-year-old female with a history of diverticulitis and bowel perforation with subsequent hemicolectomy presented with three weeks of abdominal pain, bloody output from ostomy and rectum, and an enlarging painful peristomal wound. She was initially seen by outpatient dermatology for a small ulcer; wound culture grew E. coli, and she was started on ciprofloxacin. Over the next week, the ulcer rapidly grew and inpatient examination revealed an 11.5 x 11 x 0.5 cm deep peristomal ulcer with violaceous borders.

Photobiomodulation: a promising innovative approach for preventing oral mucositis in patients undergoing hematopoietic stem cell transplantation.

This single-center retrospective study aims to assess the feasibility, safety, and tolerability of CareMin650, a new photobiomodulation device, for both preventing oral mucositis (OM) and reducing its severity in the setting of hematopoietic stem cell transplantation (HCT). Patients who underwent autologous HCT for hematological malignancies between November 2020 and October 2021 could be included. Prophylactic photobiomodulation (PBM) was used daily from day 1 of conditioning until the day of neutrophil recovery at a dose of 3J/cm2. Curative PBM was started at a dose of 6J/cm2 when at least one grade 1 OM had occurred. For each OM case, time of onset, National Cancer Institute-Common Terminology Criteria for Adverse Events (NCI-CTCAE) v5.0 grade for OM, analgesic dose, and time to resolution were reported. Twenty-five consecutive patients were included. The median age was 58years (range, 39-74) and 14 (56%) were male. Twenty-one patients (84%) received a high-dose melphalan conditioning regimen for multiple myeloma, and 4 (16%) patients received BEAM conditioning for aggressive lymphoma. A total of 178 CareMin650 sessions were performed, with a median of 7days of application (range, 4-12), with no device-related adverse events (AEs). According to the NCI-CTCAE v5.0 scale, 76% (19 of 25) of patients presented grade 0 or 1 mucositis (no ulcers), five patients (20%) developed small ulcers (grade 2), and only one patient developed grade 4 mucositis. Satisfaction rates were high among patients and users. Photobiomodulation provides excellent safety and tolerance, as well as promising efficacy, both as a preventive and curative strategy, in patients undergoing autologous HCT.

Diffuse intestinal ulcerations: Diagnostic challenge in a patient with complicated celiac disease

A 48‐year‐old female patient presented with longstanding unrecognized celiac disease (CD), a family history of CD, and a short duration of alarming symptoms. The diagnostic evaluation revealed the concomitant presence of small and large bowel ulcers raised a dilemma about differential diagnosis in her case. Pathologic examination of tissue specimens from the jejunal ulcer led to the diagnosis of enteropathy‐associated T‐cell lymphoma. In recent years, the availability of modern cross‐sectional imaging and endoscopy modalities has dramatically improved the detection and characterization of small bowel lesions. Characterization of small bowel ulcers by endoscopy and radiology imaging in a patient with suspected complicated CD (CCD) needs to be made in conjunction with all clinical factors, as there is a wide overlap of the possible etiologic factors. Enteropathy‐associated T‐cell lymphoma is a highly aggressive T‐cell lymphoma with a poor prognosis, since early diagnosis and appropriate treatment may be delayed due to nonspecific clinical and endoscopic presentation. Therefore, it is crucial to timely recognize patients with suspected CCD and properly navigate diagnostic imaging tools, acquire adequate biopsy, and perform immunophenotyping to set early diagnosis in patients with diffuse intestinal ulcers and CD.

Unusual Ulcer Bleeding in the Stomach

Emergency upper gastrointestinal endoscopy in a 45 years old man with a complicated medical history obtained a small ulcer in the gastric corpus bedded in a round impression of 4 cm in diameter and no active bleeding during investigation. We decided to perform an immediate angio-CT-examination of thorax and abdomen. Gastric ulcer and impression were induced by a partially thrombosed aneurysm of the splenic artery. Emergency angiography with percutaneous transluminal implantation of a covered stent into the splenic artery completely bridged the aneurysm. The patient resolved and left the hospital after 12 days. Literature review shows that currently an immediate switch from endoscopy to vascular surgery is the best option in such cases. Emergency endoscopists have to identify the so called herald lesion as what it is and to initiate further diagnostic steps at once, since the second bleeding is mostly fatal. This may increase the prognosis significantly to 20-90 % survival. Unfortunately, in a current survey 50 % of gastroenterologists felt themselves not good informed about this fact and would probably not have done the correct decisions.

Selective IgA deficiency and presumptive polyclonal spike in the beta fraction in a dog with leishmaniosis

AbstractA 1‐year‐old, entire, crossbred, female dog examined for apathy, lethargy, unilateral nosebleed of 2‐month duration and the presence of symmetrical ulcerative dermatitis (small ulcers covered by a haemorrhagic crust and surrounded by alopecia on the tip of the ear pinna). Laboratory alterations included anaemia and hyperglobulinemia with a presumptive polyclonal spike in the beta fraction. High antibody levels to Leishmania infantum were detected by enzyme‐linked immunosorbent assay. An anti‐Leishmania therapeutic protocol was established and a reduction of the anti‐Leishmania antibodies was detected by an end point sera dilution enzyme‐linked immunosorbent assay during the first weeks of therapeutic protocol, while C‐reactive protein concentration was reduced during the period of time when meglumine antimoniate was administered. A good clinical response to the treatment was detected after initiating the anti‐Leishmania treatment. Quantitative serology is useful in the short‐term, because using a two‐fold serial dilution technique correlates with the clinical response.

Global N6-methyladenosine methylation analysis reveals the positive correlation between m6A modification and mRNA abundance during Apostichopus japonicus disease development

N6-methyladenosine (m6A), the most abundant epitranscriptomic modification in eukaryotic messenger RNA (mRNA), plays important roles in regulation of gene expression for fundamental biological processes and diverse physiological functions, including combating with pathogen infection. Here, we were first profile transcriptome-wide m6A sequencing in four stages of skin ulceration syndrome-diseased Apostichopus japonicus following Vibrio splendidus infection, including Control (healthy), Early (small ulcer), Later (extensive ulcer), and Resistant (no ulcer) groups. Our results revealed that three experimental groups were all extensively methylated by m6A and the proportion of the m6A modified genes were also significantly increased to 28.90% (Early), 27.97% (Later), and 29.98% (Resistant) when compared with Control group (15.15%), indicating m6A modification could be induced by V. splendidus infection. Intriguingly, we discovered a positive correlation between the m6A methylation level and mRNA abundance, indicating a positive regulatory role of m6A in sea cucumber gene expression during V. splendidus infection. Moreover, genes with specific and differentially expressed m6A methylation in Later group were both enriched in cell adhesion, while Early and Resistant groups were both mainly involved in DNA conformation change and chromosome organization when compared with Control, suggesting the higher-methylated m6A might serve as “conformational marker” and associated to the initiation of related anti-disease genes transcription in order to improve disease resistance of sea cucumber. Subsequently, we selected the pivotal genes enriched in cell adhesion pathway and found that the IggFc-binding protein (FcGBP) and Fibrocystin-L both had higher levels of m6A methylation and higher level of mRNA expressions in Later group. Conversely, Fibrinogen C domain-containing protein 1 (F1BCD1) gene presented as an antibacterial role in sea cucumber and showed higher mRNA expression and higher m6A methylation in Resistant group and lower mRNA level in Later group. The levels of m6A methylation and mRNA abundance of FcGBP and F1BCD1 genes indicates disease occurrence or disease resistant were also verified by MeRIP-qPCR. Overall, our study presents the first comprehensive characterize of dynamic m6A methylation modification in the different stages of disease in sea cucumber. These data provide an invaluable resource for future studies of function and biological significance of m6A in mRNA in marine invertebrates.

Lactobacillus complex capsules ameliorate aspirin-related small intestinal mucosal injury: a prospective, randomized, controlled clinical trial

Objectives Aspirin can reduce cardiovascular disease risk; however, it can increase the risk of gastrointestinal injury. Lactobacilli have some protective effects; however, there are few studies on their effects on humans. This study investigates the effects of Lactobacillus complex capsule treatment on the aspirin-related small intestinal mucosal injury. Methods This single-center, prospective, randomized controlled clinical trial included 69 patients using enteric-coated aspirin for >1 month between May and December 2019. After baseline magnetically controlled capsule endoscopy (MCCE), patients with aspirin-related small intestinal mucosal injury were randomly assigned (1:1) to receive enteric-coated aspirin and Lactobacillus complex capsules containing a combination of Lactobacillus rhamnosus I, Lactobacillus rhamnosus II, and Enterococcus faecium (probiotics group) or enteric-coated aspirin only (control group) for 2 months. After treatment, the patient underwent MCCE again. The primary outcome was the change in small intestinal mucosal injury scores from baseline to post-intervention. Results Twenty-five patients in the probiotics group and 28 in the control group completed the trial. The decrease in small intestinal mucosal injury scores from baseline to post-intervention was significantly greater in the probiotics group than that in the control group (p < .001). The improvement rates of red spots and erosions in the probiotics group were higher compared with the control group (p = .027 and .022, respectively), and the improvement rate of small intestinal ulcers in the probiotics group was 75.0%; however, there was no improvement in the control group. Conclusion Lactobacillus complex capsules can ameliorate aspirin-related small intestinal mucosal injury.

Evaluation of podophyllin and Trichloroacetic acid for the treatment of genital warts in Iraqi female patients

Background: human paillomavirus infections (genital warts) are the most frequent sexually transmitted viral infections. a wide range of treatment options is available with different efficacy. Objective: To evaluate the efficacy of podophyllin, trichloracetic acid (TCA) in the treatment of genital warts and side effects of them. Subjects and methods: a total of sixty patients with genital warts were randomly selected, 30 in each group, in the Department of Dermatology, medical city for a Duration of 11 months from January 2009 to December 2009 treated with 35 % podophyllin in the tincture of benzoin or 50% TCA) .Forty-eight patients were followed up for three months. Results: warts cleared in 63% and 70% of the patients after treatment with podophyllin and TCA respectively within 3 months. Soreness happened in 6 patients with podophyllin and in 9 patients with TCA. small ulcers happened in 1 patient by podophyllin and 2 patients with TCA. pain was in 5 patients treated by podophyllin and in 6 patients treated by TCA. erythema was noticed in 10 patients treated by podophyllin and in 11 patients treated by TCA. Conclusion: there was a higher clearance rate with TCA and earlier response. The occurrence of adverse reactions is little more with TCA

Colonic cryptococcosis presenting with chronic diarrhea in a person with advanced human immunodeficiency virus disease: a case report

Cryptococcus neoformans infection usually occurs in patients with advanced human immunodeficiency virus (HIV) infection or with a CD4 T lymphocyte count of &lt;100 cells/μL. Pulmonary and central nervous system infections are the most frequently encountered forms of cryptococcosis; however, colonic cryptococcosis is uncommon. We describe the case of a 41-year-old antiretroviral-naïve man with HIV infection diagnosed eight years prior and intermittent diarrhea for 4 months who presented to the emergency department with a 1-day history of low-grade fever and confusion. Brain magnetic resonance imaging and cerebrospinal fluid analysis revealed normal results; however, he was diagnosed with Pneumocystis jirovecii pneumonia based on chest computed tomography and bronchoalveolar lavage analysis. Trimethoprim-sulfamethoxazole administration was initiated followed by antiretroviral treatment. Although his condition gradually improved, he developed fever and abdominal discomfort, and the diarrhea worsened. Endoscopy revealed a small ulcer in the distal transverse colon. Histopathological examination of a colon tissue sample revealed cryptococcal infection. He improved substantially during liposomal amphotericin B and fluconazole treatment. We encountered a rare case of colonic cryptococcosis that caused chronic diarrhea in a patient with advanced HIV infection. Colonic cryptococcosis should be considered when patients with acquired immune deficiency syndrome present with gastrointestinal symptoms.

Clinical and pathological investigations in ulcer disease of Cyrinus carpio caused by Aeromonas hydrophila

The Indian carps are the most important food fishes and they have a considerable economic impact on the country's economy. In several parts of the country, they are widely cultivated. The Indian Major Carps include the Catla catla, Labeo calbasu, Cirrhinus mrigala, and Labeo rohita, to name a few species. The fish Cyprinus carpio, both in the wild and in captivity, is vulnerable to Aeromonas hydrophila infections. Investigations carried out on Cyrinus carpio to better understand the implications of a pathogenic Aeromonas hydrophila isolates impacts on fish health revealed that the pathogen affects severely. The fish species that were injected with the bacterial suspension developed lesions of a similar nature, and dead fishes with ulcers on their bodies were found in all of the tanks. Even after 15 days of incubation and observation, no difference was observed in the fishes in the control group of fishes. Despite this, not all of the fish who got ulcers perished. Healing has been shown in some fish that had small ulcers, according to the research. Cyprinus carpio injected with a mixed bacterial suspension of AH-04 and AH-07 recorded a death rate was 65.0 percent.

Recurrent aphthous stomatitis: A comprehensive review and recommendations on therapeutic options.

Recurrent aphthous stomatitis (RAS) is a common chronic disease in the oral mucosa that affects about 20% of the population. It is characterized by solitary or multiple, recurrent, small ulcers with erythematous haloes and yellow/gray floors. RAS can be managed through a wide variety of preventative measures and therapies, intending to reduce ulcer pain, stimulate ulcer healing, and/or prevent ulcer recurrence. First-line treatment options include topical medications in the form of corticosteroids (triamcinolone acetonide), anti-inflammatory drugs (amlexanox), antibiotics (doxycycline), and antiseptics (lidocaine). In more severe cases of RAS where local treatment is insufficient, systemic drugs in the form of corticosteroids (prednisone), immunomodulatory drugs (thalidomide), and antibiotics/antimicrobials (clofazimine) can prove effective. This review will summarize current treatment options for RAS with discussion of prevention, topical measures, natural treatments, systemic therapies, and new potential therapies. Furthermore, this review will provide recommendations on therapeutic options for RAS based on disease severity and patient circumstances.

Effects of the modified excision combined with bidirectional photodynamic therapy on refractory hidradenitis suppurativa: a retrospective study.

To describe the clinical features of refractory hidradenitis suppurativa (HS) patients (Hurley stageII and stage III) and evaluate the efficacy of combined treatment of the modified excision with bidirectional photodynamic therapy (PDT). A retrospective, multicenter study was conducted in 35 refractory HS patients. They were treated with the modified excision combined with bidirectional PDT. The outcomes, patients' satisfaction, adverse effects, and the Dermatology Life Quality Index (DLQI) were observed. There were more males than females (6:1). The axilla was the most frequently affected region (37.5%). All patients had experienced treatment failures before and had good response to our combined therapy (clearance rate > 75%). The average time required for complete wound healing was 11days. After 1year of follow-up, no significant recurrence was observed. The DLQI decreased significantly after the combined treatment. The comprehensive evaluation of scar and the deformation showed good cosmetic results after treatment. Reversible adverse events such as small patchy blackness, necrosis, or ulcer in the tip of the flap occurred in six patients (17.1%). Of the 35 patients, 30 were very satisfied with the treatment. This case series finds that the modified excision combined with bidirectional PDT may hold promise for radical treatment of Hurley stage II and stage III.

Cryptogenic multifocal ulcerating stenosing enteritis and other under-recognised small bowel inflammatory enteropathies.

Capsule endoscopy and more sensitive radiological techniques have resulted in more enteropathies being detected. A rare disease of unknown aetiology, 'cryptogenic multifocal ulcerating stenosing enteritis' or 'chronic nonspecific multiple ulcers of the small intestine' (CNSU), has long been recognised. This review aims to describe how disease can be better diagnosed and differentiated from other small bowel inflammatory disorders. Genetic studies have shown that some patients with CNSU (the term used in Japanese studies) express SLCO2A1 gene mutations, a gene which encodes a prostaglandin transporter expressed on vascular endothelium, allowing a more specific diagnosis of 'chronic enteropathy associated with SLCO2A1'. Mutations in the PLA2G4A gene result in cytosolic phospholipase A2α deficiency and reduced arachidonic acid for prostaglandin synthesis leading to a severe ulcerating, stenosing and fistulating small bowel disease. A 'prostaglandin-related enteropathy' should be considered in patients with atypical small bowel ulceration and stenosis. Genetic analysis will allow the detection of SLCO2A1 and PLA2G4A gene mutations. However, a careful history of medication use and a urinary metabolite screen may reveal the use of nonsteroidal anti-inflammatory drugs, a common cause of small bowel injury which is well recognised as being mediated by prostaglandin inhibition.

Ficus septica exudate, a traditional medicine used in Papua New Guinea for treating infected cutaneous ulcers: in vitro evaluation and clinical efficacy assessment by cluster randomised trial

Infected cutaneous ulcers are major health problems for children living in rural areas of Papua New Guinea. The inaccessibility of affected populations and lack of access to basic healthcare, make a local plant-based therapy an attractive treatment option. We assessed Ficus septica exudate in biological assays relevant to wound healing. We then carried out a clinical trial to determine the exudate's efficacy in healing small cutaneous ulcers compared with Savlon antiseptic cream, and soap and water washing. Pre-clinical in vitro assessment of the exudate was carried out using assays to monitor the pro-inflammatory responses of M1 macrophages and neutrophils, antibacterial assays using known ulcer pathogens, an Ames test for mutagenicity and LC-MS chemical analysis of the exudate. An open label cluster-randomised clinical trial was performed, enrolling participants from three different clusters with skin lesions less than 1 cm in diameter. Each cluster comprising 50 participants was randomly assigned to one of three treatment arms namely topical exudate, topical Savlon antiseptic cream, and standard care (soap and water treatment), all administered daily for 2 days. The primary outcome was clinical healing/improvement measured at days 7 and 14, assessed by three dermatologists using blinded photographs. The primary analysis was assessed as non-inferiority of F. septica treatment based on the risk difference for healing/improvement. In vitro, the exudate which is rich in the alkaloid ficuseptine, was found to be non-mutagenic whilst also inhibiting pro-inflammatory responses and exhibiting antibacterial activity. When administered to participants enrolled in the clinical trial, no significant differences were observed between the healing efficacy of F. septica exudate and the two comparator treatments (Savlon antiseptic cream and soap/water treatment). At day 14, but not at day 7, the efficacy of F. septica exudate for healing/improving the ulcers was non-inferior to Savlon antiseptic cream or water/soap treatment. F. septica exudate is non-mutagenic and has both bactericidal and anti-inflammatory properties. When applied topically to small cutaneous ulcers, the exudate has a healing effect that is non-inferior to Savlon antiseptic cream and standard treatment with soap and water at day 14. Our findings, which should be confirmed in larger clinical trials, have important public health implications.