Isolation and characterization of cDNA clones encoding a 32-kDa dense-granule antigen of Sarcocystis muris (Apicomplexa)

BACKGROUND AND STUDY AIMS: A second-look endoscopy is often performed to evaluate the efficacy of a prior injection therapy in patients with bleeding peptic gastric or duodenal ulcers. Although this strategy is widely established, it does not rely on unequivocal data from controlled studies. In a prospective, randomized, controlled multicenter trial we assessed the effect of programmed endoscopic follow-up examinations with eventual retreatment on the outcome of bleeding ulcers in these patients. PATIENTS AND METHODS: One hundred and five patients with gastric or duodenal peptic ulcers presenting with active (Forrest type I) or recent (Forrest type IIa and IIb) bleeding upon endoscopy within four hours after admission were included in the study. Emergency treatment consisted of the sequential injection of both epinephrine (1:10,000 v/v) and up to 2 ml of fibrin/thrombin around the ulcer base. Fifty-two patients were randomized to receive programmed endoscopic monitoring with eventual retreatment in cases of Forrest type I, IIa, or IIb ulcers beginning within 16-24 hours after the index bleed. Follow-up endoscopies were continued until the macroscopic appearance revealed a Forrest type IIc or III ulcer. Fifty-three patients in the control group were closely monitored, and only received a second endoscopy when there was clinical or biochemical evidence of recurrent bleeding. The groups did not differ with respect to age, sex, site and severity of bleeding. RESULTS: The numbers of patients with recurrent bleeding were similar whether they were endoscopically monitored or not (21% versus 17%, P=0.80 chi-squared test). In addition, there was no statistically significant difference between the two groups with respect to the number of blood units transfused, need for surgical intervention, hospital stay or number of deaths (Mann-Whitney U-test). Improving local ulcer stigmata was not related to a better outcome. CONCLUSIONS: Programmed endoscopic follow-up examinations with eventual retreatment in patients locally injected for an acute or recent hemorrhage from a gastric or duodenal ulcer did not influence their outcome when compared to patients receiving only a second endoscopic intervention upon evidence for recurrent hemorrhage. Scheduled control endoscopies cannot be recommended after an initial successful endoscopic treatment of peptic ulcer bleeding when selection of the patients for second-look endoscopy is directed by the Forrest criteria.     

Secondary ulcer perforation after endoscopic hemostasis with fibrin glue

Emergency treatment of bleeding ulcer of the duodenum is endoscopy and endoscopic blood-staunching. In high-risk patients with Forrest Ia lesions or ulcers with visible vessel (Forrest IIa) endoscopic follow-up or early elective operation is required. Fibrin sealing can improve the results of endoscopic injection therapy for bleeding ulcer. Nevertheless, severe complications such as secondary perforation of the fibrin clot or recurrent bleeding can occur. Identification of high-risk patients and complications requires close monitoring and attention. A case of a secondary perforation of a bleeding ulcer of the duodenum after fibrin sealing is reported.     

Multicenter prospective study of the current status of treatment for bleeding ulcer in Germany

The current state of ulcer treatment in Germany was analysed in a prospective multi-centre study. It was based on 1139 consecutive patients admitted to the participating hospitals because of upper gastrointestinal bleeding. The source of the bleeding was identified by diagnostic endoscopy in 1075 patients (94%), from a gastric and/or duodenal ulcer in 546 of them (mean age 62 +/- 18 years). Using Forrest's classification, 4% of patients were in bleeding stage Ia, 17% in stage Ib, 16% stage IIa, 30% stage IIb and 33% stage III. An attempt to arrest bleeding through the endoscope was made in 233 patients (43%): more often with tissue-preserving substances (epinephrine +/- NaCl in 36%, fibrin glue +/- epinephrine in 24%) than with tissue-damaging procedures (epinephrine + polidocanol +/- NaCl in 26%, epinephrine + thermocoagulation in 7%). Primary haemostasis was achieved in 219 patients (94%). There was a total of 66 recurrences of bleeding (12%), but the rate was 18% after endoscopic haemostasis. 64 patients (12%) required operative intervention, including initial emergency operations. Severe complications (infections, organic failure) occurred in 82 patients (16%). 114 of the 546 patients were in the high risk group (older than 60 years; high amount of bleeding). Their bleeding recurrence and mortality rates (27 and 22%, respectively) were significantly higher (P < 0.01) than those of the total group. Overall mortality rate was 11% (58 patients). The mortality rate depended on the severity of initial bleeding (26% for Forrest group Ia). After recurrent bleeding the mortality rate was 34% with conservative and 33% with operative treatment. 7% of all deaths were the direct result of bleeding. The following factors prognostically closely correlated with mortality rate: age of patient (P < 0.01); haemoglobin < 8 g/dl on admission (P < 0.05); initial severity of bleeding (Forrest group I; P < 0.05); and recurrence of bleeding (P < 0.001).     

Effects of thyroid hormone replacement therapy on nocturnal apnea in elderly patients with hypothyroidism

BACKGROUND AND STUDY AIMS: Dieulafoy's disease is a rare cause of upper gastrointestinal tract hemorrhage. The aim of the study was to evaluate the efficacy of endoscopic hemostasis and to analyze the mortality of patients with hemorrhage due to Dieulafoy's disease. PATIENTS AND METHODS: The retrospective analysis included patients from our institution who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions in the period between January 1994 and December 1996. RESULTS: Twenty-five patients were examined (18 men and 7 women, average age 52.6, SD+/-15.3, range 25-78). In 20 patients endoscopic injection sclerotherapy was performed (diluted epinephrine 1:10,000 plus polidocanol 1%) and Nd:YAG laser photocoagulation in five patients. In all patients a total of 44 interventional endoscopies were carried out. Repeated endoscopic hemostasis did not prove successful in two patients (8%, 2 men), and they were treated operatively. During the postoperative period one patient died because of multiorgan failure. The total mortality rate of all patients in which endoscopic hemostasis was done was 16% (4/25). None of the 21 surviving patients had rebleeding on long-term follow-up (mean: 29.4 months). CONCLUSIONS: Endoscopic hemostasis is a major therapeutic advance in the management of Dieulafoy's disease hemorrhage. Interventional endoscopy has decreased the need for surgical management and significantly reduced mortality.     

Treatment of Helicobacter pylori reduces the rate of rebleeding in peptic ulcer disease

BACKGROUND: We evaluated whether therapy designed to eradicate Helicobacter pylori infection resulted in a reduction in rebleeding in patients with peptic ulcer disease. Patients presenting because of major upper gastrointestinal hemorrhage from peptic ulcer and whose ulcers healed in a study in which they were randomized to receive ranitidine alone or triple therapy plus ranitidine were followed up regularly with endoscopy. No maintenance anti-ulcer therapy was given after ulcer healing. METHODS: Patients received ranitidine, 300 mg, or ranitidine plus triple therapy. Triple therapy consisted of tetracycline, 2 g; metronidazole, 750 mg; and bismuth subsalicylate, 5 or 8 tablets (151 mg bismuth per tablet), and was administered for the first 2 weeks of treatment; ranitidine therapy was continued until the ulcer had healed or 16 weeks had elapsed. After ulcer healing, no maintenance antiulcer therapy was given. Development of ulcer recurrence with or without recurrent upper gastrointestinal bleeding was evaluated. RESULTS: Thirty-one patients with major upper gastrointestinal bleeding from peptic ulcer were studied; 17 received triple therapy and 14 ranitidine alone. Major rebleeding occurred significantly (p = 0.031) more often in those in the ranitidine group (28.6%), compared with none (0%) in the triple therapy group. CONCLUSION: Eradication of H. pylori infection reduces the rate of ulcer recurrence and rebleeding in complicated ulcer disease.     

Acute ulcer bleeding. A prospective randomized trial to compare Doppler and Forrest classifications in endoscopic diagnosis and therapy

The aim of our prospective randomized study involving 100 patients was to investigate whether Doppler ultrasound can be used to select patients at risk for ulcer rebleeding. Ulcers in the Forrest group classified as having a visible vessel or a clot were treated prophylactically by injection with epinephrine solution. In the Doppler group, in contrast, only ulcers with a positive Doppler signal were treated endoscopically. In the Doppler group, rebleeds occurred significantly less frequently (2%, P < 0.03) than in the Forrest group (14%). Emergency surgery was only necessary in the Forrest group (0% vs 5%; P = 0.02). Bleeding-related mortality was 0% and 4% (P = 0.15) and the overall mortality 0% and 10% (P = 0.02), in the Doppler and Forrest groups, respectively. These results appear to show that Doppler-based injection treatment is superior to endoscopic treatment based exclusively on the Forrest classification. In our study, Doppler-based local endoscopic treatment reduced the danger of a rebleed and thus the number of emergency operations and the overall mortality.     

Is endoscopic injection hemostasis of bleeding gastrointestinal ulcers obsolete in 1995?

Bleeding non-neoplastic lesions of the upper gastrointestinal tract, not due to portal hypertension, are a frequent cause of emergency admission. In the present paper we report our retrospective experience in hemostatic injection treatment of these lesions. From May 1990 to May 1994, 164 patients were admitted to our institution for a bleeding gastrointestinal lesion. In 124 cases an ulcer classified according Forrest's criteria was detected. Four patients underwent immediate surgery. The second group of 86 patients (FIIa/FIIb/FIII) were treated conservatively. The third group of 34 patients (FIa/FIb/FIIa) underwent perilesional injection of adrenaline 1:10,000 and polidocanol 1% saline solution during endoscopic examination; 29% (25 pts) of the second group re-bled during the first 72 h vs 8.8% (3 pts) of the third group. The postoperative morbidity in the rebleeding patients was higher in the second group: 38.4% vs 0%. The importance of immediate, inexpensive, and simple hemostatic treatment extended to Forrest IIa lesions is emphasized.     

Prospective, randomized trial of hypertonic glucose water and sodium tetradecyl sulfate for gastric variceal bleeding in patients with advanced liver cirrhosis

BACKGROUND AND STUDY AIMS: Information about the appropriate endoscopic treatment of gastric variceal bleeding is sparse. We therefore designed a prospective and randomized study to evaluate and compare efficacy and complication rates of two agents, hypertonic glucose water (50% GW) and sodium tetradecyl sulfate (STS), in treating acute gastric variceal bleeding after esophageal varix eradication. PATIENTS AND METHODS: Of 51 patients with advanced cirrhosis of the liver (Child's C), with acute gastric variceal bleeding initially evaluated, 25 patients were randomized to receive 1.5% STS and 26 to receive 50% glucose water. Treatment was aimed at achieving initial and permanent hemostasis by variceal eradication. RESULTS: Control of acute gastric variceal bleeding was achieved in 80% of the STS group and 92% of the GW group. The rebleeding rate in the STS group was 70%, while in the GW group it was 30% (P < 0.05). Overall, obliteration was achieved in only 32% of the STS group and 81% of the GW group during admission (P < 0.05). There was a trend toward a higher gastric ulcer rate in the STS group compared with the GW group (92% vs. 30%; P < 0.05). The rebleeding control rate and permanent hemostasis rate in the GW group (70%, 54%) were also significantly higher than in the STS group (21%, 12%; P < 0.05; P < 0.05). The hospital mortality for the STS group was 50%, and for the GW group 30%. CONCLUSION: Treatment with hypertonic glucose water in gastric vericeal bleeding was superior to treatment with STS in controlling bleeding and in achieving vericeal obliteration, less rebleeding, and a lower complication rate. The results of this study suggest that hypertonic glucose water is a clinically effective, easily available, and safe sclerosing agent.     

Short and long term course of elderly patients with peptic ulcer bleeding--analysis of factors influencing fatal outcome

OBJECTIVE: To study long and short term survival in patients aged 60 years or over admitted with a peptic ulcer bleeding and find out which factors influence outcome. DESIGN: Cohort study with matched controls. SETTING: Two emergency hospitals, Sweden PATIENTS: 676 of the 687 patients aged 60 years or over admitted to the two emergency hospitals serving Gothenburg, Sweden during 1989-1993 who fulfilled the diagnostic criteria and whose case notes were available for study. MAIN OUTCOME MEASURES:Seven year survival rates and odds ratios for risk factors based on multiple logistic regression analyses. RESULTS: 37 patients died and the timing was evenly distributed within the first 30 days of admission with a cumulated case-fatality rate of 5.5% at day 30. Mortality was increased among the patients compared with the control group during the subsequent years. Factors that influenced day 30 mortality were age and Forrest class. CONCLUSION: Mortality is increased among patients with peptic ulcer bleeding even long after the event. Old age and signs of recent haemorrhage increase the risk.     

Risk factors of persistent or recurrent bleeding and mortality in peptic ulcer hemorrhage

The mortality rate of peptic ulcer haemorrhage has remained unchanged, mainly attributed to rebleeding in an increasingly elderly population with more coexisting systemic diseases. The value of clinical factors and endoscopic findings in predicting in-hospital further haemorrhage and death are analysed. Over a 2-year period, 157 consecutive patients were admitted with bleeding from peptic ulcer, 19 died and 37 had further bleeding. The predictive value of each factor was determined by the chi 2 test with a Yates-correction (significant, p < 0.05). Significant predictive factors of further bleeding were shock, a transfusion requirement > 4 units during the first 48 hours and endoscopic stigmata of recent haemorrhage. The combination of these factors was not of better predictive value than shock alone. The number of coexisting illnesses per patient was strongly related to fatality rate. Other significant factors indicative of an increased mortality included steroid, onset of bleeding during a hospital stay, alcohol, further bleeding, and > 4 units transfused over the first 48 hours. Shock remains the most valuable sign in predicting further bleeding and is superior to endoscopic stigmata. The close relationship between the mortality rate and coexisting illnesses underlines the fact that the majority of deaths result from non peptic ulcer disease.     

Endoscopic hemostasis of nonvariceal, non-peptic ulcer hemorrhage

The majority of patients who present with acute upper gastrointestinal hemorrhage are found to be bleeding from acid peptic disease including ulcer, esophagitis and gastritis, and variceal disease. Mallory-Weiss tear, Dieulafoy's lesion, cancer, and other rare lesions account for the bleeding source in the remaining patients. Endoscopic hemostasis may be effective in many of the conditions, but only Mallory-Weiss tear and Dieulafoy's lesion are encountered frequently enough to be clinically significant.     

Metabolism of ricinoleate by Neurospora crassa

BACKGROUND: From January 1993 to December 1994, we conducted a prospective study to investigate the evolutionary change of rebleeding risk in bleeding peptic ulcers. To obviate possible confounding factors that would influence decision making for discharge of patients, subjects with coexistent acute illnesses, systemic bleeding disorders, alcoholism, and use of nonsteroidal anti-inflammatory drugs were excluded. METHODS: Emergency endoscopies were performed in patients with hematemesis or a melena within 24 hours of admission. Ulcer lesions were divided into six categories according to endoscopic findings. The residual risks of rebleeding of each type of ulcers were calculated for 10 days, and the critical point of acceptable rebleeding risk after discharge was set at 3%. RESULTS: Three hundred ninety-two patients with bleeding peptic ulcers completed the study. The ulcers, characterized by clean bases, red or black spots, adherent clots, nonbleeding visible vessels without local therapy, nonbleeding visible vessels with local therapy, and bleeding visible vessels with local therapy took 0, 3, 3, 4, 4, and 3 days, respectively, to decrease rebleeding risk to below the critical point. All episodes of fatal rebleeding (n = 4) occurred within 24 hours after admission. CONCLUSIONS: Patients with clean-based ulcers can be discharged in the first day of admission. The optimal duration required for hospitalization of patients with ulcers characterized by nonbleeding visible vessels at initial endoscopy is 4 days. The remaining patients with ulcers marked by other bleeding stigmata may be discharged after a 3-day observation.     

Comparative study of biological glues: cryoprecipitate glue, two-component fibrin sealant, and "French" glue

BACKGROUND: Although biological glues have been used clinically in cardiovascular operations, there are no comprehensive comparative studies to help clinicians select one glue over another. In this study we determined the efficacy in controlling suture line and surface bleeding and the biophysical properties of cryoprecipitate glue, two-component fibrin sealant, and "French" glue containing gelatin-resorcinol-formaldehyde-glutaraldehyde (GRFG). METHODS: Twenty-four dogs underwent a standardized atriotomy and aortotomy; the incisions were closed with interrupted 3-0 polypropylene sutures placed 3 mm apart. All dogs had a 3- by 3-cm area of the anterior wall of the right ventricle abraded until bleeding occurred. The animals were randomly allocated into four groups: in group 1 (n = 6) bleeding from the suture lines and from the epicardium was treated with cryoprecipitate glue; in group 2 (n = 6) bleeding was treated with two-component fibrin sealant; group 3 (n = 6) was treated with GRFG glue; group 4 (n = 6) was the untreated control group. The glues were also evaluated with regard to histomorphology, tensile strength, and virology. RESULTS: The cryoprecipitate glue and the two-component fibrin sealant glue were equally effective in controlling bleeding from the aortic and atrial suture lines. Although the GRFG glue slowed bleeding significantly at both sites compared to baseline, it did not provide total control. The control group required additional sutures to control bleeding. The cryoprecipitate glue and the two-component fibrin sealant provided a satisfactory clot in 3 to 4 seconds on the epicardium, whereas the GRFG glue generated a poor clot. There were minimal adhesions in the subpericardial space in the cryoprecipitate and the two-component fibrin sealant groups, whereas moderate-to-dense adhesions were present in the GRFG glue group at 6 weeks. The two-component fibrin sealant was completely reabsorbed by 10 days, but cryoprecipitate and GRFG glues were still present. On histologic examination, both fibrin glues exhibited minimal tissue reaction; in contrast, extensive fibroblastic proliferation was caused by the GRFG glue. The two-component and GRFG glues had outstanding adhesive property; in contrast, the cryoprecipitate glue did not show any adhesive power. The GRFG glue had a significantly greater tensile strength than the two-component fibrin sealant. Random samples from both cryoprecipitate and the two-component fibrin glue were free of hepatitis and retrovirus. CONCLUSIONS: The GRFG glue should be used as a tissue reinforcer; the two-component fibrin sealer is preferable when hemostatic action must be accompanied with mechanical barrier; and finally, the cryoprecipitate glue can be used when hemostatic action is the only requirement.     

The impact of Helicobacter pylori eradication on peptic ulcer healing

OBJECTIVE: Current literature was reviewed analyzing the outcome of peptic ulcer healing in relation to the results of the posttherapeutic Helicobacter pylori (HP) status. METHODS: Literature was reviewed along with an analysis of 60 studies, comprising a total of 4329 patients. RESULTS: Successful Helicobacter pylori eradication was found to induce a better response in peptic ulcer healing, regardless of diagnosis: gastric ulcer 88% vs 73% (odds ratio [OR] 2.7, p < 0.01), duodenal ulcer 95% vs 76% (OR 5.6, p < 0.0001), and peptic ulcer 95% vs 76% (OR 6.6, p < 0.0001), for patients having their HP infection successfully cured versus those remaining HP-positive, respectively (Fisher's exact test). For all evaluated time points (< or = 6, 7-8, and 10-12 wk after beginning treatment), HP-negative patients had higher healing rates than HP-positive patients (95% vs 82%, 94% vs 69%, and 96% vs 78% with corresponding OR of 4.2, 6.5, and 7.4, all p < 0.0001, Fisher's exact test). The use of concomitant acid suppression therapy during initial HP eradication provided a benefit on peptic ulcer healing only for patients with persistent HP infection (improved healing rates of 78% vs 67%; otherwise rates were 94-96%). Likewise, prolonged acid inhibition in HP treatment failures after the initial HP treatment phase resulted in 7-20% improved healing rates, whereas patients becoming HP-negative did not profit. CONCLUSION: Successful HP eradication therapy accelerates peptic ulcer healing even without concomitant acid suppression.     

One-week antibiotics versus maintenance acid suppression therapy for Helicobacter pylori-associated peptic ulcer bleeding

Bleeding peptic ulcer is the most important cause of upper gastrointestinal bleeding. Our aim was to compare the effect of anti-Helicobacter therapy with maintenance treatment of H2-receptor antagonist in the prevention of relapses of ulcer and bleeding. Patients with bleeding duodenal or gastric ulcers and H. pylori infection were randomized to receive either a one-week course of triple therapy with bismuth subcitrate, metronidazole, and tetracycline plus ranitidine or a six-week course of ranitidine 300 mg/day. After the ulcers healed, the antibiotic-treated patients were not given any medication, whereas the ranitidine-treated patients continued to receive a maintenance dose of 150 mg/day. One hundred twenty-six patients were randomized to receive anti-Helicobacter therapy and 124 patients to receive long-term ranitidine. H. pylori eradication was achieved in 98.2% in those who received triple therapy and 6.1% in those who received ranitidine (P < 0.0001). At the six-week follow-up, ulcer healing was documented in 88.2% in those who received triple therapy and 86.1% in those who received ranitidine (P = 0.639). Recurrent ulcer developed in nine of the ranitidine-treated patients and three of them presented with recurrent upper gastrointestinal bleeding. One patient in the antibiotic group developed recurrent ulcer without rebleeding (P = 0.01). It is concluded that eradication of H. pylori is sufficient for the prevention of recurrent bleeding ulcers.     

The evaluation of argon laser photocoagulation in a series of animal models of upper gastrointestinal bleeding

During the past five years we have evaluated argon laser photocoagulation in various canine models of upper gastrointestinal hemorrhage. In gastric erosions, the eight-watt argon laser was uniformly effective in stopping bleeding. In our standard acute ulcer model the seven-watt argon laser was effective in stopping bleeding from most ulcers and only occasionally produced deep injury. With the addition of a jet of CO2 exiting the laser catheter coaxial to the laser beam, the argon laser was 100% effective and no deep injury resulted. The application of the argon laser in a more physiologic canine bleeding model using a single bleeding vessel in an ulcer base is currently under study. The development of improved animal models of gastrointestinal bleeding should contribute to the identification of effective and safe endoscopic hemostatic methods.     

Use of autologous fibrin glue in dermatologic surgery: application of skin graft and second intention healing

OBJECTIVE: To evaluate the efficiency of biological sealant, an autologous fibrin glue, in dermatological surgery. DESIGN: Randomized clinical trial. SETTING: The Dermatology Service of Hospital das Clinicas, Universidade de Campinas (UNICAMP), referral center. PATIENTS: 14 patients with malign epithelial cutaneous tumors participated in the evaluation, each having two tumors, generally facial and symmetrical, in order to perform a comparative evaluation on the same individual. PROCEDURES: The glue was prepared beforehand with a sample of autologous blood. Surgical extirpation of the tumor was followed by grafts or second intention healing. OUTCOMES: The efficiency of the sealant was then evaluated in relation to hemostasis, adhesion, surgical time and evolution of the granulation tissue, clinically and histologically. RESULTS: Immediate hemostasis and graft adhesion, with a significant reduction of surgical time, and in the open wounds there was immediate hemostasis and a clinical increase in granulation tissue, but with no histological differences among the groups on the 7th day. CONCLUSION: It is an adjuvant resource in skin cancer surgery.     

Fibrin sealant: current and potential clinical applications

There are few well-controlled studies of the clinical efficacy of fibrin sealant, defined by lives saved or reduced need for blood transfusions. Evaluation of fibrin sealant in trauma situations, e.g. liver laceration, has been difficult to perform. Only recently has fibrin sealant been actively promoted by US manufacturers as a commercially valuable alternative to the relatively inexpensive crude bovine thrombin and cryoprecipitate that are in current use. Regulatory agencies and manufacturers are aware that patients in the USA are receiving a suboptimal form of fibrin glue since cryoprecipitate is not virally inactivated and has a variable fibrinogen concentration. In addition, bovine thrombin is not regulated with respect to factor V content or any other impurities. During the past year regulatory agencies, together with manufacturers and clinicians, have begun to define clinically valid endpoints for efficacy of a commercially prepared fibrin sealant. These may include improvement in hemostasis compared with a placebo or agents considered to be 'standard of care'. Thus, the regulatory agencies may be willing to consider studies in animals that demonstrate efficacy as well as surrogate endpoints, such as reduced factor concentrate requirements in patients with severe hemophilia requiring dental extraction. As fibrin sealant becomes available in a liquid and potentially in a bandage form, it may also become an essential matrix for recombinant factors that can affect endothelial function.     

Statistical methods of computing reference values for side-to-side differences in nerve conduction studies

OBJECTIVE: To evaluate the utility of surgery in the treatment of peptic ulcer disease. METHODS: The clinical history of patients operated for peptic ulcer disease in a 15 year period were reviewed. The demographic data, indications for surgery, surgical procedure, morbidity, mortality and long term results, were analyzed. RESULTS: 349 patients were operated for peptic ulcer disease or its complications, 56% male. In 78% surgery was elective, mostly due to pyloric obstruction. In the remaining 22% perforation or bleeding ulcer were the main causes for emergency surgery. The most frequent elective procedure was vagotomy and drainage (66%); in urgent surgery, a definitive procedure was done in 35% of the perforations and in 94% of the bleeding ulcers. The 30-day mortality in urgent surgery was 14%; in elective surgery there was no mortality. A satisfactory long term result was obtained in 80% of the patients. CONCLUSIONS: An indication for surgical treatment of complicated peptic ulcer disease was above 50%, and 90 per cent in recent years. The frequency of urgent surgery is increasing and reached 60% of surgeries for this disease. Whenever possible, a definitive procedure is recommended.     

Complex posttraumatic stress disorder: evidence from the primary care setting

The efficacies of somatostatin and octreotide have been widely studied in the control of bleeding from oesophageal varices. It has also been suggested that these drugs may be useful for the control of non-variceal upper gastrointestinal (UGI) bleeding, including that from peptic ulcers. In approximately 80% of patients presenting with non-variceal UGI bleeding, haemorrhage ceases spontaneously and does not recur. However, the remaining 20% of patients require active treatment. Results from recent studies have indicated that somatostatin is an effective treatment for the control of non-variceal UGI bleeding in high-risk patients, i.e. those in whom haemorrhage does not cease spontaneously or is likely to recur. In contrast there is no good evidence available at present to support a role for octreotide in this indication. The efficacy of somatostatin in controlling bleeding in patients with non-variceal UGI bleeding at high risk of mortality upon admission, or rebleeding following endoscopy, coupled with an excellent safety and tolerability profile, suggests that it may be a valuable therapeutic option in the management of non-variceal bleeding.