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At least 163 records · Page 9Linked to original sources
PubMed1995

The role of intragastric acidity and stress ulcus prophylaxis on colonization and infection in mechanically ventilated ICU patients. A stratified, randomized, double-blind study of sucralfate versus antacids.

UNLABELLED: This study evaluates the effects of sucralfate and antacids on intragastric acidity, colonization of stomach, oropharynx and trachea, and the incidence of ventilator-associated pneumonia (VAP) in mechanically ventilated patients in intensive care units. We conducted a prospective randomized double-blind trial in which patients were stratified on initial gastric pH. Intragastric acidity was measured with computerized, continuous intragastric monitoring. The diagnosis of VAP was established with protected specimen brush and/or bronchoalveolar lavage. The study included consecutive eligible patients with mechanical ventilation and nasogastric tube. INTERVENTIONS: After stratification on initial intragastric pH into two groups, patients from both groups were randomly assigned to receive either antacids (a suspension of aluminum hydroxide and magnesium hydroxide), 30 mL every 4 h, or sucralfate, 1 g every 4 h. Continuous intragastric pH monitoring was performed in 112 patients (58 antacids, 54 sucralfate). Using predetermined criteria, colonization of stomach, oropharynx, and trachea, and the incidence of VAP were assessed. Altogether, 141 patients were included (74 receiving antacids, 67 sucralfate) and continuous intragastric pH monitoring was performed in 112 patients, with a mean of 75 h per patient. The median pH and the percentage of time with a pH < 4.0 were calculated from each measurement. No significant differences in median pH values (4.7 +/- 2.2 and 4.5 +/- 2.0 for antacids and sucralfate, respectively) were observed. Median pH values were higher in patients with gastric bacterial colonization than in noncolonized patients (5.5 +/- 2.1 and 3.3 +/- 2.0, p < 0.01), but colonization of oropharynx and trachea was not related to intragastric acidity. Thirty-one patients (22%) developed VAP, with a similar incidence in both treatment groups. In addition, antibiotic use, duration of hospitalization, and mortality rates were similar in both groups. Enteral feeding did not change intragastric acidity significantly but increased gastric colonization with Enterobacteriaceae, without influencing oropharyngeal and tracheal colonization. Antacids and sucralfate had a similar effect on intragastric acidity, colonization rates, and incidence of VAP. Intragastric acidity influenced gastric colonization but not colonization of the upper respiratory tract or the incidence of VAP. Therefore, it is unlikely that the gastropulmonary route is important for the development of VAP.

Antacids↗
PubMed1986

Does dimethicone increase the efficacy of antacids in the treatment of reflux oesophagitis?

Dimethicone is a common additive to antacids, although its value in the treatment of reflux oesophagitis is unproven. Its efficacy was assessed by comparing the effect of a dimethicone-containing antacid gel (Asilone Gel) with a simple antacid gel in a double-blind trial in 45 patients with reflux oesophagitis. Thirty-eight patients completed the eight-week course of therapy. Antacid therapy alone resulted in a significant improvement of both symptoms and oesophagitis in gastro-oesophageal reflux. The inclusion of dimethicone in the antacid gel preparation did not confer any benefit in terms of symptomatic assessment but did confer a small advantage with regard to objective markers of oesophageal inflammation, suggesting that a dimethicone-containing antacid is of value in the treatment of symptomatic gastro-oesophageal reflux.

Antacids↗
PubMedDate not supplied

Oral bioavailability of nizatidine and ranitidine concurrently administered with antacid.

This four-way crossover open-label study on eight healthy subjects was designed to investigate the effect on bioavailability of orally administered nizatidine given concurrently with an antacid (magnesium hydroxide-aluminium hydroxide mixture). Ranitidine was used as a comparison. Subjects were hospitalized overnight for each drug application which was given as a single dose [nizatidine or ranitidine (300 mg) or antacid (20 ml) of a neutralizing capacity of 50 mmol hydrochloric acid]. Plasma nizatidine or ranitidine concentrations were measured by high performance liquid chromatography. No statistically significant difference occurred in the kinetic profile of nizatidine after antacid administration although it took longer to reach maximum concentration in plasma. The area under the concentration-time curve was also reduced (by less than 10%) and there was a longer lag between administration and absorption. Bioequivalence (Westlake test) for ranitidine in the presence or absence of antacid was confirmed (difference less than 12%). For nizatidine, with or without antacid, the value of the Westlake test was just above the limit for bioequivalence (21.4%), whereas the Student's t-test for related means (one-tailed distribution) gave P = 0.045. There was no clinically relevant nizatidine-antacid interaction at the doses used in this study.

Adult↗
PubMedDate not supplied

Effect of antacid on bioavailability of a sustained-release theophylline preparation.

The effect of coadministration of an antacid on bioavailability of a sustained-release theophylline tablet preparation (Theo-Dur) was studied by crossover comparison in five young, healthy, nonsmoking volunteers. Water 90 ml, or "high potency" aluminum-magnesium hydroxide antacid (Mylanta II) 10 ml and water 80 ml were administered concurrently with sustained-release theophylline 600 mg. Eleven blood samples were collected over the next 24 hours. Serum was analyzed with high pressure liquid chromatography technique to determine theophylline concentration. Peak serum concentration (Cmax) and time to peak concentration (tmax) were determined, and area under the 24-hour serum concentration-time curve (AUC) was calculated by the trapezoidal rule for each subject at each study interval. The Student's paired t-test was used to compare Cmax, tmax, and AUC for both treatments. A uniform difference was found between groups in Cmax. Cmax was higher in subjects when treated with the antacid (10.45 +/- 3.03 vs. 8.30 +/- 2.90 micrograms/ml, p less than 0.05) than when given theophylline alone. The mean tmax for the two treatments did not differ (10.4 +/- 1.67 h-combination vs. 10.8 +/- 1.1 h-theophylline, p greater than 0.05). Likewise, mean AUC was unchanged by the coadministration of antacid (140.65 +/- 41.6 micrograms/ml.h--combination vs. 155.13 +/- 46.6 micrograms/h--theophylline, p greater than 0.05). The use of a high-potency antacid product did not decrease the extent of theophylline absorption from this sustained-release product, but did increase Cmax and, presumably, rate of absorption. High-potency aluminum-magnesium antacids can probably be used in combination with this sustained-release theophylline tablet without detriment to therapy.

Adult↗
PubMed2004

Lack of effect of omeprazole or of an aluminium hydroxide/magnesium hydroxide antacid on the pharmacokinetics of lumiracoxib.

OBJECTIVE: To evaluate the effects of multiple doses of omeprazole and of a single dose of an aluminium hydroxide/magnesium hydroxide (Al/Mg) antacid on the single-dose plasma pharmacokinetics of lumiracoxib. STUDY DESIGN: Open-label, randomised, three-period, crossover study. POPULATION STUDIED: Healthy subjects aged 18-65 years. METHODS: Fourteen subjects who met eligibility criteria were each administered three treatments in random order: (A) lumiracoxib 400 mg as a single oral dose; (B) oral omeprazole 20 mg once daily for 4 consecutive days, then lumiracoxib 400 mg as a single oral dose just prior to oral omeprazole 20 mg on day 5; and (C) lumiracoxib 400 mg as a single oral dose immediately prior to a 20 mL dose of Al/Mg antacid (magnesium hydroxide 800 mg and aluminium hydroxide 900 mg). The interval between each lumiracoxib dose was 7 days. Analysis of variance was performed to determine whether lumiracoxib alone differed from lumiracoxib plus omeprazole or from lumiracoxib plus Al/Mg antacid for overall exposure (area under the concentration-time curve from zero to infinity [AUC( infinity )]) and peak concentration (C(max)), with treatment sequence, subject, period and treatment as factors. Ratios of geometric means between lumiracoxib plus omeprazole and lumiracoxib plus Al/Mg antacid to lumiracoxib alone (reference) were calculated for AUC( infinity ) and C(max). If the mean ratios, with 90% CIs, fell within the interval 0.80-1.25, the treatments were considered equivalent. RESULTS: Arithmetic mean plasma lumiracoxib concentration-time profiles were similar for all treatments, with a rapid rise in concentration after administration, reaching C(max) values (mean +/- SD) of 9.24 +/- 1.96, 8.81 +/- 2.30, and 10.43 +/- 3.24 mg/L within 2-3 hours for treatments A, B and C, respectively. AUC( infinity ) was similar for the three treatments (36.75 +/- 7.73, 34.88 +/- 8.40 and 35.50 +/- 5.72 mg. h/L). All ratios of geometric means with 90% CIs fell within the interval used for establishing bioequivalence, except for the C(max) comparison between lumiracoxib plus Al/Mg antacid and lumiracoxib alone, which was 1.11 (0.95, 1.31). CONCLUSIONS: Coadministration of lumiracoxib with omeprazole or with an Al/Mg antacid had no clinically significant effect on lumiracoxib single-dose plasma pharmacokinetics. Lumiracoxib can, therefore, be administered concurrently with either of these agents without need for lumiracoxib dosage alteration.

Adolescent↗
PubMed1992

Eosinophil cationic protein and phospholipase A2 activity in human gastric juice. With emphasis on Helicobacter pylori status and effects of antacids.

To elucidate possible new effects of antacids, gastric juice from 15 volunteers with known Helicobacter pylori status were analysed for eosinophil cationic protein (ECP), phospholipase A2 (PLA2) activity, phosphatidylcholine (PC), and bile acids (BA) before and after administration of one tablet of antacid or placebo in a double blind cross-over design. Geometric mean ECP concentrations were more than 13 times higher in gastric juice from H. pylori-positive (12.9 micrograms/l) than from H. pylori-negative (0.97 micrograms/l) subjects (p = 0.0032). Geometric mean PLA2 activity was 1.31 U/l for the negative subjects and 4.02 U/l for the positive subjects (p = 0.13). There were no differences between positive and negative subjects with regard to either PC or BA concentration. Regardless of H. pylori status, mean PC concentration increased significantly after antacids as compared with placebo (p = 0.024). The effect of antacids did not differ significantly from placebo for ECP, PLA2 activity, or BA concentration. Hence, antacids may not act by binding 'toxic' H. pylori-associated gastric juice components like ECP or PLA2. Increased concentration of PC may indicate an increased protective capacity induced by antacids.

Adult↗
PubMed1999

Clopidogrel bioavailability: absence of influence of food or antacids.

Two open, randomized, crossover bioavailability studies were carried out to assess the influence of concurrent antacid medication and food on the bioavailability of clopidogrel. A fed/fasting study was conducted in 12 elderly male subjects. Each subject took a single 75 mg dose of clopidogrel on two occasions-in the morning after an overnight fast, either during a standardized breakfast, or with breakfast delayed by 4 hours after dosing. A washout period of 7 days was observed between the two dosings. Twelve healthy male subjects participated in the antacid study. They fasted overnight and for 4 hours after dosing and took a single 75 mg dose of clopidogrel at 8:00 a.m. on two occasions separated by a washout period of 14 days. For one dose, Maalox 2 x 400 mg tablets were taken 1 hour before the clopidogrel dose. Pharmacokinetic parameters of SR26334, the main circulating metabolite of clopidogrel, were derived from plasma concentrations of the latter compound determined before and at regular intervals over 36 hours after dosing. For the fed/fasting study, mean Cmax values (+/-SD) were 2.7+/-0.62 mg/L and 2.1+/-0.96 mg/L for the fasting state and the fed state, respectively and the 90% CI of Cmax ratio was [0.57 - 0.97]. Mean AUC(0-obs) values (AUC to the last observed value) were 7.1+/-1.6 mg.h/L and 7.4+/-1.64 mg.h/L, respectively, and the 90% Cl of AUC ratios were [0.90 - 1.02] and [0.89 - 0.97], respectively. For the antacid study, mean Cmax values were 2.6+/-0.84 mg/L and 2.5+/-0.87 mg/L for the no-antacid regimen and the antacid regimen, respectively, and the 90% CI of Cmax ratio was [0.74 - 1.16]. Mean AUC(0-obs) values were 6.3+/-1.34 mg.h/L and 5.8+/-1.33 mg.h/L, respectively, and the 90% CI of AUC ratios was [0.89+/-0.97]. Thus, exposure to SR26334, and therefore net absorption of clopidogrel, was not significantly modified by food or by prior antacid ingestion.

Adolescent↗
PubMed1958

Effectiveness of antacids in reducing digestive disturbances in patients treated with prednisone and prednisolone.

To appraise the efficiency of complemental antacid administration in preventing and reducing digestive disturbances during prolonged treatment with prednisone and prednisolone, 100 patients with active rheumatoid arthritis who were maintained on combined antacid and prednisone or prednisolone therapy for periods of one year or longer, were studied clinically and roentgenographically. Antacid therapy consisted of 300 mg. of dried aluminum hydroxide gel and 50 mg. of magnesium trisilicate taken with each 2.5 mg. dose of the steroids. Digestive symptoms, such as indigestion, heartburn, sour eructations, gnawing epigastric distress and the like, were experienced by 18 per cent of patients during treatment with prednisone or prednisolone combined with antacids. Among patients who had been maintained on the steroids without antacids beforehand, the incidence of digestive complaints was reduced from 38 per cent to 17 per cent by the addition of alkali therapy, and the severity of the distress decreased in others. Active peptic ulcers were detected roentgenographically in three of the 100 patients. In two instances the ulcers were asymptomatic and in two instances they were considered as reactivations of previously healed lesions. The incidence of active ulcers in this series was substantially lower than that reported by several investigators among patients treated with prednisone and prednisolone without the concomitant administration of alkalis. The size of dosage and individual susceptibility appeared to be important factors in the development of digestive disturbances from steroids. Results of the study indicated that the complemental use of antacids with each divided dose of steroid is highly effective in reducing the frequency and severity of digestive symptoms during prednisone and prednisolone administration. The low incidence (3 per cent) for roentgenographically demonstrable active lesions in the series suggests that the addition of acid-neutralizing agents during prolonged treatment with these steroids may afford at least partial protection against the development and reactivation of peptic ulcers.

Aluminum Hydroxide↗
PubMed2006

Evaluation of the buffering capacity of powdered cow's, goat's and soy milk and non-prescription antacids in the treatment of non-ulcer dyspepsia.

BACKGROUND: Non-ulcer dyspepsia (NUD) is the term most commonly used to describe a heterogeneous and often ill-defined group of dyspepsia patients whose symptoms of upper abdominal pain, discomfort or nausea persist in the absence of identifiable cause. Treatment choice commonly includes over the counter medicines and home remedies, e.g. milk. OBJECTIVE: To determine the relative buffering capacity of goat's, cow's and soy milk, non-prescription antacid drugs and combinations thereof. METHODS: The buffering capacities of 25 ml aliquots of each of the powdered milk products, the antacids alone and the combination of antacid and milk were determined. Statistical analysis was used to determine any significant differences in buffering capacity. RESULTS: When the antacids were examined alone, significant differences in buffering capacity were observed. When powdered milk products were examined alone, cow's milk had a significantly higher buffering capacity than either goat's or soy milk. There was no significant difference between goat's and soy milk. In the combination of cow's milk with each of the antacids, brand A and B had a similar buffering capacity, significantly higher than that observed with brand C. CONCLUSIONS: The combination with best observed buffering capacity was brand A with cow's milk, and the weakest buffering capacity was observed with brand C with soy milk. The results obtained can be attributed to the chemical constituents of the antacids and the milk products.

Acid-Base Equilibrium↗
PubMed1991

The effect of food and antacids on lansoprazole absorption and disposition.

Bioavailability of lansoprazole, a new gastric proton pump inhibitor, was investigated in 12 healthy subjects. Each subject received in random order, lansoprazole (30 mg) alone or associated with standard meal or with antacids (aluminium and magnesium hydroxides) or one hour later than antacids. Lansoprazole and metabolite (sulfone (AG 1813), sulfide (AG 1777) and hydroxylated (AG 1908) metabolites) plasma concentrations were determined using a specific high pressure liquid chromatographic assay procedure, with a limit of detection of 2 ng/ml. The time to peak was significantly later with food (p less than 0.001) and its magnitude was significantly decreased (600 +/- 330 ng/ml vs 1151 +/- 344 ng/ml, p less than 0.001). The bioavailability of lansoprazole was significantly decreased by food, about 27%, (p less than 0.05) and slightly decreased by concomitant administration of antacids (NS), the effect was more pronounced in male subjects (p less than 0.05). Lansoprazole is presented as an enteric-coated granules, the concomitant administration of antacids, increasing the gastric pH, increased the absorption rate of lansoprazole. When antacids were administered one hour before lansoprazole, no effect was observed on lansoprazole bioavailability. This study showed that lansoprazole must be administered in fasting state and not simultaneously with antacids.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed1991

Elevated plasma aluminum levels in normal infants receiving antacids containing aluminum.

Aluminum toxicity is a documented cause of encephalopathy, anemia, and osteomalacia. Excretion is primarily renal; therefore, patients with renal insufficiency are at risk for aluminum accumulation and toxicity. This has been demonstrated in uremic children treated with aluminum-containing antacids. The purpose of this study was to determine whether plasma aluminum levels were elevated in infants with normal renal function during prolonged aluminum-containing antacid use. Ten study infants (mean age = 5.8 months), who had been receiving antacids for at least 1 week, were compared with 16 control infants (mean age = 9.8 months) not receiving antacids. The study patients consumed 123 +/- 16 mg/kg per day (mean +/- SEM) of elemental aluminum for an average of 4.7 weeks. Their plasma aluminum level (37.2 +/- 7.13 micrograms/L) was significantly greater than that of the control group (4.13 +/- 0.66 micrograms/L) (P less than .005). It is concluded that plasma aluminum levels may become elevated in infants with normal renal function who are consuming high doses of aluminum-containing antacids. The safety of antacids containing aluminum should not be assumed and they should be used judiciously in infants, with careful monitoring of the aluminum dose and plasma level.

Aluminum↗
PubMed1975

Pharmacology and clinical use of antacids.

The pharmacology of antacids, with particular reference to their clinical use in treating acid-peptic disease, is discussed. Liquid antacid suspension should be given at least as often as one hour after each meal and at bedtime. Inthe treatment of the acute phase of acid-peptic disease, hourly antacid is recommended. The dose should be planned in terms of milliequivalents of acid neutralizing capacity and should be adjusted according to the type of disease under treatment. All antacids have side effects, the most serious of which are metabolic. In clinical terms, the harmful sustemicside effects of calcium carbonate and sodium bicarbonate outweigh their benefit as neutralizing agents; they should rarely be employed in the treatment of acid-peptic disease. The more common antacid side effects of diarrhea (magnesium hydroxide) and constipation (aluminum hydroxide) are best managed by appropriately alternating the agents or by using one of the various antacid mixtures.

Antacids↗
PubMed1988

Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid.

Intestinal folic acid transport is a saturable process with a pH optimum of 5.5 to 6.0. Because of the possible effects of antacids and acid-lowering drugs on the pH of the proximal small intestine, the influence of these drugs on folic acid absorption was studied by using tritium-labeled pteroylmonoglutamic acid (PGA) in 30 subjects (21 women, nine men) of 56 to 89 years of age. Both cimetidine and an antacid containing aluminum and magnesium hydroxide reduced folate absorption from a liquid formula meal (p less than 0.01, p less than 0.001, respectively). Although ranitidine also caused a fall in folic acid absorption from the liquid meal, the change was not statistically significantly different from when PGA was given with the meal alone. Both histamine receptor antagonists tended to maintain a high intraluminal pH in the proximal small intestine after meals, which in part could explain the inhibition of folate absorption. However, neither drug was found to chemically interact with folic acid, and neither drug inhibited the dihydrofolate reductase. The antacid was found to precipitate folic acid at a pH of greater than 4.0, thus removing it from the aqueous phase. This appears to be the explanation for the lowered folate absorption in the presence of antacid. Although the effects of these drugs on reducing folic acid absorption were relatively small, such reductions could become clinically significant in chronic antacid or H2 receptor antagonist use or intensive antacid or H2 receptor antagonist use by individuals eating diets that are marginal in folate content.

Aged↗
PubMed1989

Activated aluminum complex derived from solubilized antacids exhibits enhanced cytoprotective activity in the rat.

Removing the buffering capacity of aluminum-containing antacids by acidification greatly increased their cytoprotective activity over the parent antacid. Commercially available antacids were acidified with 6 N HCl. Peak mucosal protective activity occurred at pH 2.5, and declined at lower pH. At pH 2.5, the antacid suspensions became solubilized and no acid-neutralizing capacity remained. This solution was named activated aluminum complex. Based on aluminum ion content, each aluminum-containing antacid suspension tested demonstrated a comparable increase in potency on acidification against ethanol-induced lesions. HCl (pH 2.5) was inactive against ethanol-induced lesions. At cytoprotective doses, activated aluminum complex did not cause gastric lesions when orally administered by itself, demonstrating that it is not acting as a local mucosal irritant. The data suggest that solubilization of aluminum-containing antacids in acidic medium enhances their mucosal protective activity, probably by releasing an activated species of aluminum ion reported to be a hexaaquoaluminum cation.

Aluminum↗
PubMed1979

[Therapy with antacids].

The usefulness of antacids in peptic ulcer disease is based on their ability to neutralize secreted gastric acid and to inhibit pepsin activity. The neutralizing capacity (expressed as mval of neutralized hydrochloric acid at a given pH) of different antacids depends upon their chemical composition. To achieve adequate neutralization of stimulated gastric acid secretion antacids have to be taken one and three hours after a meal in a dosage neutralizing 40-80 mval of acid. So far antacids have not been shown to be more effective in relieving ulcer symptoms than placebo. On the contrary an adequate antacid regimen will promote the healing of both gastric and duodenal ulcers in outpatients. Furthermore antacid prophylaxis will reduce the occurrence of acute gastrointestinal bleeding in critically ill patients.

Aluminum Hydroxide↗
PubMed1986

Antacid and formula effects on gastric acidity in infants with gastroesophageal reflux.

A variety of peptic diseases are treated with antacids. Antacid dose requirements for young children have not been extensively evaluated. Moreover, the effects of formula feedings on antacid requirements are also unknown. We have investigated the effects of antacids and formula feedings on gastric acidity in infants less than 1 year of age. Small formula feedings of 15 mL/kg per feeding significantly improve antacid buffering of 0.5 mL/kg per dose of standard magnesium-aluminum hydroxide antacids.

Aluminum Hydroxide↗
PubMed1979

Cimetidine versus antacid in scleroderma with reflux esophagitis. A randomized double-blind controlled study.

The effectiveness of cimetidine vs. antacid in the treatment of patients with scleroderma and symptomatic reflux esophagitis was studied in a double-blind cross-over controlled trial. Fifteen patients were initially randomized to either cimetidine (300 mg four times daily) with placebo antacid, or placebo tablet (1 four times daily) with Mylanta II (30 ml four times daily and PRN). After 8 wk of therapy on the initial regimen, each patient was crossed over to the alternate regimen for an additional 8 wk of therapy. The severity of symptoms during each treatment period was estimated by patient interviews and changes in esophagitis were evaluated endoscopically. Cimetidine gave significantly greater relief of heartburn than antacid regardless of the initial randomization. Cimetidine also resulted in significant endoscopic improvement of the esophageal mucosa whereas antacid was without effect. Neither cimetidine nor antacid produced any improvement in esophageal stricture size or lower esophageal sphincter pressure. Cimetidine was without toxicity whereas antacid therapy frequently produced diarrhea.

Adult↗
PubMed1985

Controlled clinical assessment of the efficacy and tolerance of triletide versus antacids in patients with gastric and duodenal ulcers.

A study was carried out in 30 out-patients with endoscopically confirmed active, benign gastric or duodenal ulceration to assess the comparative effectiveness and tolerance of treatment with triletide, a new synthetic tripeptide with anti-ulcer properties, with that of conventional antacids. Patients were allocated at random to receive treatment with either 1.6 g aluminium hydroxide and 1.6 g magnesium hydroxide per day or the antacids plus 1.5 g triletide per day over a period of 8 weeks. Heartburn and epigastric pain, monitored every other week, were significantly relieved by both treatments, but to a significantly greater extent (70% vs 20% on average, p less than 0.01) and significantly faster (p less than 0.01) in the presence of triletide. Endoscopic control showed that the patients who had triletide experienced complete healing in a significantly greater proportion (73% vs 27%, p less than 0.02) than those who had antacids only. The efficacy of treatments was the same, regardless of the actual ulcer location. Routine haematology and haematochemistry findings were unaffected by either treatment, and subjective possible side-reactions were limited to constipation (9 complaints overall) which is a well-known side-effect of antacid treatment. It would appear, therefore, that triletide is at least as well tolerated as antacids, while promoting the healing of peptic ulcers in a significantly greater proportion of patients and easing symptoms significantly faster and to a greater extent than antacids alone, regardless of the ulcer location.

Adult↗