A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function (ejection fraction : 27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.

Introduction: Tramadol (TRM) has been included as a weak opioid at the second step of the WHO analgesic ladder and has been widely used in palliative medicine. Here we report a case of amelioration of cancer pain by TRM therapy in a female patient with myasthenia gravis (MG). Case:The patient was a 70’s woman who was diagnosed with advanced endometrial carcinoma and suffered from chest pain caused by chest metastasis. 25 mg of a TRM capsule was orally administered three times a day. The dose was increased to 50 mg twice a day. It was resulted in sound pain relief with transient muscle weakness but without a myasthenic crisis.

BACKGROUND/AIMS: Despite improvements in endoscopic hemostasis and pharmacological therapies, upper gastrointestinal (UGI) ulcers repeatedly bleed in 10% to 20% of patients, and those without early endoscopic reintervention or definitive surgery might be at a high risk for mortality. This study aimed to identify the risk factors for intractability to initial endoscopic hemostasis. METHODS: We analyzed intractability among 428 patients who underwent emergency endoscopy for bleeding UGI ulcers within 24 hours of arrival at the hospital. RESULTS: Durable hemostasis was achieved in 354 patients by using initial endoscopic procedures. Sixty-nine patients with Forrest types Ia, Ib, IIa, and IIb at the second-look endoscopy were considered intractable to the initial endoscopic hemostasis. Multivariate analysis indicated that age > or =70 years (odds ratio [OR], 2.06; 95% confidence interval [CI], 1.07 to 4.03), shock on admission (OR, 5.26; 95% CI, 2.43 to 11.6), hemoglobin <8.0 mg/dL (OR, 2.80; 95% CI, 1.39 to 5.91), serum albumin <3.3 g/dL (OR, 2.23; 95% CI, 1.07 to 4.89), exposed vessels with a diameter of > or =2 mm on the bottom of ulcers (OR, 4.38; 95% CI, 1.25 to 7.01), and Forrest type Ia and Ib (OR, 2.21; 95% CI, 1.33 to 3.00) predicted intractable endoscopic hemostasis. CONCLUSIONS: Various factors contribute to intractable endoscopic hemostasis. Careful observation after endoscopic hemostasis is important for patients at a high risk for incomplete hemostasis.
Asian Continental Ancestry Group* ; Emergencies ; Endoscopy ; Hematemesis ; Hemorrhage* ; Hemostasis ; Hemostasis, Endoscopic* ; Humans ; Melena ; Mortality ; Multivariate Analysis ; Peptic Ulcer* ; Risk Factors ; Serum Albumin ; Shock ; Ulcer

Lenvatinib hasapplicationsin thyroid and hepatocellular carcinomas. When lenvatinib wasapproved for hepatocellular carcinoma in Japan, the manufacturer noted an increase of 5% in the incidence of side effects than those observed in thyroid cancer, based on the clinical-trial data. The monitoring of side effectsisimportant during chemotherapy. It isdifficult to confirm all the side effects within a single practice, and it is important to consider the incidence and severity of side effects before prescribing a particular treatment regimen. An antineoplastic agent is often used for different diseases, and it may be difficult to confirm a specific side effect. Because clinical conditions vary among different diseases, it is likely that the onset of side effects also differs. We investigated the difference between the onset of side effects in thyroid and hepatocellular carcinomas using the Japanese Adverse Drug Event Report database. The main side effects reported for thyroid cancer included bleeding, hypertension, cardiac disorders, myelosuppression,acute cholecystitis, delayed wound healing, infection, gastrointestinal perforation, fistula formation, and pneumothorax. In addition,patients with hepatocellular carcinoma experienced liver damage and hepatic encephalopathy. A significant strong correlation was observed between the drug dose and number of reports of the varied side effects. We compared the side effects in patients with thyroid cancer to those with hepatocellular carcinoma; although the same drug was used, there was varied expression of the side effects. Thisneedsto be taken into account when determining which drugsare to be used for the treatment of a particular cancer type.

The patient was a 68-year-old woman who was diagnosed with stage IIIA cervical cancer and pyometra. Concurrent chemoradiotherapy was planned. She was admitted to our hospital 3 weeks after the initial examination due to vaginal bleeding and worsening of lower abdominal pain. On hospital day 5, she developed a fever, and free gas in the peritoneal cavity and ascites were confirmed by contrast-enhanced computed tomography. Emergency surgery was performed for suspected generalized peritonitis attributed to perforation in the digestive tract or uterus. A large amount of purulent ascites and 2 perforations in the anterior wall of the uterus, but none in the digestive tract, were observed. Peritoneal lavage and drainage were performed, and a colostomy was created. The patient was managed in the intensive care unit until postoperative day 13 due to septic shock and acute renal failure. After the peritonitis resolved, radiation therapy alone was provided, and then chemotherapy was started to treat residual lesions. Pyometra recurred, and transvaginal drainage was performed to prevent perforation of the uterus. However, a few days later, a colouterine fistula and an enterocutaneous fistula developed simultaneously, and her general condition worsened. In advanced cervical cancer complicated by pyometra, various complications can develop that are difficult to manage (e.g., uterine perforation and fistula formation due to radiation enteritis and dermatitis). 　This case demonstrates the importance of uterine drainage at appropriate timing, which can contribute to improved prognosis.