Treatment of dermatophyte onychomycosis with three pulses of terbinafine (500 mg day for a week).

We assessed the safety and efficacy of pulse therapy with terbinafine tablets in 55 patients with dermatophytic onychomycosis. One pulse consisted of oral terbinafine tablets (500 mg day(-1)) given for 1 week usually followed by a 3-week interval. This regimen was repeated twice. Topical 1% terbinafine cream was applied daily. Efficacy was assessed based on both clinical and mycological examinations 1 year after treatment initiation. We observed a complete cure in 41 patients (74.5%), marked improved in three patients (5.6%), slight improvement in three patients (5.6%) and drop out in six patients (10.7%). Two patients (3.6%) discontinued terbinafine because of gastrointestinal disturbance (one patient) and drug-induced eruption (one patient). No patient had abnormal laboratory findings, including liver function tests. In summary, a regimen of three pulses of terbinafine therapy given daily for 1 week in combination with topical application of terbinafine cream appears to be safe and effective in treating dermatophytic onychomycosis and offers advantages in convenience and cost-effectiveness compared with continuous dosing.

[Present diagnostic status of scirrhous type gastric cancer--with special reference to the endoscopic diagnosis].

First, we presented an actual diagnostic situation in nowadays for gastric cancer of Borrmann 4, which is virtually the same as scirrhous gastric cancer. Among 12 patients treated by the author, all of whom were discovered late, only 3 underwent surgery. In fact, with inoperable cases in Borrmann 4, even those endoscopically found to show insufficient stretching of the gastric wall, thickening and tortuosity of folds, uneven gastric mucosa, redness and white coating, there may be negative in gastric biopsy. However, the significance of an endoscopic examination for diagnosis of scirrhous cancer is in obtaining proof of the carcinoma (especially when still operable) by gastric biopsy. Thus, one must strive not to overlook slight redness, white coating which means small erosions, but to go over gastric biopsy again and again. Next, with carcinoma presenting a leather bottle (linitis plastica type) of the stomach itself, the II c portion of the stomach consisted of fundic glands (undifferentiated carcinoma) shall become the primary focus supporting Nakamura's theory. One case of diffuse invasive cancer, mistakenly diagnosed as a II c case, and two cases of regional type, one similar to II c and the other a Borrmann 2 carcinoma of advanced carcinoma showing strongly fibrous scirrhous tendency toward infiltration, were jointly monitored.

[A case of repetitive monomorphic ventricular tachycardia].

We present a case treated with aprindine and metoprolol combined with a DDD type pacemaker for repetitive monomorphic ventricular tachycardia. A 50-year-old man was admitted because of palpitation and near syncope attack. Electrocardiogram showed repetitive monomorphic ventricular tachycardias (RBBB LAD type) and R-R interval of about 440 msec and I degree A-V block in sinus rhythm. Electrophysiologic study disclosed that overdrive pacing in HRA suppressed ventricular tachycardias. Left ventriculography revealed a dilated left ventricular and decreased contractility. Antiarrhythmic agents such as quinidine sulfate, procainamide, disopyramide, mexiletine, lidocaine and propranolol were not effective. But, the combination of propranolol and aprindine decreased the rate of the ventricular tachycardia. With aprindine 60 mg/day and metoprolol 60 mg/day combined with the atrioventricular sequential pacing at 85/min, ventricular tachycardia completely disappeared.

Circulating cell-free DNA as a predictive marker for distant metastasis of hepatitis C virus-related hepatocellular carcinoma.

In a previous study, we showed that levels of cell-free DNA (cfDNA) were significantly higher in sera of patients with hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) than in sera of non-HCC patients with HCV. To confirm this finding, we analysed serum cfDNA levels in a cohort of 96 patients with HCV-related HCC and in 100 HCV carriers without known HCC. Again we found that serum cfDNA levels were significantly higher in HCC patients than in HCV carriers (115.9+/-98.3 vs 34.4+/-40.4 ng ml(-1) (mean+/-s.d.), P<0.0001). Of 87 eligible patients who underwent curative hepatectomy, those with a high cfDNA level had a significantly shorter overall survival (OS) time than those in whom the cfDNA level was not high. Cox proportional hazards model showed the cfDNA level to be an independent prognostic factor for OS and cancer recurrence in distant organs. Our results suggest that the serum cfDNA level reflects the metastatic potential of HCV-related HCC and that it can be a useful predictive biomarker for distant metastasis after curative surgery.

Effects of four antiarrhythmic drugs on the induction and termination of paroxysmal supraventricular tachycardia.

The electrophysiological effects of antiarrhythmic drugs were tested in 36 patients with recurrent paroxysmal supraventricular tachycardia (PSVT), 25 of whom had accessory pathway reentrant tachycardia (APRT) and 11 A-V nodal reentrant tachycardia (AVNRT; 10 of the slow-fast type one of the fast-slow type). The test drugs were procainamide (used in 19 patients), verapamil (in 27), disopyramide (in 31), and propranolol (in 15). The drugs were tested for their ability to terminate episodes of PSVT as well as to inhibit their induction. Procainamide had an inhibitory effect on APRT in nine of 12 patients (75%) and terminated episodes of APRT in seven of 11 patients (63.6%); in all of them V-A block was responsible for the termination. In four of six patients (66.7%) with slow-fast AVNRT and in one patient with fast-slow AVNRT, inhibition of the induction of tachycardia attacks was noted after procainamide. Termination of AVNRT was seen in the same number of patients. Verapamil inhibited the induction of APRT in 12 of 18 patients (66.7%) and terminated episodes of APRT in 10 of 16 patients (62.5%), all by A-V block. In six of eight patients (75%) with slow-fast AVNRT, inhibition of the induction as well as termination of tachycardia were noted after verapamil. Disopyramide had an inhibitory effect on APRT in seven of 23 patients (30.4%) and terminated APRT in five of 21 patients (23.8%) by V-A block, while AVNRT (all slow-fast type) was terminated in only one of eight patients (12.5%) by disopyramide. Disopyramide was less effective than previously reported. This could be attributed to a relatively low dosage and slow infusion speed. Propranolol inhibited the induction of APRT and terminated episodes of APRT in only one of 10 patients (10%). In two of four patients (50%) with slow-fast AVNRT, an inhibitory effect by propranolol was noted, but termination was seen in only one patients.

Study on the genesis of the double potential recorded in the high right atrium in atrial flutter and its role in the reentry circuit of atrial flutter.

To investigate the genesis of the double potential (DP), which is two separate waves, and its role in the reentry circuit of atrial flutter (AF), we performed overdrive pacing (ODP) from the high right atrium (HRA) in six cases of spontaneous AF in which the DP was recorded in the HRA. In four of the six cases, when the DP was arbitrarily designated D1 and D2, D1 and D2 showed progressive fusion during ODP. In addition, the D1 return cycle, immediately after the termination of ODP, corresponded to the AF cycle, and the D2 return cycle corresponded to the pacing cycle. This may indicate that the DP is caused by the collision of two directional waves. Furthermore, it is suggested that the HRA plays an important role in preventing a possible shortcutting of reentry waves and in stabilizing the reentry circuit of AF.

AV nodal reentrant tachycardia with Mahaim fiber conduction.

Paroxysmal tachycardia with widened QRS complexes was found in a 46-year-old woman. In sinus rhythm, the patient had electrocardiographic evidence of type B preexcitation with a left bundle branch block pattern. The resting PR interval (160 msec) and A-H interval (100 msec) were within normal limits, but the H-V interval (10 msec) was abnormally short. Programmed atrial extrastimuli at progressively shorter coupling intervals resulted in sudden prolongation of the A-H interval from 120 msec to 250 msec, and the His bundle activities became incorporated just after initiation of the QRS complexes. The QRS morphology was changed but the change was minimal, and atrial echo beats or sustained tachycardia with wide and preexcited QRS complexes were elicited. It is postulated that the site of reentry is within the AV node with preexcitation occurring as the result of conduction in an anomalous nodoventricular pathway.

Shift of atrial reentrant tachycardia with transient entrainment to an uncommon and a common type of atrial flutter.

Atrial reentrant tachycardia (ART) which demonstrated transient entrainment shifted to an uncommon type of atrial flutter (AF) with premature atrial stimulation, and then returned to ART spontaneously. Subsequently, this ART shifted to a common type of AF by rapid atrial pacing, which was further transformed into an uncommon type of AF and finally terminated by rapid atrial pacing. The mechanism of AF in clinical cases is still controversial, but in this case, AF, both uncommon and common types, is considered due to macro-reentry within the atria. To explain the shift of ART to AF and mutual transformation between common and uncommon type of AF, we made a schematic figure of reentry loop within the atria of ART and AF.