Severe chronic active hepatitis induced by UFTR containing tegafur and uracil

Summary A 77-year-old female patient developed severe hepatic injury after the administration of UFT^R, which contains tegafur and uracil, for postoperative chemotherapy of colon cancer. Liver damage was recognized 10 months after its administration. Serum markers for viral hepatitis and various autoantibodies were negative. The wedged biopsied liver specimen revealed advanced chronic active hepatitis with periportal confluent necrosis, marked intralobular spotty necrosis, and significant proliferation of pseudo-bile ductules. Although the cessation of the drug and conservative therapies improved hepatic function, an accidental readministration of UFT^R caused her severe hepatic damage again. These findings suggest that liver injury in the present case was caused by UFT^R. Histological findings were unique. Although tegafur is known to worsen hepatic function when given to patients with liver cirrhosis, UFT^R may also cause severe hepatic injury in those without preexisting liver disease.     

Changes in the isolated delayed component as an endpoint of catheter ablation in arrhythmogenic right ventricular cardiomyopathy: predictor for long-term success

Introduction: Although successful ablation of ventricular tachycardia (VT) is feasible in arrhythmogenic right ventricular cardiomyopathy (ARVC), long-term recurrence is common. The aim of this study was to assess the usefulness of a change in the isolated delayed component (IDC) as an endpoint of the catheter ablation in ARVC.
Methods and Results: Eighteen patients (48 ± 11 years) with ARVC were studied. Detailed endocardial mapping of the right ventricle (RV) was performed during sinus rhythm. IDCs were recorded in 16 patients and the latest IDCs were related to the VT circuit. Catheter ablation was carried out in the areas with the IDCs. At the end of the session, the IDC was electrically dissociated in one, disappeared in five, exhibited second-degree block in one, was significantly delayed (≥50 ms) in three, and remained unchanged in six. The change in the IDC was correlated with the change in the type II/III late potentials in the signal-averaged electrocardiography (ECG) and the inducibility of the clinical VT after the ablation. During a follow-up of 61 ± 38 months, VT recurred in six. The patients with a changed IDC had a significantly lower VT recurrence than those with no IDC or an unchanged IDC (P < 0.02).
Conclusion: In patients with ARVC, (1) the IDCs during sinus rhythm are related to the clinical VT and can be a target for the ablation, (2) a change in the IDC can be used as an endpoint, and (3) qualitative analyses of the serial signal-averaged ECGs may be useful for the long-term follow-up.     

Idiopathic ventricular arrhythmias arising from the pulmonary artery: Prevalence, characteristics, and topography of the arrhythmia origin

BACKGROUND: The characteristics of idiopathic ventricular tachycardias (VTs) or idiopathic premature ventricular contractions (PVCs) arising from the pulmonary artery (PA) have not been sufficiently clarified. OBJECTIVE: The purpose of this study was to clarify the prevalence, characteristics, and preferential sites of idiopathic VT/PVCs arising from the PA (PA-VT/PVCs). METHODS: Data obtained from 276 patients with idiopathic VT/PVCs who underwent radiofrequency (RF) catheter ablation were analyzed. RESULTS: Twelve VT/PVCs (4%) were PA-VT/PVCs, and their onset (34 +/- 14 years) was the youngest among all subgroups. Because those QRS morphologies were similar to VT/PVCs arising from the right ventricular outflow tract (RVOT-VT/PVC) and the earliest ventricular activation was from the RVOT, an initial ablation was performed in the RVOT in all patients. However, RF catheter ablation at the RVOT resulted in a QRS morphology change in all patients, so thereafter PA mapping and ablation was performed. A characteristic potential during sinus rhythm and/or the arrhythmia was recorded at the successful PA ablation site in all patients. A perfect or good pace map was obtained in 7 (70%) of 10 patients. The successful ablation site was the septal side of the PA close to the posterolateral attachment in 9 patients (75%) and the septal side close to the anterior attachment in the remaining 3 (25%). No PA-VT/PVCs recurred during follow-up of 27 +/- 13 months. CONCLUSION: PA-VT/PVCs should always be considered when the ECG suggests RVOT-VT/PVCs and RF catheter ablation in the RVOT results in both a failed ablation and a change in QRS morphology. PA-VT/PVCs often originate from the septal side of the PA.     

Management of hepatitis B: Consensus of the Japan Society of Hepatology 2009

Recently, much progress has been made in the field of hepatitis B, such as natural history of the disease in relation to the amount of hepatitis B virus (HBV) DNA, genotypes of HBV influencing the natural course and treatment effects, mutations of HBV influencing the severity of the disease and development of hepatocellular carcinoma, and antiviral treatment such as nucleos(t)ide analogues and pegylated interferon. To make the consensus for the diagnosis, management and treatment of hepatitis B, a meeting was held during 45th annual meeting of Japan Society of Hepatology (JSH) in June 2009. In the meeting, recommendations and informative statements were discussed on the following subjects: (i) natural history of HBV infection; (ii) clinical implication of HBV genotypes; (iii) HBV mutations and their potential impact on pathogenesis of HBV infection; (iv) indications for antiviral treatment of chronic hepatitis B; (v) nucleos(t)ide analogues for chronic hepatitis B; and (vi) interferon therapy for chronic hepatitis B. The presenters reviewed the data on these subjects and proposed the consensus statements and recommendations. These statements were discussed among the organizers and presenters, and were approved by the participants of the meeting. In the current report, the relevant data were reviewed and the 12 consensus statements and nine recommendations on chronic hepatitis B were described.     

Effect of cardiac resynchronization therapy in isolated ventricular noncompaction in adults: follow-up of four cases

Background: An isolated ventricular noncompaction (IVNC) is an unclassified cardiomyopathy and, despite the increasing awareness of and interest in this disorder, the role of cardiac resynchronization therapy (CRT) remains obscure. Objective: The purpose of this study was to clarify the long‐term effect of CRT on IVNC in adult patients. Methods: Four cases of IVNC were included in this study. Before the CRT device was implanted, all four patients (54 ± 16‐year‐old, 4 males) presented with symptomatic congestive heart failure. Echocardiography revealed their systolic dysfunction and their left ventricular ejection fraction (LVEF) was 21 ± 8%. There was also mechanical dyssynchrony observed between the LV septum and free wall area. The QRS duration was “narrow” (112 and 120 ms) in two patients. One patient had been resuscitated from ventricular fibrillation (VF) and two had nonsustained ventricular tachycardia (VT). A CRT defibrillator (CRT‐D) was implanted in three patients with VT/VF and a CRT pacemaker (CRT‐P) in a patient without VT/VF. The LV lead was positioned in a lateral branch of the coronary sinus where a thickened noncompacted wall existed. Results: During the follow‐up period (28 ± 23 months), their congestive heart failure had improved in terms of the cardiothoracic ratio on the chest X‐ray, B‐type natriuretic peptide level, LV systolic dimension, and LVEF. No episodes of defibrillation shocks were observed. Conclusion: CRT may improve the prognosis and quality‐of‐life in patients with an IVNC with mechanical dyssynchrony.     

Gallbladder carcinoma presenting as exfoliative dermatitis (erythroderma)

Although exfoliative dermatitis (erythroderma) secondary to malignancy is commonly associated with lymphomas or leukemias, coincident gastrointestinal (GI) malignancy and erythroderma is rare. The authors recently encountered a patient with gallbladder carcinoma presenting as erythroderma. A 77-yr-old Japanese man presented with a 3-mo history of erythematous eruptions with pruritus over almost the entire body. After confirming the diagnosis of erythroderma, asymptomatic gallbladder carcinoma was found. Further investigations detected no malignancies in other organs. An extended cholecystectomy was performed. Histologic examination of resected specimens revealed poorly differentiated adenocarcinoma with negative resection margins. The eruptions with pruritus resolved within 1 wk after the operation. This is the first report, to our knowledge, of coincident biliary malignancy and erythroderma. The experience of the current patient suggests that erythroderma secondary to GI malignancy may resolve spontaneously after curative resection of the tumor.     

Noninvasive estimation of fibrosis progression overtime using the FIB‐4 index in chronic hepatitis C

Summary. The FIB‐4 index is a simple formula to predict liver fibrosis based on the standard biochemical values (AST, ALT and platelet count) and age. We here investigated the utility of the index for noninvasive prediction of progression in liver fibrosis. The time‐course alteration in the liver fibrosis stage between paired liver biopsies and the FIB‐4 index was examined in 314 patients with chronic hepatitis C. The average interval between liver biopsies was 4.9 years. The cases that showed a time‐course improvement in the fibrosis stage exhibited a decrease in the FIB‐4 index, and those that showed deterioration in the fibrosis stage exhibited an increase in the FIB‐4 index with a significant correlation (P < 0.001). Increase in the ΔFIB‐4 index per year was an independent predictive factor for the progression in liver fibrosis with an odds ratio of 3.90 (P = 0.03). The area under the receiver operating characteristic curve of the ΔFIB‐4 index/year for the prediction of advancement to cirrhosis was 0.910. Using a cut‐off value of the ΔFIB‐4 index/year <0.4 or ≥0.4, the cumulative incidence of fibrosis progression to cirrhosis at 5 and 10 years was 34% and 59%, respectively in patients with the ΔFIB‐4 index/year ≥0.4, whereas it was 0% and 3% in those with the ΔFIB‐4 index/year <0.4 (P < 0.001). In conclusion, measurement of the time‐course changes in the FIB‐4 index is useful for the noninvasive and real‐time estimation of the progression in liver fibrosis.