Validation of the 3-day rule for stool bacterial tests in Japan.

OBJECTIVE: Stool cultures are expensive and time consuming, and the positive rate of enteric pathogens in cases of nosocomial diarrhea is low. The 3-day rule, whereby clinicians order a Clostridium difficile (CD) toxin test rather than a stool culture for inpatients developing diarrhea >3 days after admission, has been well studied in Western countries. The present study sought to validate the 3-day rule in an acute care hospital setting in Japan. METHODS: Stool bacterial and CD toxin test results for adult patients hospitalized in an acute care hospital in 2008 were retrospectively analyzed. Specimens collected after an initial positive test were excluded. The positive rate and cost-effectiveness of the tests were compared among three patient groups. PATIENTS: The adult patients were divided into three groups for comparison: outpatients, patients hospitalized for ≤3 days and patients hospitalized for ≥4 days. RESULTS: Over the 12-month period, 1,597 stool cultures were obtained from 992 patients, and 880 CD toxin tests were performed in 529 patients. In the outpatient, inpatient ≤3 days and inpatient ≥4 days groups, the rate of positive stool cultures was 14.2%, 3.6% and 1.3% and that of positive CD toxin tests was 1.9%, 7.1% and 8.5%, respectively. The medical costs required to obtain one positive result were 9,181, 36,075 and 103,600 JPY and 43,200, 11,333 and 9,410 JPY, respectively. CONCLUSION: The 3-day rule was validated for the first time in a setting other than a Western country. Our results revealed that the "3-day rule" is also useful and cost-effective in Japan.

[Primary adenosquamous carcinoma of the liver presenting with hematochezia due to tumor invasion of the colon].

A 69-year-old female was referred to our hospital with hematochezia. Dynamic computed tomography demonstrated a large tumor with rim enhancement and central necrosis that invaded into the transverse colon. The tumor was resected, and histopathological examination revealed mixed adenocarcinoma and squamous cell carcinoma with partial abscess formation. On the basis of a literature review and the findings from the present case, rim enhancement with central necrosis on imaging appears to be characteristic of this disease.

[S-1-based chemotherapy for unresectable advanced gastric cancer of the elderly or patients with renal dysfunction].

OBJECTIVE: S-1 based therapy is a valued standard chemotherapy regimen for unresectable gastric cancer in Japan. S-1/ CDDP therapy has been highly effective, especially for patients under 75 years old who have good organ function. However, it is the elderly and/or patients with renal dysfunction who make up the majority of the candidates for chemotherapy in general hospitals. These factors make it difficult to apply the results of RCTs to chemotherapy regimens. AIM AND METHODS: To investigate clinical outcomes, the medical records of patients who had received S-1 based chemotherapy for gastric cancer at our hospital from January 2002 to September 2009 were retrospectively reviewed. RESULTS: A total of 78 patients were evaluated for analyses. Among the patients, 23(29%)were the elderly, 8(10%)had renal dysfunction, and 27(35%)were either the elderly or those who had renal dysfunction. S-1/CDDP therapy was provided for 63% of the patients. Regarding the outcomes from therapy, RR was 44%, mPFS was 5. 4 months, and MST was 10. 6 months. Regarding survival benefit for OS, the elderly, the intestinal type, and therapy with S-1 alone were considered to be good factors in multi-variant analysis, but no significant differences were confirmed. CONCLUSION: In general practice, the elderly and/or patients with renal dysfunction account for 35%, and S-1-based chemotherapy has been proven to be very effective. However, additional effects of CDDP were not shown in this study.

[The usefulness and limitations of the new Japanese criteria for severity assessment in acute pancreatitis].

New Japanese criteria for severity assessment in acute pancreatitis were introduced in October 2008. The new criteria are simpler than the previous ones, and are also expected to be more useful for the severity assessment. We retrospectively analyzed the clinical factors in our patients to predict prognosis, and evaluated the usefulness and limitations of the new criteria. There were few missing data in the new criteria compared with the previous criteria. The areas under the receiver operating characteristic (ROC) curves for mortality prediction were 0.870 for the new criteria and 0.884 for the previous criteria. However, there were more patients whose disease severity on admission were underestimated using the new criteria and who finally progressed to worse stages including death. This evidence strongly suggests the lower sensitivity of the new criteria in mortality prediction. Repeated assessment of severity after admission will be indispensable in the proper treatment of patients with acute pancreatitis.

[A case of HIV coinfected with hepatitis B virus treated by entecavir].

A 45-year-old male active homosexual was given a diagnosis of HIV-1 and acute hepatitis B in August 2007. Since his liver function became rapidly impaired, anti-HBV therapy with oral administration of entecavir (ETV) was started, and resulted in a favorable outcome. However, serum concentration of HIV-RNA decreased by log 1.26 within 60 days, which strongly suggested the inhibition of HIV proliferation by ETV. To prevent the appearance of mutated HIV, novel therapeutic strategies should be established in HIV/HBV-coinfected patients.