BACKGROUND:Recent advances in cancer treatment and improvements in prognosis have led to increasing recognition of the critical role of shared decision-making (SDM) between patients and healthcare providers in determining treatment strategies. SDM requires not only information on surgery-related outcomes and health-related quality of life, but also consideration of patient-specific factors such as the social background. However, determinants of surgical choice among Japanese patients remain unclear, and this study aimed to identify the influencing factors. METHODS:This multicenter, cross-sectional study evaluated patient-reported outcomes in 577 Japanese patients who underwent mastectomy (MT), breast-conserving surgery (BCS), or immediate breast reconstruction (IBR). Participants completed questionnaires to assess the factors influencing surgical decision-making, including sociodemographic, psychosocial, and healthcare provider-related factors. Clinical data were obtained from the medical records, and multivariate analyses were conducted to identify the factors associated with the selection of surgical procedures. RESULTS:The most frequently cited factor was the surgeon's opinion (92.2%), followed by fear of recurrence (43.8%) and partner's opinion (35.5%). Partner's opinion was significantly more influential in BCS and IBR selection than in MT selection (P = 0.012), whereas concern about recurrence was the main factor influencing MT selection (P = 0.002). Multivariate analysis suggested the nurse's opinion was significantly associated with IBR, while concern about recurrence was inversely related. CONCLUSIONS:Considering that the factors influencing decision-making vary by surgical procedure, it is essential to tailor surgical choices to each patient's values and lifestyle. Strengthening decision-support systems by involving the entire healthcare team will be an important priority moving forward.
AIM:The relationship between oral health and gut microbiota diversity remains unclear, especially in vulnerable populations. We aimed to explore the association between oral health status and gut microbiota diversity in older inpatients recovering from stroke. METHODS:This cross-sectional study was conducted in a convalescent rehabilitation ward. Participants were older post-stroke inpatients. Oral health was assessed using the Revised Oral Assessment Guide (ROAG), with scores ≥ 9 indicating oral problems. Gut microbiota diversity was analyzed by 16S rRNA gene sequencing of fecal samples, and measured using the Shannon index (prespecified primary outcome), richness (observed features/OTUs), and Faith's phylogenetic diversity (PD). Multivariable linear regression analysis was performed to examine the association between ROAG scores and diversity indices, adjusting for potential confounders. RESULTS:Participants were 156 older patients after stroke (mean age 78.6 years). Oral problems were present in 121 patients (77.6%). After adjusting for confounders including age, sex, stroke type, comorbidities, and nutritional intake, the total ROAG score was associated with the Shannon index (B = -0.044, 95% CI: -0.082 to -0.005). In exploratory analyses, no clear associations were found between ROAG scores and richness (B = -3.774, 95% CI: -7.844 to 0.296) or Faith's PD (B = -0.087, 95% CI: -0.451 to 0.277). CONCLUSION:In this registry-based cross-sectional study, poorer oral health (higher ROAG score) was associated with lower gut microbiota α-diversity (Shannon index). Given multiple outcomes and no preregistered analysis plan, these findings are exploratory/hypothesis-generating and require confirmation in independent cohorts and longitudinal studies.
Neoadjuvant chemotherapy (NAC) for breast cancer (BC) facilitates minimally invasive surgical approaches for both the primary tumor and axillary lymph nodes (LNs). When NAC is effective, breast-conserving surgery may be feasible, and axillary lymph node dissection (ALND) may be avoided. However, ALND is still commonly performed in node-positive patients, even when post-NAC imaging shows no evidence of residual nodal metastases. Recently, tailored axillary surgery/dissection (TAS/TAD) has gained attention. TAS involves pre-NAC placement of a marker in biopsy-proven metastatic LNs, followed by targeted excision of the marked LN, sentinel LNs, and any palpable nodes after NAC. This less invasive strategy may provide sufficient local control if the false-negative rate (FNR) of axillary evaluation is kept below 10%. Virtual sonography (VS)—a fusion technique combining real-time ultrasound (US) with pre-acquired imaging such as CT or MRI—enables accurate localization of target lesions. Commercial US systems already integrate this technology, offering benefits including minimal invasiveness, repeatability, and cost-effectiveness. In this ongoing study, we apply VS to enhance TAS precision during surgery following NAC. To evaluate the clinical utility of VS in TAS for patients with axillary LN metastases undergoing NAC in a prospective, multicenter observational setting. In TAS, a marker is inserted into the metastatic LN prior to NAC as a surgical guide. While US is standard for identifying the marker, detection rates vary. TAS is considered feasible when the marker identification/excision rate reaches ≥ 95%. To enhance detection accuracy, this study utilizes VS for marker localization. Approved by the Central Ethics Committee of Gifu University (Approval No. 2024-005), this study follows these procedures: 1) Histopathological confirmation of axillary LN metastasis prior to NAC. 2) US-guided placement of an UltraCor™ Twirl™ marker in the metastatic LN. 3) Acquisition of axillary US volume data and longitudinal marker tracking using VS at three key time points: before NAC, after the second cycle, and preoperatively. 4) Measurement of the time required for marker identification using fusion imaging at the final preoperative session. 5) US-guided injection of blue dye (0.1-0.2 mL) into/around the marker-identified LN based on fusion images. 6) TAS during BC surgery, followed by radiographic confirmation of marker retrieval in the excised specimen. Marker presence confirms TAS success. Backup ALND will be performed thereafter. Inclusion: 1) Primary BC with histologically or cytologically confirmed axillary LN metastasis. 2) Clinical stage cT0-T4, cN1-N3, M0 (Stage IIA-IIIC). 3) Planned NAC ( ≥ 3 cycles). 4) Age ≥ 20 years. 5) ECOG performance status 0-2. 6) Written informed consent. -Exclusion: 1) Inability to insert a marker into/around the metastatic LN. 2) Contraindications to NAC for systemic or medical reasons. Marker identification rate of metastatic axillary LNs using US-US fusion (VS), confirmed by radiography of the excised specimen post-TAS. 1) Marker identification rate at NAC completion via US-US fusion. 2) Time required for marker identification via fusion imaging. 3) Number of metastatic LNs retrieved via TAS and ALND. 4) FNR of TAS (i.e., cases with metastases found only in ALND among those with any positive nodes). Assuming a 95% expected rate and an 83% threshold, a one-sided test with 2.5% significance and 80% power requires 58 patients. Allowing for a 5% dropout rate, the target enrollment is 62 patients. M. Futamura, S. Junta, I. Kazuhiro, S. Takehiko, K. Keitaro, N. Shogo, Y. Miwa, N. Akira, O. Mai, M. Nobuhisa, U. Takayoshi, A. Sadako. A prospective multicenter study on the clinical utility of virtual sonography for metastatic axillary lymph nodes during neoadjuvant chemotherapy in breast cancer patients (FUSION-03) [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2025; 2025 Dec 9-12; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2026;32(4 Suppl):Abstract nr PS5-07-05.
QuestionWhat is the association between ward-based implementation of a nutrition clinical framework and mortality and length of stay in older inpatients, and does it differ by nutrition status at admission?FindingsIn this cohort study using a difference-in-differences approach in 17 057 older inpatients, implementation of the nutrition clinical framework was not associated with clinical outcomes in the overall cohort. In the malnourished stratum, the framework's implementation was associated with lower in-hospital mortality and shorter length of stay, although these results were no longer significant after adjustment for multiple comparisons.MeaningThe findings suggest that a ward-based nutrition clinical framework may help prioritize dietitian-led care for older inpatients with malnutrition. This cohort study evaluates the association of a nutrition clinical framework with clinical outcomes among older patients treated in a Japanese university hospital. ImportanceThe Academy of Nutrition and Dietetics Nutrition Care Process is a standardized, 4-step framework for nutrition assessment, diagnosis, intervention, and monitoring. Although the framework has been widely adopted globally, its association with improved clinical outcomes, including mortality and length of stay (LOS), remains unclear.ObjectiveTo evaluate the association of nutrition clinical framework implementation, delivered as an institutional clinical practice change, with clinical outcomes in older inpatients (aged >= 65 years), with a focus on effect modification by nutrition status.Design, Setting, and ParticipantsThis cohort study using a difference-in-differences design was conducted among older adult inpatients (aged >= 65 years) at a Japanese university hospital between January 1, 2022, and June 30, 2025, with a follow-up period of 1 year after admission.ExposuresInstitutional nutrition clinical framework implementation in 9 wards from July 1, 2024, to June 30, 2025, in which dedicated registered dietitians delivered the full 4-step process as part of a hospital-wide clinical practice change.Main Outcomes and MeasuresThe main outcomes were in-hospital mortality, 6-month mortality, 1-year mortality, overall mortality, and LOS. All outcomes were stratified by Mini Nutritional Assessment-Short Form (MNA-SF) score (<= 7, malnourished; 8-11, at risk of malnutrition; >= 12, normal nutrition status).ResultsAmong 17 057 inpatients included in the study (mean [SD] age, 78.1 [7.5] years, 9070 male [53.2%]), in-hospital mortality in the malnourished stratum was lower during the implementation period (odds ratio [OR], 0.45; 95% CI, 0.22-0.91; P = .03). Nutrition clinical framework implementation was also associated with lower 6-month mortality (OR, 0.59; 95% CI, 0.35-0.98; P = .04) and shorter LOS (exponentiated coefficient, 0.87; 95% CI, 0.77-0.98; P = .03) among malnourished patients; after Benjamini-Hochberg adjustment, these findings were no longer significant. The bayesian posterior probability that the OR was less than 1 was at least 96% in all outcomes, and a dose-response association was observed for LOS (P for trend = .01).Conclusions and RelevanceThis study found that ward-based implementation of the nutrition clinical framework was associated with lower in-hospital mortality and shorter LOS among patients with malnutrition at admission, whereas no such associations were observed in the overall cohort. These findings suggest that targeted clinical nutrition delivery may be a useful strategy for prioritizing limited dietitian resources for high-risk inpatients; however, confirmation in multicenter prospective studies is needed.
