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.
Abstract Introduction The beneficial effects of Angiotensin Receptor Neprilysin Inhibitors (ARNI) on heart failure (HF) patients, particularly those with reduced left ventricular ejection fraction (LVEF), have been highlighted in several randomized controlled trials. Since 2020, ARNI has been available for HF treatment in Japan, a country known for its aging population. However, the inclusion of octogenarians in previous trials has been limited, leaving a gap in evidence regarding ARNI's effectiveness in the elderly. Objective This study aims to explore the real-world efficacy and safety of ARNI treatment among octogenarian HF patients in Japan, reflecting its status as a leading aging society. Methods The Prospective Area Registry of ARNI for Congestive Heart failUre in Tokyo East (PARACHUTE) trial, a multicenter registry, was conducted. It involved patients newly prescribed ARNI for chronic HF regardless of LVEF between 2020 and 2021. We compared patient backgrounds, changes in NT-proBNP levels at 6 months, and the rate of ARNI discontinuation between groups aged below and above 80 years. Results The study enrolled 105 patients, with an average age of 75 years. Forty-six patients (44%) were over 80 years old, and the majority (72%) were male. Among the younger group, 50% had preserved LVEF, compared to 32% in the octogenarian group (p=0.01). Median NT-proBNP levels across all patients decreased significantly from 2,540 pg/mL at baseline to 998 pg/mL at 6 months. The reduction in NT-proBNP was similar between the two age groups, with no significant interaction (p=0.46). Discontinuation rates due to any cause were not significantly different between younger and older patients (7% vs. 13%, p=0.28). Conclusion ARNI treatment resulted in significant reductions in NT-proBNP levels in HF patients, both under and over 80 years of age, with comparable discontinuation rates. These findings highlight the effectiveness and safety of ARNI in the management of chronic HF in the elderly, offering valuable real-world evidence from Japan's unique demographic context.
Introduction Guideline-directed medical therapy (GDMT) has been demonstrated to reduce morbidity and mortality in patients with heart failure (HF). In addition to the need for GDMT, a large number of cardiovascular and non-cardiovascular medications are prescribed to patients with HF, especially the elderly, due to multiple comorbidities and chronic health conditions, such as chronic pain, musculoskeletal problems, insomnia or gastrointestinal issues. Polypharmacy may reduce adherence to GDMT and compromise its optimisation, potentially leading to worse clinical outcomes in patients with HF.Methods and analysis The Polypharmacy Evaluation for improving adherence, Regimen Simplification, Enhancement and Utilization of Standard therapy in Heart Failure (PERSEUS-HF) trial is a prospective, multicentre, randomised, open-label trial testing whether a comprehensive medication management programme (CMMP) improves medication adherence at 6 months compared with standard of care in patients with HF and polypharmacy (≥ five regular oral medications). Three hundred patients are randomly assigned to receive either a CMMP or standard of care in a 1:1 ratio. The CMMP incorporates deprescribing potentially inappropriate medications based on the established Beers Criteria, structured medication education and counselling, optimising GDMT, reducing dosing frequency, using polypill, transitioning to as-needed medication and using unit-dose packaging. The primary endpoint is the change in total Adherence Starts with Knowledge 20 score from baseline to 6 months. The PERSEUS-HF trial will evaluate the efficacy of CMMP in improving medication adherence in patients with HF and polypharmacy.Ethics and dissemination This study was approved by the Institutional Review Board of the Gunma University Hospital, with the participants’ hospitals approving the execution of the study (IRB2025-070).Clinical trial registration jRCT1030250606
While most thyroid cancers have a favorable prognosis, anaplastic thyroid carcinoma (ATC) is highly aggressive and results in a poor prognosis. ATC frequently arises from preexisting benign goiters or highly differentiated thyroid cancers, typically presenting with rapidly progressing local symptoms and often accompanied by distant metastasis. We report a case of ATC that rapidly progressed to intrapulmonary metastases and malignant pleural effusion. Despite a previous histological diagnosis of benign goiter and the absence of local symptoms at the final presentation, the patient died just 20 days after the onset of symptoms. In patients with thyroid tumors accompanied by rapid progression of intrathoracic lesions, ATC must be considered as a differential diagnosis, even if they were previously diagnosed with a benign goiter.
Backgrounds/Objectives: Advances in prevention and medical care in the field of cardiology have led to an increase in the number of older patients with heart failure. In this population, assessment of nutritional status is particularly important. However, the prognostic impact of severity-based nutritional assessment at admission remains unclear. We conducted a study to elucidate the impact of malnutrition severity at admission on the prognosis of older patients hospitalized for acute heart failure (AHF). Methods: This study investigated the relationship between the Geriatric Nutritional Risk Index (GNRI) at admission and prognosis in 214 older patients aged ≥65 years who were hospitalized for AHF (mean age, 85 ± 8 years; male, 49%) between 2019 and 2023. GNRI was assessed by dividing patients into four groups: GNRI > 98 as normal (n = 64), 92 ≤ GNRI < 98 as mild risk (n = 54), 82 ≤ GNRI < 92 as moderate risk (n = 66), and GNRI < 82 as severe risk (n = 30). The discriminative performance of GNRI for 1-year all-cause mortality was compared with that of the Controlling Nutritional Status (CONUT) score and the Prognostic Nutritional Index (PNI). Results: During a median follow-up of 356 days, 76 deaths were observed. Worse GNRI categories were associated with older age, underweight, frailty, and anemia. Multivariable Cox proportional hazards models revealed that moderate GNRI risk (hazard ratio (HR), 2.69; 95% confidence interval (CI), 1.34-5.40) and severe GNRI risk (HR, 9.75; 95% CI, 4.30-22.10) were associated with higher all-cause mortality when compared with normal GNRI, along with age (HR per 1-year increase, 1.07; 95% CI, 1.03-1.11). Sensitivity analysis using GNRI as a continuous variable demonstrated similar results; GNRI was inversely associated with all-cause mortality (HR per 1 GNRI increase, 0.92; 95% CI, 0.90-0.95). In a subgroup analysis of age ≥85 years, the inverse association between GNRI and all-cause mortality was consistent. For 1-year all-cause mortality, GNRI showed moderate discrimination (area under the curve (AUC), 0.71; 95% CI, 0.63-0.80). Although the AUC of GNRI was not significantly different from that of the CONUT score or the PNI, GNRI demonstrated significantly better risk reclassification (net reclassification improvement, 0.47 vs. CONUT, p = 0.05; 0.43 vs. PNI, p = 0.02). Conclusions: In older patients with AHF including the oldest-old, nutritional status assessed by the GNRI at admission was predictive of prognosis. The importance of evaluating nutritional status at admission in clinical settings is reaffirmed.
