Perspectives of hospitalized heart failure patients: preferred and perceived participation roles in treatment decisions.

Shared decision-making (SDM) is a pivotal process in seeking optimal individual treatment and incorporating clinical evidence and patients' autonomous preferences. However, patients' actual attitudes toward participation in decision-making for state-of-the-art heart failure (HF) treatment remain unclear. We conducted a questionnaire-based survey distributed by nurses and physicians specializing in HF care to assess patients' preferred and perceived participation roles in treatment decision-making during the index hospitalization, rated on five scales (from extremely passive to purely autonomous attitudes). Simultaneously, we investigated the important factors underlying treatment decision-making from the perspective of hospitalized HF patients. Of the 202 patients who were approached by our multidisciplinary HF team between 2017 and 2020, 166 (82.2%) completed the survey. Logistic regression analyses were conducted to identify the clinical determinants of patients who reported that they left all decisions to physicians (i.e., extremely passive attitude). Of the 166 participants (male 67.5%, median age 73 years), 32.5% preferred an extremely passive attitude, while 61.4% reported that they actually chose an extremely passive attitude. A sole determinant of choosing an extremely passive decision-making role was lower educational status (odds ratio: 2.11, 95% confidence interval 1.11-4.00). The most important factor underlying the decision-making was "Physician recommendation" (89.2%). Notably, less than 50% considered "In alignment with my values and preferences" as an important factor underlying treatment decision-making. The majority of HF patients reported that they chose an extremely passive approach, and patients prioritized physician recommendation over their own values and preferences.

Confidence in self-care after heart failure hospitalization.

BACKGROUND: Understanding patient perspectives of self-care is critical for improving multidisciplinary education programs and adherence to such programs. However, perspectives of self-care for patients with heart failure (HF) as well as the association between patient perspectives and patient-physician communication remain unclear. METHODS: Confidence levels regarding self-care behaviors (eight lifestyle behaviors and four consulting behaviors) and self-monitoring were assessed using a self-administered questionnaire survey, which was directly distributed by dedicated physicians and nurses to consecutive patients hospitalized with HF in a tertiary-level hospital. Patient-physician communication was evaluated according to the quality of physician-provided information regarding "treatment and treatment choices" and "prognosis" using the Prognosis and Treatment Perception Questionnaire. Out of 202 patients, 187 (92.6 %) agreed to participate, and 176 completed the survey [valid response rate, 87.1 %; male, 67.0 %; median age, 73 (63-81) years]. Multivariate logistic regression analyses were conducted to predict low confidence in self-care (score in the lowest quartile). RESULTS: High confidence (confident or completely confident >75 % of patients) was observed for all self-care behavior categories except low-salt diet (63.1 %), regular exercise (63.1 %), and flu vaccination (65.9 %). Lower confidence in self-care behavior was associated with low quality of patient-physician communication. With regard to self-monitoring, 62.5 % of patients were not confident in distinguishing worsening symptoms of HF from other diseases; non-confidence was also associated with low quality of patient-physician communication. CONCLUSIONS: Hospitalized patients with HF had low confidence regarding regular exercise, salt restriction, and flu vaccination. The results also suggest patient-physician communication affects patient confidence.

Social Isolation and Implementation of Advanced Care Planning Among Hospitalized Patients With Heart Failure.

Background The implementation of advance care planning (ACP) in heart failure management is insufficient. Social isolation (SI) could be a barrier to ACP initiation, albeit the relationship between SI and patients' preference for ACP or end-of-life care remains unknown. Methods and Results We conducted a questionnaire survey, including assessments of SI using the 6-item Lubben Social Network Scale as well as patients' perspectives on ACP and end-of-life care. Of the 160 patients approached by our multidisciplinary heart failure team during admission, 120 patients (75.0%) completed the survey (median age, 73.0 years; men, 74.2%). A Cox proportional hazard model was constructed to elucidate the short-term (180-day) prognostic impact of SI. Overall, 28.3% of participants were at high risk for SI (6-item Lubben Social Network Scale score <12). High-risk patients had more negative attitudes toward ACP than those without (61.8% versus 80.2%; P=0.035). The actual performance of ACP conversation in patients with and without high risk were 20.6% and 30.2%, respectively. Regarding preference in end-of-life care, "Saying what one wants to tell loved ones" (73.5% versus 90.6%; P=0.016) and "Spending enough time with family" (58.8% versus 77.9%; P=0.035) were less important in high-risk patients. High risk for SI was associated with higher 180-day risk-adjusted all-cause mortality (hazard ratio, 7.89 [95% CI, 1.53-40.75]). Conclusions In hospitalized patients with heart failure, high risk for SI was frequently observed. High-risk patients were associated with a negative attitude toward ACP, despite higher mortality. Further research is required to establish an ideal approach to provide ACP in socially vulnerable patients.

Elderly aortic stenosis patients' perspectives on treatment goals in transcatheter aortic valvular replacement.

AIMS: Transcatheter aortic valvular replacement (TAVR) is increasingly being performed for elderly patients with aortic stenosis (AS), and current guidelines acknowledge the importance of shared decision-making in their management. This study aimed to evaluate elderly symptomatic severe AS patients' perspectives on their treatment goals and identify factors that influence their treatment choice. METHODS AND RESULTS: We performed a pre-procedural cross-sectional survey using a questionnaire at a single university hospital. The questionnaire included three primary domains: (i) symptom burden, (ii) goals and important factors related to treatment, and (iii) preferred place of residence after treatment. We investigated 98 symptomatic severe AS patients who underwent TAVR (median age 86 years, 26% men). None of the patients died during hospitalization, and most of them (94%) were discharged home. Prior to TAVR, the three most common symptom burdens were poor mobility (52%), shortness of breath (52%), and weakness (44%). The reported preferred treatment goals were symptom burden reduction (78%), independence maintenance (68%), ability to perform a specific activity/hobby (62%), and improvement in prognosis (58%). In total, 54% of the patients rated 'in alignment with my values' as the factor that affected their decision to undergo TAVR. Nearly all patients (95%) stated that they preferred to live at home after TAVR. CONCLUSIONS: Among elderly AS patients with varying symptoms who underwent TAVR, symptom burden reduction was the most cited patient-reported goal. Nearly all the patients preferred to live at home after the procedure. Encouraging patients to define their specific goals may improve the quality of shared decision-making in such settings.

Preferences on advance care planning and end-of-life care in patients hospitalized for heart failure.

AIMS: Early engagement in advance care planning (ACP) is recommended in heart failure (HF) management. We investigated the preferences of patients with HF regarding ACP and end-of-life (EOL) care, including their desired timing of ACP initiation. METHODS AND RESULTS: Data were collected using a 92-item questionnaire survey, which was directly distributed to hospitalized patients by dedicated physicians and nurses in a university hospital setting. One-hundred eighty-seven patients agreed to participate (response rate: 92.6%), and 171 completed the survey [valid response rate: 84.7%; men: 67.3%; median age: 73.0 (63.0-81.0) years]. Logistic regression analyses were conducted to identify the predictors of positive attitudes towards ACP. Most recognized ACP as important for their care (n = 127, 74.3%), 48.1% stated that ACP should be initiated after repeated HF hospitalizations in the past year, and 29.0% preferred ACP to begin during the first or second HF hospitalization. Only 21.7% of patients had previously engaged in ACP conversations during HF management. Positive attitudes towards ACP were associated with lower depressive symptoms [two-item Patient Health Questionnaire; odds ratio (OR): 0.75, 95% confidence interval (CI): 0.61-0.92, P-value: 0.006], marriage (OR: 2.53, 95% CI: 1.25-5.12, P-value: 0.010), and a high educational level (OR: 2.66, 95% CI: 1.28-5.56, P-value: 0.009), but not with severity of HF (represented by Seattle Heart Failure Model risk score). Regarding EOL care, while 'Saying what one wants to tell loved ones' (83.4%), 'Dying a natural death' (81.8%), and 'Being able to stay at one's favorite place' (75.6%) were the three most important factors for patients, preferences for 'Receiving sufficient treatment' (56.5%) and 'Knowing what to expect about future condition' (50.3%) were divergent. CONCLUSIONS: Despite patients' preferences for ACP conversations, there was a discrepancy between preference and engagement in ACP among patients hospitalized for HF. Patients' preferences regarding EOL care may differ; physicians need to consider the appropriate ACP approach to align with patients' care goals.

Propionibacterium acnes-associated Sarcoidosis Possibly Initially Triggered by Interferon-alpha Therapy.

A 46-year-old woman with uveitis was referred to our respiratory diseases department in July 2018. Her medical history included transient bilateral hilar mediastinal lymphadenopathy (BHL) and multiple pulmonary nodules in May 2013 during pegylated interferon-alpha and ribavirin treatment for chronic hepatitis C infection. Five years post-treatment, chest X-ray revealed BHL and nodular recurrence. A biopsy of the subcutaneous buttock nodules revealed scattered non-caseating epithelioid granulomas with positive PAB immunohistochemical staining. This seem to be the first report of Propionibacterium acnes-associated sarcoidosis possibly initially triggered by interferon-alpha therapy. Understanding the mechanisms underlying interferon-triggered P. acnes-associated sarcoidosis may clarify the sarcoidosis immunopathogenesis.

Prognostic Understanding and Preference for the Communication Process with Physicians in Hospitalized Heart Failure Patients.

BACKGROUND: Heart failure (HF) is a highly prevalent, heterogeneous, and life-threatening condition. Precise prognostic understanding is essential for effective decision making, but little is known about patients' attitudes toward prognostic communication with their physicians. METHODS AND RESULTS: We conducted a questionnaire survey, consisting of patients' prognostic understanding, preferences for information disclosure, and depressive symptoms, among hospitalized patients with HF (92 items in total). Individual 2-year survival rates were calculated using the Seattle Heart Failure Model, and its agreement level with patient self-expectations of 2-year survival were assessed. A total of 113 patients completed the survey (male 65.5%, median age 75.0 years, interquartile range 66.0-81.0 years). Compared with the Seattle Heart Failure Model prediction, patient expectation of 2-year survival was matched only in 27.8% of patients; their agreement level was low (weighted kappa = 0.11). Notably, 50.9% wished to know "more," although 27.7% felt that they did not have an adequate prognostic discussion. Compared with the known prognostic variables (eg, age and HF severity), logistic regression analysis demonstrated that female and less depressive patients were associated with patients' preference for "more" prognostic discussion. CONCLUSIONS: Patients' overall prognostic understanding was suboptimal. The communication process requires further improvement for patients to accurately understand their HF prognosis and be involved in making a better informed decision.

Patient confidence regarding secondary lifestyle modification and knowledge of 'heart attack' symptoms following percutaneous revascularisation in Japan: a cross-sectional study.

OBJECTIVE: To assess patient perspectives on secondary lifestyle modification and knowledge of 'heart attack' after percutaneous coronary intervention (PCI) for coronary artery disease (CAD). DESIGN: Observational cross-sectional study. SETTING: A single university-based hospital centre in Japan. PARTICIPANTS: In total, 236 consecutive patients with CAD who underwent PCI completed a questionnaire (age, 67.4±10.1 years; women, 14.8%; elective PCI, 75.4%). The survey questionnaire included questions related to confidence levels about (1) lifestyle modification at the time of discharge and (2) appropriate recognition of heart attack symptoms and reactions to these symptoms on a four-point Likert scale (1=not confident to 4=completely confident). PRIMARY OUTCOME MEASURE: The primary outcome assessed was the patients' confidence level regarding lifestyle modification and the recognition of heart attack symptoms. RESULTS: Overall, patients had a high level of confidence (confident or completely confident,>75%) about smoking cessation, alcohol restriction and medication adherence. However, they had a relatively low level of confidence (<50%) about the maintenance of blood pressure control, healthy diet, body weight and routine exercise (≥3 times/week). After adjustment, male sex (OR 3.61, 95% CI 1.11 to 11.8) and lower educational level (OR 3.25; 95% CI 1.70 to 6.23) were identified as factors associated with lower confidence levels. In terms of confidence in the recognition of heart attack, almost all respondents answered 'yes' to the item 'I should go to the hospital as soon as possible when I have a heart attack'; however, only 28% of the responders were confident in their ability to distinguish between heart attack symptoms and other conditions. CONCLUSIONS: There were substantial disparities in the confidence levels associated with lifestyle modification and recognition/response to heart attack. These gaps need to be studied further and disseminated to improve cardiovascular care.

Synergistic effects of interferon-beta and nivolumab in oral mucosal melanoma.

Mucosal melanoma is a rare aggressive cancer with a very poor prognosis. Clinical and pathological characteristics of mucosal melanoma differ from those of cutaneous melanoma and there are no established management guidelines for mucosal melanoma. Complete surgical excision is one of the most effective treatments for localized lesions, while targeted therapies and immunotherapies, such as monoclonal antibodies that target cytotoxic T-lymphocyte-associated molecule-4, and the programmed death (PD)-1/PD-ligand 1 pathway inhibitors, are treatment options for unresectable or metastatic lesions. Here, we describe the case of a patient with oral mucosal melanoma with multiple metastases. In our case, local injection of interferon (IFN)-ß with dacarbazine-nimustine-vincristine therapy provided antitumor effects on an invasive tumor on the upper gingiva. Nivolumab therapy produced complete remission of lymph node and bone metastases. In contrast, the remaining in situ portion of oral mucosal melanoma on the hard palate was refractory to IFN-ß monotherapy and nivolumab therapy. However, after administration of nivolumab, peritumoral injection of IFN-ß showed rapid therapeutic effects. Our case suggested that nivolumab upregulated the antitumor effects of IFN-ß, which induced the recruitment of CD8+ T cells into the tumor microenvironment contributing to the deletion of tumor cells. Combination therapy of IFN-ß and nivolumab may be a potential treatment option for patients with oral mucosal melanoma.

Multicentric Reticulohistiocytosis with Dermatomyositis-like Eruptions.

A 68-year-old man presented with polyarthritis, proximal muscle weakness, and erythema of the face, arms, neck, and anterior chest that resembled the V-neck sign. Initially, dermatomyositis (DM) was considered because of the erythema, polyarthritis, and muscle weakness. He also had mediastinal and hilar lymphadenopathy on contrast-enhanced computed tomography. Unexpectedly, a biopsy of the forehead skin revealed numerous multinucleated giant cells. A biopsy of a solitary nodule on the dorsum of his right middle finger revealed similar multinucleated giant cells with ground-glass cytoplasm, leading to the diagnosis of multicentric reticulohistiocytosis (MRH). Although MRH is rare, it should be remembered that MRH can mimic DM.

Combination of pulse therapy with terbinafine tablets and topical terbinafine cream for the treatment of dermatophyte onychomycosis: a pilot study.

We performed a pilot study to assess the safety and efficacy of pulse therapy with terbinafine tablets in 66 patients with dermatophyte onychomycosis. One pulse consisted of oral terbinafine tablets (500 mg/day) given for 1 week followed by a 3-week interval. Topical 1% terbinafine cream was applied daily. The number of pulses was determined by the extent of improvement in the affected nails and by the patient's requests, up to a maximum of six pulses. Efficacy was assessed based on both clinical and mycological examinations 1 year after treatment initiation. We observed a complete cure in 51 patients (77.3%), marked improvement in five patients (7.6%), improvement in five patients (7.6%) and slight improvement in one patient (1.5%). Four patients (6.0%) showed no change. In the patients who were completely cured, the average number of pulses used was 3.7 +/- 1.4 pulses and the treatment duration was 3.3 +/- 1.6 months. Nine patients experienced adverse effects, consisting of gastrointestinal disturbance (eight patients) and drug-induced eruption (one patient). There were no abnormal findings in the laboratory tests, including liver function tests. In summary, terbinafine pulse therapy in combination with topical application of terbinafine cream appeared safe and effective in this pilot study.

A Chinese-Japanese boy with black dot ringworm due to Trichophyton violaceum.

A 4-year and 8-month-old Chinese-Japanese boy, who had been visiting Dalian, China frequently, developed multiple alopecia lesions 1 year previously. At his initial visit to our department, multiple patchy alopecia with black dots was observed in the parietal scalp area. Multiple erythematous macules were also seen on the face, nape and right dorsum of the hand. A diagnosis of tinea capitis and tinea corporis was obtained on the basis of potassium hydroxide (KOH) microscopic examination of hair and scales from the lesions. Colonies grown on Sabouraud cycloheximide-chloramphenicol agar culture were examined using Fungi-Tape and MycoPerm-blue, and numerous microconidia and a small number of macroconidia were observed. Trichophyton violaceum was identified as the causative organism on the basis of colony morphology, microscopic morphology and molecular biology technique. As T. violaceum infection is not often seen in Japan, we suspected that the patient was infected by T. violaceum during his stay in Dalian. Conidia formation is rarely observed with T. violaceum, and only five cases with T. violaceum macroconidia formation have been reported in Japan (including this case). We also report the method for visualizing conidia formation of T. violaceum using Fungi-tape and MycoPerm-blue.

How do patients with neglect see a horizontal line? Analysis of performances in coloured line bisection task.

Twelve patients with left unilateral spatial neglect were examined with a newly devised "coloured line bisection task". They were presented with a horizontal line printed in blue on one side and in red on the other side; the proportions of the blue and red segments were varied. Immediately after placement of the subjective midpoint, the line was concealed and the patients were asked to name the colours of the right and left ends. Five patients who identified the left-end colour almost correctly had no visual field defect, while the other seven whose colour naming was impaired on the left side had left visual field defect. The rightward bisection errors were similarly distributed in the fair and poor colour-naming patients except for two patients from the latter group. The lesions of the fair colour-naming patients spared the lingual and fusiform gyri, which are known to be engaged in colour processing. Patients with neglect whose visual field is preserved may neglect the leftward extension of a line but not the colour in the neglected space. The poor colour-naming patients frequently failed to name the left-end colour that appeared to the left of their subjective midpoint, which indicates that they hardly searched leftward beyond that point. In such trials, they reported that the left end had the same colour as the right end. The results suggest that in patients with neglect and left visual field defect, both the leftward extent and the colour of a line may be represented on the basis of the information from the attended right segment.

Image of a line is not shrunk but neglected. Absence of crossover in unilateral spatial neglect.

Patients with left unilateral spatial neglect following right hemisphere lesions usually err rightward when bisecting a horizontal line. For very short lines (e.g. 25 mm), however, leftward errors or seemingly 'right' neglect is often observed. To explain this paradox of crossover in the direction of errors, rather complicated models have been introduced as to the distribution of attention. Neglect may be hypothesized to occur in representational process of a line or estimation of the midpoint on the formed image, or both. We devised a line image task using a computer display with a touch panel and approached the representational image of a line to be bisected. Three patients with typical left neglect were presented with a line and forced to see its whole extent with cueing to the left endpoint. After disappearance of the line, they pointed to the right endpoint, the left endpoint, or the subjective midpoint according to their representational image. The line image between the reproduced right and left endpoints was appropriately formed for the 200 mm lines. However, the images for the shorter 25 and 100 mm lines were longer than the physical lengths with overextension to the left side. These results proved the context effect that short lines may be perceived longer when they are presented in combination with longer lines. One of our patients had an extensive lesion that involved the frontal, temporal, and parietal lobes, and the other two had a lesion restricted to the posterior right hemisphere. The image for a fully perceived line may be represented far enough into left space even when left neglect occurs after a lesion that involves the right parietal lobe. The patients with neglect placed the subjective midpoint rightward from the centre of the stimulus line for the 100 and 200 mm lines and leftward for the 25 mm lines. This crossover of bisection errors disappeared when the displacement of the subjective midpoint was measured from the centre of the representational line image. Left neglect may occur consistently in estimation of the subjective midpoint on the representational image, which may be explained by a simple rightward bias of attentional distribution.