Direct oral anticoagulants (DOACs) have largely supplanted warfarin for stroke prevention in atrial fibrillation due to their superior safety and efficacy profiles. Although standard dosing regimens are well-established, lower doses—often referred to as ultra‐low-dose (ULD) DOACs—have been investigated in selected populations to balance thrombotic and bleeding risks. The concept of ULD DOACs was first introduced in the 2013 European Heart Rhythm Association Practical Guide specifically for post‐acute coronary syndrome patients with residual thrombotic risk. Clinical trials, including ATLAS ACS-TIMI 51 and COMPASS, demonstrated that rivaroxaban 2.5 mg twice a day reduced ischemic events when combined with aspirin, although this benefit was accompanied by an increased risk of major bleeding. Similarly, the ELDERCARE-AF trial revealed that edoxaban 15 mg once a day effectively prevented stroke in frail older patients. Conversely, evidence supporting ULDs of dabigatran and apixaban remains limited. Despite their potential benefits, inappropriate dose reductions based on subjective physician judgment rather than rigorous clinical guidelines may result in suboptimal anticoagulation and a heightened risk of thromboembolic events. This review explores the indications, supporting evidence, and potential risks associated with ULD DOACs, underscoring the need for well-designed studies to establish clear guidelines.

Background and Objectives: In chronic heart failure (HF), natriuretic peptide (NP) levels are higher in atrial fibrillation (AF) compared to sinus rhythm (SR). However, due to the loss of atrial contraction, AF patients are prone to hemodynamic decompensation at earlier stages.Since NP levels reflect disease severity, acutely decompensated AF patients may exhibit lower NP levels compared to SR patients, who retain greater hemodynamic reserve. Methods: We analyzed 5,048 patients with acute HF from the Korea Acute Heart Failure registry with available NP data. NP levels and echocardiographic parameters were compared between AF and SR patients. The association of NP levels with in-hospital and one-year mortality was also assessed according to cardiac rhythm. Results: Brain natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were measured in 2,027 and 3,021 patients, respectively. NP levels were lower in AF than in SR (median BNP, 740 vs. 1,044 pg/mL; median NT-proBNP, 4,420 vs. 5,198 pg/mL), particularly in HF with reduced or mildly reduced ejection fraction. A similar trend was observed regardless of HF onset or etiology. AF patients had smaller left ventricular (LV) end-diastolic diameter and larger left atrial size compared to SR patients. Higher NP tertiles were associated with increased in-hospital and one-year mortality in both groups. Conclusions In acute HF, NP levels are lower in AF than in SR. AF patients also exhibited smaller LV chamber sizes. Nevertheless, NP levels remain strong predictors of outcomes in both AF and SR patients.

Heart failure (HF) is a major cause of mortality and morbidity in South Korea, imposing substantial physical, emotional, and financial burdens on patients and society. Despite the high burden of symptom and complex care needs of HF patients, palliative care and hospice services remain underutilized in South Korea due to cultural, institutional, and knowledge-related barriers. This position statement from the Korean Society of Heart Failure emphasizes the need for integrating palliative and hospice care into HF management to improve quality of life and support holistic care for patients and their families. By clarifying the role of palliative care in HF and proposing practical referral criteria, this position statement aims to bridge the gap between HF and palliative care services in South Korea, ultimately improving patient-centered outcomes and aligning treatment with the goals and values of HF patients.

Purpose: Adjuvant chemotherapy (AC) is recommended for muscle-invasive or lymph node-positive upper urinary tract urothelial carcinoma (UTUC) after radical nephroureterectomy (RNU). However, disease recurrences are frequently observed in pT1 disease, and AC may increase the risk of overtreatment in pT2 UTUC patients. This study aimed to validate a risk-adapted scoring model for selecting UTUC patients with ≤pT2 disease who would benefit from AC. Materials and Methods: We retrospectively analyzed 443 ≤pT2 UTUC patients who underwent RNU. A risk-adapted scoring model was applied, categorizing patients into low- or high-risk groups. Recurrence-free survival (RFS) and cancer-specific survival (CSS) were analyzed according to risk group. Results: Overall, 355 patients (80.1%) and 88 patients (19.9%) were categorized into the low- and high-risk groups, respectively, with the latter having higher pathological stages, concurrent carcinoma in situ, and synchronous bladder tumors. Disease recurrence occurred in 45 patients (10.2%), among whom 19 (5.4%) and 26 (29.5%) belonged to the low- and high-risk groups, respectively (p<0.001). High-risk patients had significantly shorter RFS (64.3% vs. 93.6% at 60 months; hazard ratio [HR] 13.66; p<0.001) and worse CSS (80.7% vs. 91.5% at 60 months; HR 4.25; p=0.002). Multivariate analysis confirmed that pT2 stage and the high-risk group were independent predictors of recurrence and cancer-specific death (p<0.001). Decision curve analysis for RFS showed larger net benefits with our model than with the T stage model. Conclusions The risk-adapted scoring model effectively predicts recurrence and identifies optimal candidates for AC post RNU in non-metastatic UTUC.

Purpose: This study aimed to evaluate and optimize microbial DNA extraction methods from urine, a non-invasive sample source, to enhance DNA quality, purity, and reliability for urinary microbiome research and biomarker discovery in bladder cancer. Materials and Methods: A total of 302 individuals (258 with genitourinary cancers and 44 with benign urologic diseases) participated in this study. Urine samples were collected via sterile catheterization, resulting in 445 vials for microbial analysis. DNA extraction was performed using three protocols: the standard protocol (SP), water dilution protocol (WDP), and chelation-assisted protocol (CAP). DNA quality (concentration, purity, and contamination levels) was assessed using NanoDrop spectrophotometry.Microbial analysis was conducted on 138 samples (108 cancerous and 30 benign) using 16S rRNA sequencing. Prior to sequencing on the Illumina MiSeq platform, Victor 3 fluorometry was used for validation. Results: WDP outperformed other methods, achieving significantly higher 260/280 and 260/230 ratios, indicating superior DNA purity and reduced contamination, while maintaining reliable DNA yields. CAP was excluded due to poor performance across all metrics. Microbial abundance was significantly higher in WDP-extracted samples (p<0.0001), whereas SP demonstrated higher alpha diversity indices (p<0.01), likely due to improved detection of low-abundance taxa. Beta diversity analysis showed no significant compositional differences between SP and WDP (p=1.0), supporting the reliability of WDP for microbiome research. Conclusions WDP is a highly effective and reliable method for microbial DNA extraction from urine, ensuring high-quality and reproducible results. Future research should address sample variability and crystal precipitation to further refine microbiome-based diagnostics and therapeutics.

Purpose: Desmopressin, frequently prescribed for nocturia, is associated with an elevated risk of hyponatremia. This study examined the incidence and risk factors of hyponatremia in male patients with benign prostatic hyperplasia using nationwide Korean health data. Materials and Methods: From the National Health Insurance Service database, we analyzed data on desmopressin and hyponatremia in Korean adults with benign prostatic hyperplasia between 2011 and 2012. The patients were followed-up until December 2020. We tested the effects of desmopressin on hyponatremia risk using propensity score-matched Cox regression models and Kaplan–Meier survival analysis. Results: Among 33,533 patients, the incidence of hyponatremia was 6.0%, 4.5%, and 5.0% in the desmopressin, alpha-blocker, and combination therapy groups, respectively. After propensity score matching, desmopressin use was not significantly associated with an increased risk of hyponatremia (hazard ratio 1.273, 95% confidence interval 0.988–1.640; p=0.062). Significant predictors of hyponatremia included advanced age, chronic heart failure, peripheral vascular disease, and renal disease. Conclusions Desmopressin prescription following careful patient selection and regular monitoring does not significantly increase the risk of hyponatremia compared to other lower urinary tract symptom treatments. Therefore, it remains a viable and effective option for managing nocturia, particularly in patients with nocturnal polyuria. However, clinicians should implement routine monitoring protocols, including serum sodium checks, particularly in high-risk populations, to ensure the safe and effective use of desmopressin.

Infectious mononucleosis is caused by the Epstein-Barr virus (EBV) and may rarely result in neurological complications. Here, we report a case of brachial neuritis following EBV-induced infectious mononucleosis. A 28-year-old female presented with a sore throat and mild fever and was diagnosed with infectious mononucleosis. At that time, she also experienced bilateral shoulder pain and muscle weakness, for which she received intravenous steroid pulse therapy followed by oral steroids. Despite treatment, she continued to exhibit persistent muscle weakness. An electrodiagnostic study later revealed axonal neuropathy with signs of regeneration in both the axillary and suprascapular nerves, consistent with brachial neuritis. The patient was instructed in exercises to strengthen her shoulder muscles and maintain joint range of motion during outpatient visits, leading to an improvement in her symptoms.

Vertebral arteriovenous fistula (VAVF) is a rare lesion characterized by an abnormal connection between the extracranial vertebral artery and the surrounding venous plexus. It typically arises due to penetrating injury, although it can occasionally result from blunt trauma. Brachial plexus injury (BPI) is also infrequently associated with VAVF. We present a rare case of VAVF caused by blunt trauma, which resulted in BPI. The patient, who had previously sustained a C2 fracture and C2–3 myelopathy from a bicycle accident, presented with new-onset weakness in the right upper extremity. His previous clinical history led to an initial suspicion of either an exacerbation of a pre-existing lesion or a shoulder injury. However, electromyography indicated that the weakness was due to BPI. Further evaluations later revealed VAVF to be the primary cause of the BPI. VAVF must be recognized as a rare potential reason for BPI, as timely intervention is essential for improving patient recovery and prognosis.