BACKGROUND: Globally, the demographic shift towards an aging population leads to significant challenges in healthcare systems, specifically due to an increasing incidence of multimorbidity resulting in polypharmacy among the elderly. Simultaneously, sleep disorders are a common complaint for elderly people. A treatment with pharmacological therapies often leads to side effects causing a high potential for dependency. Within this context, there is a high need to explore non-pharmacological therapeutic approaches. The purpose of this study is to evaluate the effectiveness of acupuncture and music therapy, both individually and combined as a multimodal therapy, in the treatment of sleep disorders in individuals aged 70 years and older.
METHODS: We conduct a confirmatory randomized controlled trial using a two-factorial study design. A total of n = 100 elderly people receive evidence-based standard care information for age-related sleep disorders. Beyond that, patients are randomly assigned into four groups of n = 25 each to receive acupuncture, receptive music therapy with a monochord, multimodal therapy with both acupuncture and music therapy, or no further therapy. The study\'s primary outcome measurement is the improvement in sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) (global score), at the end of intervention. Additionally, depression scores (Geriatric Depression Scale), health-related quality of life (Short-Form-Health Survey-12), neurovegetative activity measured via heart rate variability, and safety data are collected as secondary outcomes. Using a mixed-methods approach, a qualitative process evaluation will be conducted to complement the quantitative data.
CONCLUSIONS: The study is ongoing and the last patient in is expected to be enrolled in April 2024. The results can provide valuable insights into the effectiveness of non-pharmacological interventions for sleep disorders among the elderly, contributing to a more personalized and holistic approach in geriatric healthcare.
BACKGROUND: German Clinical Trials Register (DRKS00031886).

Primary lymphoma of the urinary bladder is extremely rare. We present the case of a 67-year-old woman diagnosed with primary extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT) of the urinary bladder. The patient presented with macroscopic hematuria. Renal ultrasound revealed a solid vascularized mass, in the inferior wall of the bladder. Pelvic computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of a polypoid lesion on the left side of the inferior bladder wall, measuring 40x45 mm, and the MRI study with gadolinium revealed that the entire bladder wall was involved. The patient underwent transurethral resection of the bladder tumor, demonstrating a histologic extensive involvement of bladder tissue by MALT lymphoma. The patient was treated with radiotherapy (24 Gy in 12 fractions) and four cycles of rituximab. She remained without evidence of disease 12 months later.

Hyalinizing clear cell carcinomas (HCCCs) are infrequent, malignant tumors characterized by their low-grade nature. They typically originate from minor salivary glands. However, these tumors can potentially emerge in any location with minor salivary glands, including the nasopharynx. This report presents two cases of HCCC in females aged 61 and 72 years, with both tumors approximately 4 cm in size. In the first case, a 72-year-old female presented with recurrent bilateral epistaxis. Imaging studies revealed a nasopharyngeal mass, surgically excised, and histopathological analysis confirmed HCCC. Postoperatively, the patient received combined chemotherapy and radiotherapy, achieving a recurrence-free status 2.5 years later. The second case involves a 61-year-old female with a two-year history of bloody nasal discharge. Imaging studies identified a nasopharyngeal lesion, surgically removed, and histopathological examination confirmed HCCC. This patient underwent radiotherapy followed by combination chemotherapy with paclitaxel and carboplatin, displaying no signs of recurrence upon reevaluation after 10 months. These cases highlight the successful management of HCCC through a comprehensive, multimodal approach, integrating surgical intervention and adjuvant therapy. The favorable outcomes emphasize the significance of a thorough treatment strategy for HCCC in the nasopharynx, providing valuable insights for clinicians. Further studies are essential to enhance our understanding of this rare entity and refine treatment protocols for optimized patient outcomes.

(1) Background: Less than 30% of patients with muscle-invasive bladder cancer (MIBC) receive neoadjuvant chemotherapy (NAC), and reasons for underuse remain unclear. One potential explanation is the concern for the increased risk of perioperative morbidity and mortality. The aim of this study is to investigate the impact of NAC on the risk of detrimental perioperative outcomes in patients with MIBC treated with radical cystectomy (RC). (2) Methods: We identified patients receiving RC for MIBC (T2-4a N0 M0) from 2016 to 2022. Moreover, 1:1 propensity score matching (PSM) was applied between RC alone versus RC plus NAC, and our analysis tested the association between NAC status and peri-operative outcomes. (3) Results: Among the 317 patients treated with RC for identified MIBC, 98 (31%) received NAC. Patients treated with NAC were younger (median yr. 64 vs. 71; p < 0.001), with a lower Charlson Comorbidity Index (3 vs. 4; p > 0.001), and received more frequently continent urinary diversion (61 vs. 32%, p < 0.001). About 43% of patients in each group were treated with robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD). After PSM, no differences were detected for the outcomes considered. (4) Conclusions: NAC is not associated with a higher rate of perioperative complications, including patients who received RARC with ICUD.

Patients with chronic peripheral neuropathy suffer greatly and their quality of life is often restricted. Drug therapy can be accompanied by undesirable side effects and intolerances, or the hoped-for effect does not materialize. Therefore, in addition to drug therapy, attempts are also made to treat the physical symptoms with complementary procedures. In the case of severe forms, the search for a suitable form of therapy is difficult. Complex treatments can be an innovative way to treat peripheral neuropathy. At the same time, several different therapy methods are carried out at high frequency by a specialized treatment team. This study aimed to provide an overview of possible complementary forms of therapy. The focus was on a comparison of two interdisciplinary complex therapies that are used in severe cases in an acute inpatient care setting in Germany. The six dimensions (energy, sleep, pain, physicality, emotional response and social isolation) of the Nottingham Health Profile (NHP) were used to assess quality of life. Both complex treatments (naturopathic complex therapy/multimodal pain therapy) showed a significant reduction in impairment in all dimensions of the NHP. In addition, a multivariate analysis was carried out to take into account several influencing variables at the same time. At the time of admission to the hospital, the degree of chronicity was recorded for each patient. This allowed statements to be made about the effect of the respective therapy depending on the chronification stage of the patient. It has been shown that patients with acutely exacerbated pain with the highest degree of chronicity also benefit from both complex treatments. The naturopathic complex treatment gives the treatment team more options. Aspects such as nutrition, methods from phytotherapy and traditional Chinese medicine can be integrated into inpatient care. Thus, a patient-centered, holistic therapy can take place. However, an interdisciplinary holistic therapy requires more time for both the practitioner and the patient. This should be taken into account in the health systems in the context of the diagnosis related groups.

The limits of the standard, behaviour-based clinical assessment of patients with disorders of consciousness (DoC) prompted the employment of functional neuroimaging, neurometabolic, neurophysiological and neurostimulation techniques, to detect brain-based covert markers of awareness. However, uni-modal approaches, consisting in employing just one of those techniques, are usually not sufficient to provide an exhaustive exploration of the neural underpinnings of residual awareness. This systematic review aimed at collecting the evidence from studies employing a multimodal approach, that is, combining more instruments to complement DoC diagnosis, prognosis and better investigating their neural correlates. Following the PRISMA guidelines, records from PubMed, EMBASE and Scopus were screened to select peer-review original articles in which a multi-modal approach was used for the assessment of adult patients with a diagnosis of DoC. Ninety-two observational studies and 32 case reports or case series met the inclusion criteria. Results highlighted a diagnostic and prognostic advantage of multi-modal approaches that involve electroencephalography-based (EEG-based) measurements together with neuroimaging or neurometabolic data or with neurostimulation. Multimodal assessment deepened the knowledge on the neural networks underlying consciousness, by showing correlations between the integrity of the default mode network and the different clinical diagnosis of DoC. However, except for studies using transcranial magnetic stimulation combined with electroencephalography, the integration of more than one technique in most of the cases occurs without an a priori-designed multi-modal diagnostic approach. Our review supports the feasibility and underlines the advantages of a multimodal approach for the diagnosis, prognosis and for the investigation of neural correlates of DoCs.

BACKGROUND: Ovarian cancer is metastatic at presentation in about 62% of cases, but brain metastases are rare, reported in 3.3-4% of patients. Brain metastasis seems to be more frequent in advanced stages at diagnosis and in patients with BRCA1/2 mutation.
METHODS: We present a case of a 47-year-old Caucasian woman, BRCA wild type, with an ovarian cancer that started with single cerebellar metastasis.
CONCLUSIONS: Brain metastases in ovarian cancer are rare and complex for diagnosis and management. This case focuses both on diagnosis and treatment, emphasizing the importance of a multimodal approach in a multidisciplinary team.

This comprehensive review introduces the critical issue of venous thromboembolism (VTE), emphasizing its prevalence, particularly in developed countries, and its role as a leading cause of preventable deaths. It discusses the components of VTE, encompassing deep vein thrombosis (DVT) and pulmonary embolism (PE), with a focus on the clinical challenges of diagnosing silent VTE in hospitalized patients. The review underscores the shocking statistics associated with VTE, including its impact on patient mortality, especially in medically treated, acutely ill patients. Despite the availability of evidence-based guidelines recommending VTE prophylaxis, there is a significant gap in implementation, making it a leading cause of unexpected hospital deaths. Additionally, the review outlines the multifaceted nature of VTE risk factors, ranging from transient to persistent and provoked to unprovoked, providing a comprehensive understanding of patient-specific considerations. The latter part of the review delves into the impact of VTE on patient health outcomes, revealing its adverse effects on survival, recurrence rates, and psychosocial well-being. Furthermore, it explores various preventive measures, including pharmacological and mechanical options, and their effectiveness, highlighting the importance of a multimodal approach. The review also touches on the challenges of guideline adherence and patient-centered considerations in VTE prevention.

Objectives A multimodal approach to pain management, including potential interventional techniques, is suggested to achieve adequate pain control. This study discusses the techniques and medications employed to manage pain in pediatric oncology patients. Methodology This study included 90 patients under 18 years of age who underwent pain management in the algology clinic between 2002 and 2020. From the algology follow-up records, the following data were recorded: demographic information, follow-up time, cancer diagnosis and stage, cause and location of pain, systems involved, duration and intensity of pain, analgesic and adjuvant drugs prescribed, routes and duration of drug administration, complications, interventional procedures if performed, \"pain intensity\" scores prior to and following treatment, and daily and total analgesic consumption of the patients. Results The mean age was 11.4±4.1 years (min-max: 2-17). Leukemia and lymphoma were the most frequently diagnosed (30%). Of the 31 features identified in the staging, 27 (87.1%) were stage 4 at admission. The causes of pain in children were neoplasms in 81.2% (n = 73). At admission, 72.3% (n = 65) had severe pain for at least a month. It was determined that 90% (n = 81) of the patients were using opioids and 28.9% (n = 26) were using dual opioids. The mean tramadol dose was 129.0±97.9 mg/day (12-380 mg/day), and the mean morphine dose was 14.8±11.3 mg/day (1-52 mg/day). The mean transdermal fentanyl dose was 33.2±21.6 µgr/h (12-75 µgr/h). Adjuvant therapy was administered in 25.6% (n = 24) of the patients. Epidural catheterization was performed on 6.6% (n = 6) of the patients. The mean initial pain scores were 5.2±1.7, which decreased to 1.5±0.7 with a significant difference (p < 0.001). In the study, 93% (n = 84) of the patients had no pain management complications noted. Conclusions The pain level that pediatric cancer patients endure critically influences their and their family\'s quality of life. The fact that opioid-related adverse effects associated with pediatric pain management occur far less frequently than previously thought may help prevent opiophobia. Effective and safe analgesia can be provided with multimodal analgesia to manage pediatric cancer pain.

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