Multimodal Care Research Articles

Concurrent Bell’s Palsy and Facial Pain Improving with Multimodal Chiropractic Therapy: A Case Report and Literature Review

Patient: Female, 52-year-old Final Diagnosis: Bell’s palsy • trigeminal neuropathy Symptoms: Facial pain • facial paresis • neck pain Medication: — Clinical Procedure: Cervical traction • exercises • soft tissue manipulation • spinal manipulation Specialty: Neurology • Rehabilitation • Traditional Medicine Objective: Rare coexistence of disease or pathology Background:Bell’s palsy, also called facial nerve palsy, occasionally co-occurs with trigeminal neuropathy, which presents as additional facial sensory symptoms and/or neck pain. Bell’s palsy has a proposed viral etiology, in particular when occurring after dental manipulation.Case Report:A 52-year-old Asian woman presented to a chiropractor with a 3-year history of constant neck pain and left-sided maxillary, eyebrow, and temporomandibular facial pain, paresis, and paresthesia, which began after using a toothpick, causing possible gum trauma. She had previously been treated with antiviral medication and prednisone, Chinese herbal medicine, and acupuncture, but her recovery plateaued at 60% after 1 year. The chiropractor ordered cervical spine magnetic resonance imaging, which demonstrated cervical spondylosis, with no evidence of myelopathy or major pathology. Treatment involved cervical and thoracic spinal manipulation, cervical traction, soft-tissue therapy, and neck exercises. The patient responded positively. At 1-month follow-up, face and neck pain and facial paresis were resolved aside from residual eyelid synkinesis. A literature review identified 12 additional cases in which chiropractic spinal manipulation with multimodal therapies was reported to improve Bell’s palsy. Including the current case, 85% of these patients also had pain in the face or neck.Conclusions:This case illustrates improvement of Bell’s palsy and concurrent trigeminal neuropathy with multimodal chiropractic care including spinal manipulation. Limited evidence from other similar cases suggests a role of the trigeminal pathway in these positive treatment responses of Bell’s palsy with concurrent face/neck pain. These findings should be explored with research designs accounting for the natural history of Bell’s palsy.

Willingness, preferences, barriers, and facilitators of a multimodal supportive care intervention including exercise, nutritional and psychological approach in patients with cancer: a cross-sectional study

PurposeSupportive care, including exercise, nutritional and psychological support, is becoming increasingly important in cancer given their impact on ‘patients’ quality and quantity of life. The purpose of this study was to explore willingness, preferences barriers and facilitators for a multimodal intervention in patients with cancer.MethodsAn anonymous questionnaire was proposed on randomly selected days to the patients visiting the cancer outpatients’ facilities at the Oncology Unit of the University Hospital of Verona. The questionnaire investigated willingness, preferences, barriers, and facilitators associated with participation in a multimodal program designed for patients with cancer. Exercise level was estimated using two open questions, nutritional risk was identified using the Nutritional Risk Screening 2002, while distress was evaluated with the Distress Thermometer.ResultsBased on 324 participants, 65% were interested in starting a multimodal intervention. Patients declared to prefer to receive instructions from dedicated experts, with a face-to-face approach, and during the anticancer treatment. Treatment-related side effects were the major obstacles for a multimodal program, while the availability of a specialized staff as exercise kinesiologists, dietitians, and psycho-oncologists was found to be an important facilitator for increasing ‘patients’ participation.ConclusionPatients patients with cancer are interested in participating in a multimodal supportive care program specifically designed for them. Information from this study may help to design a tailored multimodal intervention for patients with cancer.

Guideline-Consistent Treatment for Inflammatory Breast Cancer Provides Associated Survival Benefit Independent of Age.

Guideline-consistent treatment (GCT) for inflammatory breast cancer (IBC) includes neoadjuvant chemotherapy (NAC), modified radical mastectomy (MRM), and radiation. We hypothesized that younger patients more frequently receive GCT, resulting in survival differences. Using the National Cancer Database (2004-2018), female patients with unilateral IBC (by histology code and clinical stage T4d) were stratified by age (< 50, 50-65, > 65years). Factors associated with NAC, MRM, radiation, and "GCT" (defined as all three treatments) were identified using multivariable logistic regression. Multivariable Cox proportional hazards regression identified predictors of overall survival. Of 3278 IBC patients, 30% were younger than 50years, 44% were 50-65years of age, and 26% were older than 65years. The youngest group comprised the greatest proportion of non-White patients ([35%] vs. [29%] age 50-65years and [23%]age > 65years, p < 0.001) and was most often treated at academic facilities ([33%] vs. [28%]age 50-65years; and [23%]age > 65, p < 0.001). Patients older than 65years received NAC, MRM, and radiation less frequently, and only 35% underwent GCT (vs.[57%] age 50-65years and[52%] age < 50years; p < 0.001). On multivariable logistic regression, age older than 65years independently predicted omission of NAC (odds ratio [OR], 0.36), MRM (OR, 0.56), and radiation (OR, 0.56) (all p < 0.001), and patients older than 65years also were less likely to undergo GCT than patients 50-65years of age (OR, 0.65; p = 0.001). GCT was associated with superior overall survival in all three age groups ([hazard ratio {HR}, 0.61]age < 50 years,[HR, 0.62] age 50-65years, [HR, 0.53]age > 65 years; all p < 0.001). Advanced age alone should not limit receipt of GCT for IBC. Multimodal care should be performed for IBC patients of all ages to improve oncologic outcomes for this aggressive breast cancer subtype.

Conceptual frame work on bundle care therapy on hypertension

Present health studies show that the world is heading for heart diseases of worldwide segment. The number of people at high risk from cardiovascular disease is increasing recent studies suggest that only 2 to 7 percent of the common population have no risk factors at all, and less than 70 percent individuals have multiple risk factors. Non-communicable diseases (NCDs) are a cluster of diseases with long duration, and are generally slow in progression that affect individuals over an extended period of time causing socio economic burden to the nation. The good result of a bundle comes from the body of science behind it and the way of execution. A bundle bounds the changes together into a package of involvement which people know must be followed for every patient, every single time. Bundles may resemble a checklist but it is more than that. Bundles are different from a checklist as the latter contains many elements (more than five usually), all are not necessarily evidence based. The hypertensive safety bundle care therapy (HSBCT) on cardiovascular disease was followed. HSBCT includes Diet - DASH diet with low carbohydrate, salt restricted and high fiber diet, physical activity, spiritual practices by prayer, stress management with Pranayama, reduction of Habits like alcohol and smoking, Obesity management regular intake of Medications and regular Follow up. Thus, a multimodal care so called hypertensive safety bundle care therapy on prevention of risk for CAD (cardiovascular disease) among hypertensive patients may yield a good result by reducing the CAD risk factors.

Digital Rehabilitation for Elbow Pain Musculoskeletal Conditions: A Prospective Longitudinal Cohort Study.

Elbow musculoskeletal pain (EP) is a major cause of disability. Telerehabilitation has shown great potential in mitigating musculoskeletal pain conditions, but EP is less explored. This single-arm interventional study investigates clinical outcomes and engagement levels of a completely remote multimodal digital care program (DCP) in patients with EP. The DCP consisted of exercise, education, and cognitive-behavioral therapy for 8 weeks. Primary outcome: disability change (through the Quick Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), treatment response cut-offs: 12.0-point reduction and 30% change). Secondary outcomes: pain, analgesic intake, surgery intent, mental health, fear–avoidance beliefs, work productivity, and patient engagement. Of the 132 individuals that started the DCP, 112 (84.8%) completed the intervention. Significant improvements were observed in QuickDASH with an average reduction of 48.7% (11.9, 95% CI 9.8; 14.0), with 75.3% of participants reporting ≥30% change and 47.7% reporting ≥12.0 points. Disability change was accompanied by reductions in pain (53.1%), surgery intent (57.5%), anxiety (59.8%), depression (68.9%), fear–avoidance beliefs (34.2%), and productivity impairment (72.3%). Engagement (3.5 (SD 1.4) sessions per week) and satisfaction 8.5/10 (SD 1.6) were high. The significant improvement observed in clinical outcomes, alongside high engagement, and satisfaction suggests patient acceptance of this care delivery mode.

Impacts of Digital Care Programs for Musculoskeletal Conditions on Depression and Work Productivity: Longitudinal Cohort Study.

BackgroundComorbidity between musculoskeletal (MSK) pain and depression is highly common, and is associated with a greater symptom burden and greater loss of work productivity than either condition alone. Multimodal care programs tackling both physical and mental health components may maximize productivity recovery and return to work. Digital delivery of such programs can facilitate access, ensure continuity of care, and enhance patient engagement.ObjectiveThe aim of this study was to assess the impact of a completely remote multimodal digital care program (DCP) for MSK pain on mental health and work-related outcomes stratified by baseline depression levels.MethodsAd hoc analysis of an interventional, single-arm, cohort study of individuals with MSK pain undergoing a DCP was performed. Three subgroups with different baseline depression severity levels were established based on responses to the Patient Health Questionnaire (PHQ-9): cluster 1 (score<5: minimal depression), cluster 2 (scores 5-10: mild depression), and cluster 3 (score≥10: moderate depression). The mean changes in depression, anxiety, fear-avoidance beliefs, work productivity, and activity impairment and adherence between baseline and end of program (8-12 weeks) were assessed across subgroups by latent growth curve analysis.ResultsFrom a total of 7785 eligible participants, 6137 (78.83%) were included in cluster 1, 1158 (14.87%) in cluster 2, and 490 (6.29%) in cluster 3. Significant improvements in depression and anxiety scores were observed in clusters 2 and 3 but not in cluster 1, with average end-of-the program scores in clusters 2 and 3 below the initially defined cluster thresholds (score of 5 and 10, respectively). All clusters reported significant improvements in productivity impairment scores (mean changes from –16.82, 95% CI –20.32 to –13.42 in cluster 1 to –20.10, 95% CI –32.64 to –7.57 in cluster 3). Higher adherence was associated with higher improvements in depression in clusters 2 and 3, and with greater recovery in activities of daily living in cluster 3. Overall patient satisfaction was 8.59/10.0 (SD 1.74).ConclusionsA multimodal DCP was able to promote improvements in productivity impairment scores comparable to those previously reported in the literature, even in participants with comorbid depression and anxiety. These results reinforce the need to follow a biopsychosocial framework to optimize outcomes in patients with MSK pain.Trial RegistrationClinicalTrials.gov NCT04092946; https://clinicaltrials.gov/ct2/show/NCT04092946

Effectiveness of Multimodal Chiropractic Care Featuring Spinal Manipulation for Persistent Spinal Pain Syndrome Following Lumbar Spine Surgery: Retrospective Chart Review of 31 Adults in Hong Kong.

BackgroundThe term “persistent spinal pain syndrome type 2” (PSPS-2) has been proposed by the International Association for the Study of Pain to replace the term “failed back surgery syndrome”. This retrospective study aimed to evaluate effectiveness of multimodal care featuring chiropractic spinal manipulation (CSMT) in 31 adults in Hong Kong with PSPS-2.Material/MethodsWe identified new adult patients with PSPS-2 receiving CSMT from 2016 to 2018. Demographic and clinical data and baseline/follow-up numeric pain rating scale (NPRS) and Oswestry Disability Index (ODI) scores were extracted. Multiple linear regression was used to examine posttreatment NPRS and ODI reduction, with clinical variables as covariates.ResultsOf 6589 patients with low back pain, 31 met criteria (mean age 52.2±13.7 years). Surgeries included laminectomy (81%), discectomy (13%), and fusion (6%). Mean baseline NRPS was 6.6±1.9; ODI was 43.8±15.1%. Patients received CSMT (100%), drop technique (81%), passive modalities (65%), soft tissue manipulation (13%), flexion-distraction (13%), and mechanical traction (13%). Mean posttreatment NPRS was 0.6±1.0; ODI was 2.4±3.3%. All patients had a minimum clinically important difference for NPRS (≥2/10) and ODI (≥30%). One year after treatment, 48% maintained improvement, 42% experienced recurrence; in 10%, follow-up was unavailable. Regression analysis identified younger age, shorter symptom duration, and greater baseline NPRS as predictors of NPRS reduction; and greater baseline ODI as a predictor of ODI reduction (all P<0.05).ConclusionsPatients with PSPS-2 improved with multimodal care featuring CSMT, which was more effective in patients with younger age, shorter symptom duration, and higher baseline pain or disability levels.

Thinking and suggestions on pathway management of perioperative enhanced recovery after surgery in gastrointestinal tumors in China

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care program to decrease the risk of delayed hospitalization, medical complications, readmission and to improve patient short- and long-term outcomes with minimized level of surgical stress responses through multidisciplinary cooperation. Despite its huge success, the program has challenges for further optimization with a primary focus on modification according to the specific pathophysiology and perioperative management characteristics of patients with gastrointestinal tumors to improve the compliance and implementation rate of items. Patient education, prehabilitation, multimodal analgesia, precision surgery, early mobilization, early oral feeding and oral nutrition supplement (ONS) should be regarded as core terms suitable for all the patients. During the application of ERAS pathway management, it is necessary to fully understand the perioperative changes of organ function and pathophysiology, and to strictly implement the ERAS program and items based on evidence-based medicine. Moreover, the close collaboration of multidisciplinary teams is needed to improve the compliance and increase the adherence rate of ERAS protocol for patients, which emphasizes the dynamic, gap-free and whole course management that covers pre-hospital, pre-operative, intra-operative, post-operative and post-hospital periods. Concurrently, we encourage our patients and their families to participate in the whole healthcare activities. Even more concerning, it is indispensable to adjust ERAS program for special time and special patients. At present, several consensus and guidelines on the ERAS management of gastrointestinal tumor surgery have come out for clinical practice in China, which, however, still lacks a high-level evidence from more high-quality clinical trials conducted by Chinese researchers. It is urgent to carry out a series of large-scale randomized controlled studies in accordance with international standards to obtain high-level evidence-based medical evidence for clinical practice, which is problem-oriented and integrated with features of metabolism and perioperative management of gastrointestinal tumor surgery.

Psychological aspects during and after intensive care treatment of ARDS

Approximately 10% of all patients requiring intensive care develop acute respiratory distress syndrome (ARDS). The COVID-19 pandemic led to an accumulation of patients with severe ARDS. The experience of this severe respiratory failure is accompanied by feelings of existential anxiety in many patients.The complexity of the challenges and stresses that the disease and its treatment pose for the ARDS patient require an early multiprofessional approach to treatment already during intensive care. Psychological approaches are suitable to support the patient as well as the relatives in coping with the disease and to minimise risks for potential subsequent stress. Despite the long-term impairments of patients who have survived ARDS and the resulting need for follow-up care, suitable multimodal follow-up care concepts and the necessary care structures are still lacking. The article presents the psychological support during and after the intensive care treatment of ARDS.

Nephroblastoma Treatment and Outcomes in a Low-Income Setting.

PURPOSENephroblastoma is a highly curable pediatric cancer that requires multidisciplinary care. Few reports have assessed long-term treatment outcomes in low-resource settings using a task-shifting model of care. We report outcomes of a large cohort and factors associated with survival.METHODSWe performed a retrospective chart review of all patients with nephroblastoma presenting to the Butaro Cancer Center of Excellence in Rwanda between July 2012 and June 2018.RESULTSIn total, 136 patients were identified and treated according to International Society of Pediatric Oncology guidelines for low-income settings. Median age at diagnosis was 39.7 months (interquartile range, 25.3-61.8 months); 56.6% were female. Sixty-one (44.9%) patients presented with stage I-III disease, 35 (25.7%) with stage IV disease, and 6 (4.4%) with stage V disease; the remainder were unstaged (n = 34; 25.0%). Most patients completed surgery (n = 97; 71.3%) and postoperative chemotherapy (n = 82; 60.2%); 17 patients received radiotherapy. With a median follow-up time of 18.1 months, 44.9% of patients were alive, 41.9% had died, 8.8% were lost to follow-up, and 4.4% were referred for palliative care or declined further care at the end of the study. Three-year overall survival was 57.5% (95% CI, 48.1 to 65.8) for the entire cohort, and 80.1% (95% CI, 66.8 to 88.5) and 44.0% (95% CI, 26.8 to 60.0) for stages I-III and IV-V, respectively.CONCLUSIONWe demonstrate that patients with nephroblastoma can be successfully treated in a low-resource setting. Survival remains lower than in high-income countries, in part due to early deaths, contributing to approximately 30% of patients not being medically able to receive surgical intervention. Next steps include the development of strategies that focus on earlier diagnosis, supportive care during the early phases of therapy, and efficient and timely transitions between specialties for multimodal care.

Enhanced Recovery After Surgery Pathway in Kidney Transplantation: The Road Less Traveled.

Background.Enhanced recovery after surgery (ERAS) pathway is a multimodal perioperative care pathway designed to achieve early recovery after surgery. ERAS protocols have not yet been well recognized in kidney transplantation. The aim of this study was to investigate the impact of ERAS pathway on early recovery and short-term clinical outcomes of kidney transplant.Methods.This is a single-center retrospective analysis comparing the outcomes of 20 adult kidney transplant recipients subjected to ERAS pathway with 20 adult recipients operated before ERAS with traditional standard of care.Results.There were no significant differences between both groups regarding age, gender, race, dialysis status, living donor percentage, cold ischemia time, and warm ischemia time. Median hospital stay for ERAS patients was 2 d. Overall median pain scores were significantly lower in the ERAS group versus non-ERAS group (morning after surgery pain score 2 versus 5; peak pain score 4.5 versus 10; lowest pain score 0 versus 2; P = 0.0001). ERAS patients had earlier ambulation (walking) and oral nutrition (regular diet) (first versus second day postoperatively in traditional group). Earlier bowel movement was observed in ERAS patients. There were no significant differences in graft function or 30-d readmission rates between both groups.Conclusions.Implementation of ERAS pathway in kidney transplantation is feasible. Using ERAS is associated with less pain, earlier ambulation and advancement of oral nutrition, and short hospital stay.

Cancer pain during an epidemic and a pandemic.

Purpose of reviewAs our global population ages, cancer has become more prevalent. Thankfully, oncologic treatments are highly effective, leading to significantly improved rates of long-term survival. However, many of these therapies are associated with persistent pain syndromes. Clinicians caring for people with cancer must understand how the influence of the current epidemic of opioid misuse and the coronavirus disease 2019 (COVID-19) pandemic have complicated cancer pain management. Creative solutions can emerge from this knowledge.Recent findingsPersistent pain due to cancer and its treatment can be managed through multimodal care, although efforts to mitigate the opioid misuse epidemic have created challenges in access to appropriate treatment. Isolation measures associated with the COVID-19 pandemic have limited access to nonpharmacologic therapies, such as physical therapy, and have exacerbated mental health disorders, including anxiety and depression.SummaryCancer pain treatment requires more nuanced assessment and treatment decisions as patients live longer. Societal factors multiply existing challenges to cancer pain relief. Research is needed to support safe and effective therapies.

Acute Impact of Cancer Treatment on Head and Neck Cancer Patients: FIT4TREATMENT.

Simple SummaryHead and neck cancer treatment causes toxicities that compromise health-related quality of life (HRQoL) and treatment efficacy. Exercise training (ET) benefits are reported for many cancer types. The aim of our prospective observational study was to analyse acute treatment’s impact and ET preferences. In the pretreatment phase (n = 18), most patients presented low physical function, were moderately malnourished or at risk of malnutrition, and were willing to participate in an ET program. Patients submitted to radical chemoradiotherapy (n = 7) experienced a significant decline in HRQoL and social functioning, an increase in dysphagia severity, a reduction in handgrip strength, and nutritional status deterioration. An ET program may optimize patients’ physical fitness, achieving more efficacy with less toxicity.Head and neck cancer (HNC) treatment’s toxicities impact several health domains. Exercise training (ET) may be beneficial. This prospective observational study (NCT04996147) aimed to analyse the acute impact of HNC curative multimodal treatment on health-related quality of life (HRQoL), nutritional status, physical and cognitive functions, and ET preferences. Eighteen patients with stage III/IV HNC were evaluated at baseline (T0), and 10 patients were evaluated at the end of treatment (T1), 7 of them after radical chemoradiotherapy (rCRT). At T0, the majority referred a good HRQoL on the EORTC QLQ-C30 questionnaire (median score: 70.8), were moderately malnourished or at risk of malnutrition (78%), recognized the benefits of an ET program, and were willing to participate (78%). After rCRT, there was worsening in HRQoL (75 vs. 50 score, p = 0.014), dysphagia severity (Eating Assessment Tool: 7 vs. 31, p = 0.027; Functional Oral Intake Scale: 6 vs. 4, p = 0.041), handgrip strength (dominant: 40.9 vs. 35.8 kgf, p = 0.027; nondominant: 37.2 vs. 33.9 kgf, p = 0.043), and nutritional status (Patient-Generated Subjective Global Assessment: 7 vs. 18, p = 0.028). HNC patients subjected to radical treatment represent a vulnerable population that might benefit from multimodal supportive care strategies including an ET program.

Adenosine Conjugated Docetaxel Nanoparticles—Proof of Concept Studies for Non-Small Cell Lung Cancer

Non-small cell lung cancer, a molecularly diverse disease, is the most prevalent cause of cancer mortality globally. Increasing understanding of the clinicopathology of the disease and mechanisms of tumor progression has facilitated early detection and multimodal care. Despite the advancements, survival rates are extremely low due to non-targeted therapeutics and correspondingly increased risk of metastasis. At some phases of cancer, patients need to face the ghost of chemotherapy. It is a difficult decision near the end of life. Such treatments have the capability to prolong survival or reduce symptoms, but can cause serious adverse effects, affecting quality of life of the patient. It is evident that many patients do not die from burden of the disease alone, but they die due to the toxic effect of treatment. Thus, increasing the efficacy is one aspect and decreasing the toxicity is another critical aspect of cancer formulation design. Through our current research, we tried to uncover both mentioned potentials of the formulation. Therefore, we designed actively targeted nanoparticles for improved therapeutics considering the overexpression of adenosine (ADN) receptors on non-small cell lung cancer (NSCLC) cells. Docetaxel (DTX), an essential therapeutic as part of combination therapy or as monotherapy for the treatment of NSCLC, was encapsulated in biodegradable poly(lactic-co-glycolic acid) nanoparticles. ADN was conjugated on the surface of nanoparticles using EDC-NHS chemistry. The particles were characterized in vitro for physicochemical properties, cellular uptake, and biocompatibility. The size and zeta potential of DTX nanoparticles (DPLGA) were found to be 138.4 ± 5.45 nm and −16.7 ± 2.3 mV which were found to change after ADN conjugation. The size was increased to 158.2 ± 6.3 nm, whereas zeta potential was decreased to −11.7 ± 1.4 mV for ADN-conjugated DTX nanoparticles (ADN-DPLGA) indicative of surface conjugation. As observed from transmission electron microscopy (TEM), the nanoparticles were spherical and showed no significant change in encapsulation efficiency even after surface conjugation. Careful and systematic optimization leads to ADN-conjugated PLGA nanoparticles having distinctive characteristic features such as particle size, surface potential, encapsulation efficacy, etc., that may play crucial roles in the fate of nanoparticles (NPs). Consequently, higher cellular uptake in the A549 lung cancer cell line was exhibited by ADN-DPLGA compared to DPLGA, illustrating the role of ADN receptors (ARs) in facilitating the uptake of NPs. Further in vivo pharmacokinetics and tissue distribution experiments revealed prolonged circulation in plasma and significantly higher lung tissue distribution than in other organs, dictating the targeting potential of the developed formulation over naïve drug and unconjugated formulations. Further, in vivo acute toxicity was examined using multiple parameters for non-toxic attributes of the developed formulation compared to other non-targeted organs. Further, it also supports the selection of biocompatible polymers in the formulation. The current study presents a proof-of-concept for a multipronged formulation technology strategy that might be used to maximize anticancer therapeutic responses in the lungs in the treatment of NSCLC. An improved therapeutic and safety profile would help achieve maximum efficacy at a reduced dose that would eventually help reduce the toxicity.

Effect of multimodal intervention care on cachexia in patients with advanced cancer compared to conventional management (MIRACLE): an open-label, parallel, randomized, phase 2 trial

BackgroundCancer cachexia (CC) is a multifactorial process characterized by progressive weight loss, muscle mass, and fat tissue wasting, which adversely affects the quality of life and survival of patients with advanced stages of cancer. CC has a complex and multifactorial pathophysiology, and there is no established standard treatment. Therefore, it is often irreversible and a single treatment modality is unlikely to suppress its progression. We are conducting a randomized trial to investigate the efficacy and safety of a multimodal intervention compared to the best supportive care for patients who received palliative chemotherapy.MethodsPatients with lung or gastrointestinal cancers undergoing palliative chemotherapy are eligible. Patients are randomized into a multimodal intervention care (MIC) arm versus a conventional palliative care (CPC) arm. MIC includes ibuprofen, omega-3-fatty acid, oral nutritional supplement, weekly physical, psychiatric assessment, nutritional counseling, and complementary and alternative medicine. CPC includes basic nutritional counseling and megestrol acetate as needed (i.e., anorexia ≥ grade 2). All interventions are performed for 12 weeks per subject. The co-primary outcomes are change (kg) in total lean body mass and handgrip strength (kg) from the baseline. A total of 112 patients will be assigned to the two arms (56 in each group).DiscussionThe purpose of this study is to evaluate the effect of MIC in preventing or alleviating CC in patients who underwent palliative chemotherapy. As there is no established single treatment for CC, it is expected that the results of this clinical trial will provide new insights to significantly improve the quality of life of patients with cancer. Considering the complex mechanisms of cachexia, the effect of MIC rather than a single specific drug is more promising. In this study, we did not overly restrict the type of cancer or chemotherapy. Therefore, we attempted to measure the effects of complex interventions while preserving clinical situations. Thus, it is expected that the results of this study can be applied effectively to real-world practice.Trial registrationThis clinical trial was registered in the Clinical Research Information Service (KCT0004967), Korean Clinical Trial Registry on April 27, 2020, and ClinicalTrial.gov (NCT 04907864) on June 1, 2021.

What Predicts Improvement of Dizziness after Multimodal and Interdisciplinary Day Care Treatment?

Background: Vertigo and dizziness are common in community-dwelling people and can be treated in specialized multidisciplinary settings. To develop tailored interventions, however, we have to explore risk factors for favorable and unfavorable outcomes. Methods: We prospectively investigated patients with chronic vertigo and dizziness subjected to our 5-day multimodal and interdisciplinary day care treatment in the Center for Vertigo and Dizziness of Jena University Hospital, Germany. The Vertigo Severity Scale (VSS), the Body Sensations Questionnaire (BSQ), the Hospital Anxiety and Depression Scale (HADS), the Agoraphobic Cognitions Questionnaire (ACQ), the Mobility Inventory (MI), and the burden and intensity of dizziness (using a visual analogue scale) were assessed at baseline (n = 754) and after 6 months (n = 444). In addition, 14 Likert-scaled questions were used to quantify the change in personal attitude and behavior towards the complaints after 6 months. Results: Dizziness-related burden and intensity improved with a large effect size. The largest improvement was seen in the attitudes towards dizziness, the understanding of somatic causes, and the perceived ability to influence dizziness. However, the ability to work and to carry out professional activity was improved to a lesser extent. The overall improvement of dizziness was associated with the absence of a depressive mood, a short duration of vertigo, a lower VSS, a lower perceived intensity of vertigo, and distinct vertigo diagnoses, namely Meniere’s disease, vestibular migraine, vestibular neuritis, vestibular paroxysmia, and vestibular schwannoma. Worsening of dizziness/vertigo was associated with depressive symptoms, permanent vertigo, distinct vertigo diagnoses (central vertigo, multisensory deficit), and a higher perceived burden due to vertigo. Conclusion: The six-month outcome of patients with dizziness presented to a specialized outpatient clinic appears to be favorable. Nevertheless, people with the abovementioned risk factors at baseline have less benefit and probably need adapted and tailored vertigo interventions to improve long-term outcome.

Radiotherapy for HER 2 Positive Brain Metastases: Urgent Need for a Paradigm Shift.

Simple SummaryBrain metastases (BMs) are common among patients with advanced HER2 breast cancer. The recent introduction of systemic therapy with central nervous system activity as well as the wider use of brain stereotactic radiotherapy (SRT) are contributing to improving the outcomes for these patients. In this review, we discuss a modified approach to the treatment of HER2-positive BMs from a radiation oncologist point of view, taking into consideration new advances in multimodal therapy and combinations of the most commonly used systemic treatments and brain radiation therapy (RT).Brain metastases (BMs) are common among patients affected by HER2+ metastatic breast cancer (>30%). The management of BMs is usually multimodal, including surgery, radiotherapy, systemic therapy and palliative care. Standard brain radiotherapy (RT) includes the use of stereotactic radiotherapy (SRT) for limited disease and whole brain radiotherapy (WBRT) for extensive disease. The latter is an effective palliative treatment but has a reduced effect on brain local control and BM overall survival, as it is also associated with severe neurocognitive sequelae. Recent advances both in radiation therapy and systemic treatment may change the paradigm in this subset of patients who can experience long survival notwithstanding BMs. In fact, in recent studies, SRT for multiple BM sites (>4) has shown similar efficacy when compared to irradiation of a limited number of lesions (one to three) without increasing toxicity. These findings, in addition to the introduction of new drugs with recognized intracranial activity, may further limit the use of WBRT in favor of SRT, which should be employed for treatment of both multiple-site BMs and for oligo-progressive brain disease. This review summarizes the supporting literature and highlights the need for optimizing combinations of the available treatments in this setting, with a particular focus on radiation therapy.

Care Outcomes for Chiropractic Outpatient Veterans (COCOV): a single-arm, pragmatic, pilot trial of multimodal chiropractic care for U.S. veterans with chronic low back pain

BackgroundOver 25% of veterans seeking care at U.S. Veterans Health Administration facilities have chronic low back pain (LBP), with high rates of mental health comorbidities. The primary objective of this study was to assess the feasibility of participant recruitment, retention, and electronic data collection to prepare for the subsequent randomized trial of multimodal chiropractic care for pain management of veterans with chronic low back pain. The secondary objectives were to estimate effect sizes and variability of the primary outcome and choose secondary outcomes for the full-scale trial.MethodsThis single-arm pilot trial enrolled 40 veterans with chronic LBP at one Veterans Health Administration facility for a 10-week course of pragmatic multimodal chiropractic care. Recruitment was by (1) provider referral, (2) invitational letter from the electronic health record pre-screening, and (3) standard direct recruitment. We administered patient-reported outcome assessments through an email link to REDCap, an electronic data capture platform, at baseline and 5 additional timepoints. Retention was tracked through adherence to the treatment plan and completion rates of outcome assessments. Descriptive statistics were calculated for baseline characteristics and outcome variables.ResultsWe screened 91 veterans over 6 months to enroll our goal of 40 participants. Seventy percent were recruited through provider referrals. Mean age (range) was 53 (22–79) years and 23% were female; 95% had mental health comorbidities. The mean number of chiropractic visits was 4.5 (1–7). Participants adhered to their treatment plan, with exception of 3 who attended only their first visit. All participants completed assessments at the in-person baseline visit and 80% at the week 10 final endpoint. We had no issues administering assessments via REDCap. We observed clinically important improvements on the Roland-Morris Disability Questionnaire [mean change (SD): 3.6 (6.1)] and on PROMIS® pain interference [mean change (SD): 3.6 (5.6)], which will be our primary and key secondary outcome, respectively, for the full-scale trial.ConclusionsWe demonstrated the feasibility of participant recruitment, retention, and electronic data collection for conducting a pragmatic clinical trial of chiropractic care in a Veterans Health Administration facility. Using the pilot data and lessons learned, we modified and refined a protocol for a full-scale, multisite, pragmatic, National Institutes of Health-funded randomized trial of multimodal chiropractic care for veterans with chronic LBP that began recruitment in February 2021.Trial registrationClinicalTrials.gov NCT03254719

Implementing Enhanced Recovery After Surgery Across a United States Health System.

Enhanced recovery after surgery (ERAS) is a series of evidence-based perioperative care protocols designed to improve outcomes following surgery. The concept was founded on the principle of producing a predictable quality outcome by reducing morbidity and shortening hospital stay. The key objective of ERAS is to incorporate optimized multimodal perioperative care in a variety of different surgical specialties to reduce injury and stress during the perioperative period and promote a return to normal function rapidly.

Prehabilitation – Current Role in Surgery

&lt;b&gt;Introduction:&lt;/b&gt; Prehabilitation entails preoperative activities designed to properly prepare a patient to undergo surgery and to improve their postoperative recovery. It follows an interdisciplinary approach by improving physical fitness and nourishment status, using mental training and encouraging them to quit addictions. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Aim:&lt;/b&gt; The aim of the study was to investigate the recent publications in the field of prehabilitation.&lt;/br&gt;&lt;/br&gt; &lt;b&gt; Methods:&lt;/b&gt; We performed a systematic review in the PubMed database using the search term “preopreative OR before surgery, postoperative OR after surgery, prehabilitation”. The inclusion criteria were studies with a minimum population of 50 patients, including preoperative interventions, defined with a word prehabilitation, and describing their impact on the postoperative course of the patients. A total of 373 records were returned and 13 studies were finally included in the analysis. &lt;/br&gt;&lt;/br&gt; &lt;b&gt; Results:&lt;/b&gt; According to the selected studies, prehabilitation significantly improves postoperative complication rate, length of hospital stay, postoperative physical activity, treatment costs, perioperative transfusion rate, antibiotic administration, and patients’ adherence to postoperative recommendations. On the other hand, no statistically significant impact was found for prehabilitation on quality of life, psychological condition, readmission rate, or reoperations. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Discussion:&lt;/b&gt; Prehabilitation promotes the development of multimodal care, putting the patient’s well-being in the center. Numerous studies have indicated positive results from prehabilitation programs. The final results depend on the prehabilitation protocol, the group of patients, and the standard of care of the center. &lt;/br&gt;&lt;/br&gt; &lt;b&gt;Conclusion:&lt;/b&gt; Prehabilitation is necessary to provide the highest quality of care for a surgical patient. An interdisciplinary approach benefits the patient during the operation as well as in the postoperative period. Every surgical clinic should be aware of the concept of prehabilitation and should possibly create their own programs.