Nausea: the neglected symptom?

Management of opioid-induced nausea and vomiting in cancer patients: systematic review and evidence-based recommendations

The objectives were to review the existing literature on management of opioid-induced nausea and vomiting in cancer patients and summarize the findings into evidence-based recommendations. Systematic searches of MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were performed, using free text and MeSH/EMTREE search terms. The searches were limited to articles published in English from each database set-up date to 31 July 2009. Reference lists and relevant international conference proceedings were hand-searched. Fifty-five studies were identified, providing data on 5741 patients. The studies were classified into: (A) studies in which treatment of nausea/vomiting was the primary outcome (a total of 18 studies, of which eight studies specifically addressed opioid-induced emesis); and (B) studies in which nausea/vomiting were secondary or tertiary outcomes (37 studies). The existing evidence had several limitations, there was a lack of consistency and the overall quality was grade D. By applying the principles of the Grading of Recommendations Assessment, Development and Evaluations (GRADE) system, three weak recommendations were formulated. The current evidence is too limited to give evidence-based recommendations for the use of antiemetics for opioid-induced nausea or vomiting in cancer patients. The evidence suggests that nausea and vomiting in cancer patients receiving an opioid might be reduced by changing the opioid or opioid administration route. The evidence was also too limited to prioritize between symptomatic treatment and adjustment of the opioid treatment.

Implementation of best practice for chemotherapy-induced nausea and vomiting in an acute care setting

BACKGROUND

Chemotherapy-induced nausea and vomiting is the commonest side-effect for patients undergoing cancer treatment with chemotherapy. These symptoms can lead to nutritional deficiencies, dehydration and electrolyte imbalance, and negative impacts on quality of life. However, wide gaps exist between clinician and patient perceptions of nausea and vomiting. Effective communication about these symptoms is essential for proper treatment. We conducted a recent chart review to identify gaps in practice regarding chemotherapy-induced nausea and vomiting assessment and documentation.

AIM

The goal of this project was to improve local practice in the management of chemotherapy-induced nausea and vomiting in patients with cancer.

METHODS

This study used one pre- and two post-implementation audit strategies utilising the Joanna Briggs Institute Practical Application of Clinical Evidence System (JBI-PACES) and Getting Research into Practice (GRiP) module. The study was conducted in the 33-bed oncology ward of a large acute care hospital in Korea from February 2010 to June 2010. To facilitate evidence-based nursing practice, audit-feedback-re-audit cycles strategies were used. The audits included four criteria recommended by the Joanna Briggs Institute.

RESULTS

There were statistically significant improvements in all four criteria. The first post-implementation audit showed that all four audit criteria rated >50% in compliance. At the second follow-up audit, all four audit criteria rated 100% compliance, indicating excellent compliance with best practice. The differences between the pre- and post-data were statistically significant (P < 0.001) for all four audit criteria.

CONCLUSIONS

The results indicate that the pre- and post-implementation audits are an effective method in improvement of assessment, documentation and evidence-based nursing implementation for cancer symptom management.

Inadequate symptom control in advanced cancer patients across Europe

PURPOSE

The purpose of this study is to examine the adequacy of treatment for constipation, nausea, depression and poor sleep and the factors associated with inadequate symptom control in cancer patients receiving opioids.

METHODS

Patients receiving strong opioids for cancer pain were recruited from 17 centres in 11 European countries. By using the European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire C30, 1,938 patients reported their symptoms at four-point scales. Health care providers assessed symptoms at corresponding four-point scales and registered use of medications, demographic and disease-related variables. Symptomatic treatment was scored as 1 if not administered during the past 24 h and as 2 if administered. Adequacy of treatment was evaluated by subtracting the patients' symptom score from the treatment score. Negative scores, caused by either no treatment or ineffective treatment of a symptom, were interpreted as inadequate treatment.

RESULTS

Approximately 60% of patients with constipation, depression or poor sleep and 45% of nauseated patients were inadequately treated. Numbers of inadequately treated patients varied between countries. In general, underestimation of symptom intensity by health care providers (p < 0.001), low performance status (p < 0.05) and recent initiation of opioids (p < 0.05) increased the risk of inadequate treatment. The subset of demographic- and disease-related factors associated with inadequate treatment varied between the symptoms investigated.

CONCLUSIONS

Inadequate treatment, either no treatment or ineffective treatment, was frequent in cancer patients. There were subgroups of patients at particular risk for inadequate treatment, which might need additional attention from health care providers for achievement of adequate symptom control.

Cannabinoid-induced reduction in antral pacemaker frequency: a telemetric study in the ferret

BACKGROUND

The gastric myoelectric activity (GMA) is the electrical pacesetter potential, which drives gastric motility. Cannabinoids have broad-spectrum antiemetic and antinauseant activity. Paradoxically, they inhibit intestinal peristalsis and reduce gastric motility but their effect on GMA remains unknown.

METHODS

Ferrets were surgically implanted with radiotelemetry transmitters to record GMA, body temperature and heart rate. The effect of WIN 55,212-2 (1 mg kg(-1), i.p.), an agonist at the cannabinoid type 1 and 2 receptors was examined in conscious, unrestrained ferrets. WIN 55,212-2 was also compared to the anandamide upregulator URB 597 (5 mg kg(-1), i.p.) for a potential to modulate the emetic response and behavioral changes induced by apomorphine (0.25 mg kg(-1), s.c.).

KEY RESULTS

WIN 55,212-2 decreased GMA frequency (8.1 ± 0.4 cpm, compared to 9.6 ± 0.1 cpm in vehicle-treated animals, n = 6, P < 0.01). Apomorphine induced 9.0 ± 1.6 emetic episodes, WIN 55,212-2 inhibited the emetic response (3.3 ± 1.0 episodes, n = 6, P < 0.05) but URB 597 had no effect (9.0 ± 1.5 episodes). Apomorphine-induced hyperactivity in vehicle-treated animals (6.5 ± 3.6-16.6 ± 4.9 active behavior counts, n = 6, P < 0.01), which was reduced by WIN 55,212-2 (5.0 ± 1.5 counts, n = 6, P < 0.05).

CONCLUSIONS & INFERENCES

WIN 55,212-2 demonstrated clear antiemetic efficacy, which extends the broad-spectrum antiemetic efficacy of cannabinoids to dopamine receptor agonists in the ferret. Our results, however, suggest a more limited spectrum of action for URB 597. WIN 55,212-2 decreased the frequency of the antral electrical pacemaker, which reveals new insights into the mechanism regulating the decrease in motility induced by cannabinoids.

Risk factors at pretreatment predicting treatment-induced nausea and vomiting in Australian cancer patients: a prospective, longitudinal, observational study

PURPOSE

Despite significant advances in antiemetic management, almost 50% of cancer patients still experience nausea and vomiting during treatment. The goal of antiemetic therapy is complete prevention of treatment-induced nausea and/or vomiting (TINV); however, realisation of this goal remains elusive, thus supplementary strategies identifying patients at high risk must be employed in the interim. Consequently, we examined TINV incidence and its risk factors, including patient, clinical and pretreatment quality of life (QOL)/psychological factors.

METHODS

Two hundred newly diagnosed cancer patients beginning combined treatment participated in this prospective, longitudinal, observational study. QOL (including TINV), psychological adjustment, and patient/clinical characteristics were examined at pretreatment, on-treatment (8 weeks ± 1 week) and post-treatment.

RESULTS

Overall, 62% of patients experienced TINV, with TIN incidence (60%) doubling that of TIV (27%). Eight independent risk factors predicted 73% of TIN incidence: high premorbid/anticipatory NV, moderately/highly emetogenic chemotherapy (M/HEC), longer treatment (>3 months), female gender, surgery prior to adjuvant chemotherapy ± radiotherapy, private health insurance and low emotional functioning (pretreatment). Six independent risk factors predicted 77% of TIV incidence: premorbid/anticipatory vomiting, M/HEC, female gender, cancer resection and low role functioning (pretreatment).

CONCLUSIONS

TINV still represents a very major concern for patients. Several pretreatment risk factors for the development of TIN and TIV, respectively, were identified. Patients about to undergo cancer treatment, particularly combined treatment involving emetogenic chemotherapy and surgery, should be screened for these factors with a view to modifying standard pretreatment/maintenance antiemetic therapy. Furthermore, and consistent with recent research, it is recommended that more comprehensive interventions combining antiemetics with other effective pharmacological (e.g. anxiolytics) and non-pharmacological approaches (e.g. acupuncture, relaxation techniques) be considered by clinicians in attempts to improve control of TIN and TIV (and overall QOL) for their patients. In this way, optimal holistic care will be ensured for cancer patients by clinicians providing conventional oncology treatment.

Reduction of chemotherapy-induced anorexia, nausea, and emesis through a structured nursing intervention: a cluster-randomized multicenter trial

OBJECTIVES

The purpose of this present study was to evaluate Self-care Improvement through Oncology Nursing (SCION) program to reduce distressing anorexia, nausea, and emesis (ANE) in cancer patients undergoing chemotherapy.

METHODS

Two hundred eight patients receiving chemotherapy with moderate to high emetogenic potential participated in a cluster randomized trial on 14 wards in two German university hospitals. Additionally to standard antiemetic treatment, patients from the intervention wards received the SCION program consisting of four modules: advisory consultation, optimizing emesis prophylaxis, nutrition counseling, and relaxation. Patients from the control group received standard antiemetic treatment and standard care. Primary outcome was the group difference in ANE intensity assessed by Common Terminology Criteria for adverse events (CTCAE).

MAIN RESULTS

The SCION program did not result in a significant difference in the incidence of ANE symptoms as compared to standard care: mean difference on CTCAE scale was 0.24 pts (95%CI, -1.17 to 1.66 pts; P = 0.733). No difference could be found regarding patients' knowledge of side effects, self-care interventions, and agency. Health-related quality of life was significantly better for patients in the control group (mean difference 10.2 pts; 95%CI, 1.9 to 18.5; P = 0.017).

CONCLUSIONS

Contrary to our expectations, the groups did not differ in ANE intensity caused by the overall low acute or delayed symptom intensity. Symptom hierarchy in cancer patients alters and challenges nursing interventions targeting the patients' self-care strategies.

[Descriptive study of nursing-sensitive outcomes in oncohematological patients and nursing interventions]

OBJECTIVE

To assess the main nursing-sensitive outcomes in oncohematological patients admitted to hospital and to evaluate nursing interventions.

MATERIAL AND METHODS

We performed a prospective, observational study in the oncohematological units of the Morales Meseguer Hospital. The sample included patients admitted from March 2006 to June 2007.

RESULTS

A total of 56 patients were studied. Of these, 39 patients (69.6%) had some degree of mucositis but only six patients (10.7%) were assessed objectively by nurses. Fifty-two patients (92.9%) received anti-emetic treatment, but there were no reports of nausea or vomiting in 27 (48.2%). Ten patients (17.9%) were referred to the nutritional unit. Anxiety levels and psychosocial impact decreased during hospital admission and patient satisfaction increased but family members experienced greater stress. Pressure ulcer developed in only one patient. Four catheters (8.2%) became infected and there were five cases of catheter-related bacteremia. There were 22 cases of catheter obstruction (39.9%).

CONCLUSIONS

The incidence of mucositis, pressure ulcer and catheter-related bacteremia was lower than in other studies. There was no standard assessment of pain, nausea or vomiting. Anxiety levels were lower than in other studies. Improvement and psychosocial adjustment suggested a process of adaptation to the disease. The increase in caregiver burden was related to the disease in the long term. Satisfaction with nursing care was 55 points on a 70-point scale.

Clinical Predictors of Chemotherapy-Induced Nausea and Vomiting in Breast Cancer Patients Receiving Adjuvant Doxorubicin and Cyclophosphamide

Background:

Patients with breast cancer often receive emetogenic anthracycline–based chemotherapy as part of their treatment. Chemotherapy-induced nausea and vomiting (CINV) has been commonly reported as one of the distressing adverse effects among patients with cancer. Despite the advent of newer antiemetics and better understanding of the CINV pathophysiology, total eradication of CINV has yet to be achieved.

Objective:

To assess the incidence of nausea and vomiting in patients who have breast cancer and are receiving adjuvant doxorubicin and cyclophosphamide (AC) bolus chemotherapy, ascertain patients’ risk factors affecting CINV response, and study patient adherence to delayed antiemetics.

Methods:

This was a single-institution, prospective, observational study conducted at an outpatient cancer center in Singapore from December 2006 to December 2007. Clinical events such as CINV were collated using a standardized diary. Use of rescue antiemetics and unscheduled clinic visits due to CINV were documented.

Results:

Of a total of 108 participants, 16 patients were lost to follow-up and 1 provided incomplete information; thus, 91 patients were included in the analysis. Delayed antiemetics were given according to the institution's guideline and only 9 (9.9%) patients received aprepitant. Neither acute nor delayed vomiting was reported by a majority of patients and only 4 (4.4%) experienced grade 3 vomiting. The incidence of severe nausea was highest on day 3 of chemotherapy and affected 14.3% of patients. Anxiety and history of chemotherapy-induced nausea were associated with both acute and delayed nausea, and history of motion sickness was associated with delayed vomiting. Approximately 65% of patients were adherent to their prescribed delayed antiemetics.

Conclusions:

Most of our patients adhered to their antiemetics and tolerated AC chemotherapy reasonably well, without vomiting; yet nausea persisted. To improve CINV control, clinicians must actively communicate with patients to facilitate accurate assessment of risk factors and CINV response and to encourage adherence to delayed antiemetics.

Potential of the rat model of conditioned gaping to detect nausea produced by rolipram, a phosphodiesterase-4 (PDE4) inhibitor

Rolipram, a phosphodiesterase-4 (PDE4) inhibitor, is of current interest as a cognitive enhancer and as a treatment for inflammatory diseases. Originally developed as an anti-depressant, rolipram's efficacy was limited due to its side effects of nausea and vomiting. The experiments reported here evaluated the potential of rolipram to produce conditioned gaping (a selective measure of nausea in rats) to a flavor in the taste reactivity test (Experiment 1) and to a context (Experiment 2). In Experiment 1, rats were intra-orally infused with 17% sucrose solution prior to being injected with rolipram (Vehicle, 0.03, 0.1 or 0.3 mg/kg). Following 3 conditioning trials, rats conditioned with 0.3 mg/kg rolipram displayed conditioned gaping reactions during the infusion of sucrose. In Experiment 2, rats received 4 conditioning trials in which they were injected with 0.3 mg/kg rolipram and placed into a distinctive chamber. At test, when returned to the chamber rats displayed conditioned gaping. These results demonstrate the ability of the conditioned gaping model to detect the nauseating properties of a rolipram-paired flavor (Experiment 1) and rolipram-paired context (Experiment 2), further validating the potential use of the conditioned gaping model as a pre-clinical screening tool to evaluate the side effect of nausea produced by newly developed drugs.

Understanding the concept of chemotherapy-related nausea: the patient experience

The aim of this study was to explore the experience of chemotherapy-related nausea in patients with cancer. A qualitative study was carried out with 17 patients who had experienced nausea during their chemotherapy in the UK and USA. Nausea was described as distressing and complex symptom. Patients attempted to construct an understanding of nausea using cognitive processes such as analysing their experience of nausea and related symptoms, attributing causation to nausea and comparing their experiences not only to their own expectations, but also to others' symptom experiences. A number of concurrent and associated symptoms linked with nausea were identified. Preliminary evidence emerged for nausea as part of a cluster of symptoms. Anti-emetic medication, provider-directed management strategies and self-management strategies were used by patients to minimize the effects of nausea. Self-management techniques, such as dietary strategies, were rooted in participants' understanding of nausea and their beliefs about what caused nausea, and there was little evidence of guidance from professionals beyond advice about medication management. This study reveals some of the complexities behind chemotherapy-induced nausea, including a potential symptom cluster, and contributes towards a clearer understanding of this symptom and its effects on patients' lives.

Hormones of the gut-brain axis as targets for the treatment of upper gastrointestinal disorders

The concept of the gut forming the centre of an integrated gut-brain-energy axis - modulating appetite, metabolism and digestion - opens up new paradigms for drugs that can tackle multiple symptoms in complex upper gastrointestinal disorders. These include eating disorders, nausea and vomiting, gastroesophageal reflux disease, gastroparesis, dyspepsia and irritable bowel syndrome. The hormones that modulate gastric motility represent targets for gastric prokinetic drugs, and peptides that modify eating behaviours may be targeted to develop drugs that reduce nausea, a currently poorly treated condition. The gut-brain axis may therefore provide a range of therapeutic opportunities that deliver a more holistic treatment of upper gastrointestinal disorders.

The effect of cannabidiol and URB597 on conditioned gaping (a model of nausea) elicited by a lithium-paired context in the rat

RATIONALE

Anticipatory nausea (AN) experienced by chemotherapy patients is resistant to current anti-nausea treatments. In this study, the effect of manipulation of the endocannabinoid (EC) system on a rat model of nausea (conditioned gaping) was determined.

OBJECTIVE

The potential of cannabidiol (CBD) and the fatty acid amide hydrolase (FAAH) inhibitor, URB597 (URB) to reduce conditioned gaping in rats were evaluated.

MATERIALS AND METHODS

In each experiment, rats received four conditioning trials in which they were injected with lithium chloride immediately before placement in a distinctive odor-laced context. During testing, in experiment 1, rats were injected with vehicle (VEH), 1, 5 or 10 mg/kg CBD 30 min before placement in the context previously paired with nausea and in experiment 2, rats were injected with VEH, 0.1 or 0.3 mg/kg URB 2 h before placement in the context. Additional groups evaluated the ability of the CB(1) antagonist/inverse agonist, SR141716A, to reverse the suppressive effects of URB. Experiment 3 measured the potential of URB to interfere with the establishment of conditioned gaping.

RESULTS

When administered before testing, CBD (1 and 5, but not 10 mg/kg) and URB (0.3, but not 0.1 mg/kg) suppressed conditioned gaping. The effect of URB was reversed by pre-treatment with the CB(1) antagonist/inverse agonist, SR141716A. When administered before conditioning, URB also interfered with the establishment of conditioned gaping.

CONCLUSIONS

Manipulations of the EC system may have therapeutic potential in the treatment of AN.

A prospective observational study of chemotherapy-related nausea and vomiting in routine practice in a UK cancer centre

OBJECTIVE

The aim of the study was to assess levels of chemotherapy-induced nausea and vomiting (CINV) in routine practice.

MATERIALS AND METHODS

The study was an observational prospective evaluation using patient self-reports. One hundred and two patients with cancer in a single cancer centre in UK receiving their first chemotherapy treatment participated in the study and were followed up over four cycles, providing a total of 272 assessments of nausea and vomiting. Data was collected with the use of the MASCC Antiemesis Tool (MAT), which is an eight-item short clinical scale assessing acute and delayed nausea and vomiting after chemotherapy.

RESULTS

Results indicated that acute vomiting was experienced by 15.7% of the patients in cycle 1 and delayed vomiting by 14.7%, while acute nausea was present in 37.3% of the patients and delayed nausea in 47.1%, increasing over the subsequent cycles. Moderately emetogenic and highly emetogenic chemotherapy had the highest incidence of CINV, whereas patients receiving highly emetogenic chemotherapy showed significant levels of delayed nausea. Acute symptoms were more easily controlled than delayed symptoms.

DISCUSSION

The data suggest that, while vomiting is well controlled, nausea remains a significant problem in practice, and optimal management of CINV is yet to be achieved. Understanding more clearly the biological basis of nausea will assist in managing this complex symptom more effectively in practice.

Exposure to a context previously associated with nausea elicits conditioned gaping in rats: a model of anticipatory nausea

Following one or more chemotherapy treatments, many patients report that they experience anticipatory nausea. This phase of nausea has been interpreted as a classically conditioned response where a conditional association develops between the contextual clinic cues and the nausea and/or vomiting that developed following treatment. Although rats do not vomit, they display a distinctive gaping reaction when exposed a flavored solution previously paired with a toxin. Here we report that, even in the absence of a flavored solution, rats display conditioned gaping reactions during exposure to a distinctive context previously paired with a high dose of lithium (Experiment 1 with a distinctive odor and Experiment 3 without a distinctive odor), a low dose of lithium (Experiment 2) or provocative vestibular stimulation (Experiment 2). These results suggest that the conditioned gaping reaction in rats is selectively elicited by nausea-paired contextual stimuli, as well as flavors. This rat model of anticipatory nausea may serve as a valuable preclinical tool to evaluate the effectiveness of anti-nausea treatments and the side effect of nausea produced by newly developed pharmaceutical compounds intended for other clinical treatments.

Validation and psychometric assessment of a short clinical scale to measure chemotherapy-induced nausea and vomiting: the MASCC antiemesis tool

There is a lack of clinical tools to facilitate communication between clinicians and patients about chemotherapy-induced nausea and vomiting (CINV). The Multinational Association of Supportive Care in Cancer (MASCC) has developed such a tool, which is an eight-item scale for the assessment of acute and delayed nausea and vomiting, and is completed once per cycle of chemotherapy. The aim of the current study was to assess its psychometric properties, specifically reliability and validity, cultural transferability and equivalence, and congruence with proxy assessments, as well as to determine if accuracy of recall of CINV events using the MASCC Antiemesis Tool (MAT) differed over time from chemotherapy. A prospective study was carried out with adult cancer patients and their informal carers from two hospitals, one each in the United Kingdom (UK) and United States of America (U.S.). Patients completed the Rhodes Index for nausea, vomiting and retching (INVR) daily for the first five days after chemotherapy and were then asked to complete the MAT at one week, two weeks, or three weeks after chemotherapy. Carers completed an adapted MAT concurrently with patients. The sample consisted of 87 patients and 22 informal carers. The internal consistency reliability of the scale was high, with Cronbach alphas of 0.77 (patient sample) and 0.82 (carer sample). Responses were similar between the UK and U.S. samples in terms of nausea and vomiting, and both samples found the scale easy to use. Contrasted-groups validity (using age as a grouping variable) and concurrent validity (MAT compared with INVR) suggested that the scale is sensitive to detect the different dimensions of CINV and performed well against a daily assessment of nausea/vomiting (total score correlation r=0.86, P<0.001). Recall of events was high even three weeks after chemotherapy (correlations with INVR of 0.44-0.99, all P<0.01). Factor analysis clearly identified three factors, namely vomiting, acute nausea, and delayed nausea. Proxy assessments by carers were congruent with the patients' responses, especially in relation to vomiting. The MAT is a reliable, valid, clear, and easy-to-use clinical tool that could facilitate discussion between clinicians and patients about their nausea and vomiting experience, thereby potentially aiding treatment decisions. Regular assessment of nausea and vomiting after chemotherapy has the potential to significantly improve CINV management.

Quality of life of women with gynecologic cancer: associated factors

OBJECTIVE

To evaluate quality of life (QOL) and identify its associated factors in a cohort of women with gynecologic cancer.

METHODS

A cross-sectional study was conducted, including 103 women with cervical or endometrial cancer, aged between 18 and 75 years who were receiving their entire treatment at the institution where the investigation was carried out. QOL was measured by the World Health Organization's QOL instrument-abbreviated version (WHOQOL-BREF). Clinical and sociodemographic characteristics, in addition to prevalence of cancer-related symptoms prior to radiotherapy were investigated. Bivariate analysis was performed, applying the Mann-Whitney test. Multivariate analysis was used to identify factors associated with QOL.

RESULTS

The mean age of the participants was 56.8 +/- 11.6 years. The study included 67 (65%) women with cervical cancer and 36 (35%) women with endometrial cancer. Most participants were at an advanced stage (63.1%). The most common complaints were pain (49.5%) and vaginal bleeding (36.9%). The prevalence of anemia was 22.3%. On multivariate analysis, it was observed that anemia (P = 0.006) and nausea and/or vomiting (P = 0.010) determined impairment in physical domain. Pain negatively influenced physical domain (P = 0.001), overall QOL (P = 0.024), and general health (P = 0.013), while the history of surgery positively affected general health (P = 0.001).

CONCLUSION

Cancer-related symptoms were factors that most interfered with QOL in women with gynecologic cancer. Therefore, more attention should be focused on identifying these symptoms, adopting measures to minimize their repercussions on QOL.

Interactions between metoclopramide and morphine: enhanced antinociception and motor dysfunction in rats

1. Opioid analgesics and anti-emetics are often used concomitantly to treat pain and nausea and vomiting in people with malignant disease. We investigated interactions between the opioid analgesic morphine and the anti-emetic metoclopramide, a dopamine D2 receptor antagonist, on nociception and gross motor function. 2. To assess for antinociceptive interactions, 11 Sprague-Dawley rats were injected intraperitoneally with morphine (5.0 mg/kg) or saline in combination with metoclopramide (0.5, 1.5 and 5.0 mg/kg) or saline and, 30 min later, the tail-flick latencies to a noxious thermal stimulus (49 degrees C water) were measured. Immediately thereafter we induced reperfusion hyperalgesia in the rats' tails using a tourniquet cuff and tested nociception again. Because, in addition to its ability to block D2 receptors, metoclopramide is also a weak 5-HT(3) receptor antagonist, we assessed in a further 11 rats whether any antinociceptive interactions occurred between morphine (5.0 mg/kg) and ondansetron (0.2 and 2.0 mg/kg), an anti-emetic that selectively antagonizes 5-HT(3) receptors. To assess for motor interactions, we injected another group of nine rats with morphine (5.0 mg/kg) or saline in combination with metoclopramide (0.5 and 5.0 mg/kg) or saline and tested the ability of the animals to run on an 80 mm diameter rod rotating at 25 r.p.m. for 30 min. 3. Metoclopramide was not inherently analgesic or antihyperalgesic, but the highest dose of metoclopramide (5.0 mg/kg) enhanced the analgesic and antihyperalgesic effects of morphine. Neither dose of ondansetron was analgesic or antihyperalgesic or enhanced the antinociceptive actions of morphine. 4. Only the high dose of metoclopramide compromised running performance when administered with saline. However, coadministering morphine with metoclopramide (both doses) decreased motor performance. 5. Therefore, metoclopramide, possibly through its actions on D2 receptors and not 5-HT(3) receptors, enhances the analgesic and antihyperalgesic effects of morphine, but morphine exacerbates metoclopramide-induced motor dysfunction in rats.

Novel therapeutic approaches in pediatric and young adult sarcomas

Novel therapy as part of sarcoma treatment schemas can enhance quality of life and is important in improving outcomes of high-risk sarcomas. Additional chemotherapy and biotherapy options to reduce tumor burden and prevent metastases include intra-arterial chemotherapy in osteosarcoma; intrapleural chemotherapy, aerosol 9-nitrocamptothecin, or protracted irinotecan and temozolomide in Ewing's sarcoma; continuous hyperthermic peritoneal perfusion for malignancy involving the peritoneum, such as desmoplastic small round cell tumor; and ifosfamide with muramyl tripeptide phosphatidyl ethanolamine liposomes in osteosarcoma. These treatments bring improved control of symptoms, including reduction in nausea, mucositis, cardiotoxicity, and central nervous system toxicity. Portable infusion devices have facilitated introduction of outpatient doxorubicin, ifosfamide, and methotrexate regimens and home-infusion irinotecan. Physical approaches to eliminate sarcoma tumors and metastases are critical for durable responses. Novel local control measures include embolization before surgery, radiosensitization, anti-vascular endothelial growth factor therapy during chemo-radiotherapy, proton therapy, samarium, thermal ablation (radiofrequency ablation), and cryoablation.

Postoperative effects of opioid analgesics administered via continuous perfusion and patient controlled analgesia after open heart surgery

Critical care nurses and physicians are familiar with the principles of patient controlled analgesia and the opioid analgesics' regimens and observations necessary for pain control in the postoperative cardiac surgical patients. The objective of the study was to compare the effects of morphine, fentanyl, meperidine, remifentanil and tramadol which were administered by patient controlled analgesia and continuous intravenous infusion combination on the various parameters. This study was designed as prospective randomised trial. Fifty patients undergone open heart surgery with sternotomy were entered equally into five randomized groups. Visual analog scale was used by researcher nurse to assess the patient' pain status. Respiratory rate, heart rate and blood gases (pO2, pCO2, SaO2), radial arterial blood pressures were measured in the first 24 hrs postoperatively. Bolus requirements were determined by physicians and side effects of the analgesics were documented. Fentanyl group showed statistically higher levels of mean pO2 (p=0.002). Meperidine had the lowest number of bolus doses (p=0.001). There were no significant differences between the groups for pain management except higher visual analog scales on tramadol. Headache, stomach-ache and, palpitations were observed in our patients. Remifentanil, meperidine, fentanyl and morphine showed similar effect with each other for pain relief except tramadol.

Treatment of nausea and vomiting: gaps in our knowledge

The past 20 years have seen notable advances in our understanding of the physiology and pharmacology of the emetic reflex leading to the identification of the anti-emetic effects of 5-hydroxytryptamine(3) (5-HT(3)) and neurokinin(1) receptor (NK(1)) antagonists. The introduction of 5-HT(3) and NK(1) receptor antagonists into the clinic has had a major impact in alleviating the nausea and vomiting associated with the treatment of cancer and the sequelae to anaesthesia and surgery (post-operative nausea and vomiting, PONV). Despite these advances there are major gaps in our understanding. Interestingly, one of these is the relatively poor ability to treat nausea. Additional gaps in our knowledge are highlighted to provide a framework within which directions for research can be proposed. Particular attention is drawn to: lacunae in knowledge of some currently used anti-emetics such as the source of dopamine required to initiate emesis; the theoretical assumptions and mechanisms underlying the concept of a "universal anti-emetic"; the variety of receptors at which agonists act to have anti-emetic effects (GABA (B), CB(1), 5-HT(1A), ghrelin, opioid); issues of translation from animals to humans and the relationship between the pathways involved in emesis and certain gastrointestinal disorders such as dyspepsia and gastroesophageal reflux, with the latter being of particular interest as some agents affecting reflux are also anti-emetic. Together, the unmet clinical need to adequately control nausea, possibly by new drugs acting within the brainstem, and the significant gaps in understanding key aspects of the emetic reflex, suggest an important need to focus and re-direct research into the distressing and sometimes life-threatening symptoms of nausea and vomiting.

The continuing problem of post chemotherapy nausea and vomiting: contributions of classical conditioning

Despite continuing improvements in antiemetic therapies, nausea and vomiting following chemotherapy treatments for cancer remain significant clinical problems for many patients. The role of classical conditioning in patients' anticipatory nausea is well known, but little attention has been paid to possible conditioning effects on post treatment nausea. The present study statistically examined the contribution of anticipatory (conditioned) nausea to patients' subsequent post treatment nausea. Forty early stage breast cancer patients who developed anticipatory nausea were analyzed. Results revealed a significant correlation between the intensity of anticipatory nausea in the clinic prior to their treatment infusion and subsequent post treatment nausea during the 24 h after the infusion. These results provide support for the hypothesis that, once established, conditioned nausea may contribute to the severity of subsequent post treatment nausea in patients receiving repeated cycles of chemotherapy for cancer. The results suggest the importance of considering the contribution of conditioning process to nausea and other post treatment side effects.

Distress before chemotherapy predicts delayed but not acute nausea

INTRODUCTION

Posttreatment nausea (PTN) is a common side effect of cytotoxic cancer chemotherapy. Previous retrospective research has suggested that the severity of PTN may be, in part, related to pretreatment psychological factors (e.g., emotional distress and expectations for nausea).

MATERIALS AND METHODS

The purpose of the present study was to examine these relationships prospectively, with distress and nausea expectations assessed by validated self-report measures completed in the clinic before the participants' first outpatient treatment infusion and with PTN (0-100) assessed by end-of-day diaries completed at home on each of the first 5 days after treatment. The participants were chemotherapy-naive women (N=56) scheduled for standard adjuvant treatment for stage I-II breast cancer (mean age=45.6 years). PTN was evaluated for acute (days 0-1) and delayed (days 2-5) responses.

RESULTS

The results revealed a significant relationship between pretreatment distress and the severity of the patients' subsequent delayed nausea (p<0.007) but not a relationship with acute PTN (p<0.19). No significant relationships were seen between expectations and PTN. However, there was evidence of an additive effect of nausea expectations and distress, with the highest levels of delayed PTN seen in patients with both expectations and higher distress before treatment. The results suggest a selective effect of pre-infusion psychological variables on the delayed phase of nausea after chemotherapy, consistent with an emerging view that the different phases of nausea are mediated by different neural pathways.

CONCLUSION

Future research should examine the possibility that delayed nausea, which the literature suggests is more resistant to antiemetic drugs than acute nausea, might be responsive to psychological interventions before initial treatments.