Use of ondansetron in palliative medicine

Ondansetron was the first of several selective 5-hydroxytryptamine (5-HT3) antagonists to be available as an antiemetic. Its uses in the setting of highly and moderately emetogenic chemotherapy and radiotherapy are well established. Ondansetron has also been used to manage nausea and vomiting in other patients. We report a retrospective analysis of its use in all 16 patients who were commenced on ondansetron after admission to our institution for nausea and/or vomiting over a 4-year period. Nine patients had advanced human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), and seven had malignancy. These patients were not undergoing disease-modifying treatment and had inadequate responses to therapeutic doses of standard antiemetics, used either singly or in combination. Responses were independently reviewed and graded by two investigators. Response was judged at 48 hr after commencing therapy. Potential causes of nausea were also reviewed. Overall, 13 of 16 [81%, 95% confidence interval (CI) 54%-96%] derived benefit. Twelve of 15 patients (80%) with nausea had a demonstrable improvement, and ten of 14 patients (71%) with vomiting also improved. Eight of ten patients (80%) admitted with nausea and/or vomiting as one of their presenting problems had the symptom controlled within 48 hr of ondansetron therapy. Treatment with ondansetron was well tolerated, onset of action was rapid, and response rates were high and sustained over time. Seven of the 16 patients continued ondansetron therapy for more than 10 days. With minimal reductions in inpatient bed stays, the total costs of ondansetron could be met while at the same time better supporting patients remaining in the community.

Managing HIV. Part 5: Treating secondary outcomes. 5.19 HIV and palliative care

The goals of palliative care are the relief of pain and suffering in advanced disease and the support of the patient's carers. In HIV medicine, good palliative care often includes active treatment, and the palliative care team may work in support of the primary care doctor.

The management of spinal cord compression in patients with advanced malignancy

We retrospectively evaluated the medical records of 17 hospice patients who developed spinal cord or cauda equina compression due to metastatic epidural tumor to ascertain the nature and outcome of the disorder in this setting. Epidural compression occurred following admission to the hospice in five cases and prior to admission in 12 cases. Six patients were ambulatory following treatment, and this favorable outcome occurred only in those who were ambulatory at diagnosis. In the group of patients who were paraplegic after treatment, problems related to pain, decubitus ulcers, and constipation were most challenging. This experience highlights the need for a more vigilant approach to back pain in patients at risk of epidural compression in the hospice setting. Further studies are necessary to establish the appropriate management of these patients.

What is "high"? The development of reference points for "high" and "low"

Young children have been characterized as interpreting relative adjectives as if they were nominal or categorical terms. The categorical interpretation of relative terms, however, may be quite complex. Indeed, the mature understanding of relative terms would seem to include a complex system of reference points for the terms' categorical usages. In 5 experiments we examined the complexity of 3-5-year-old children's and adults' categorical interpretations. We specifically examined how reference points for the categorical interpretation of high and low are defined. The definition of reference points relative to the object judged, the vertical position of the observer, and the extent of vertical variation were assessed. 3 major developmental trends were observed: a trend from the application of the terms to only extreme values to their application to broader categories; a trend from nominal-like categories to ones defined flexibly relative to context (e.g., nature of object judged, and extent of vertical variation); and a trend from reference points functioning as focal points to their operating as directional category boundaries. In brief, the results suggest that the categorical usage of relative terms involves a rich and intricate knowledge system and that it takes children considerable time to acquire and organize the relevant pieces of knowledge.