Gastric Alimetry® Testing and Healthcare Economic Analysis in Nausea and Vomiting Syndromes.

BACKGROUND: Chronic nausea and vomiting syndromes (CNVS), gastroparesis and functional dyspepsia (FD) are complex disorders. Body Surface Gastric Mapping (BSGM), a new test of gastric function, using Gastric Alimetry® (Alimetry, New Zealand) may be useful for de-escalating healthcare utilisation. This study aimed to define healthcare costs and estimate health economic impacts of implementing this test in patients with chronic gastroduodenal symptoms. METHODS: Consecutive patients at a tertiary referral centre evaluated with Gastric Alimetry were included. Frequency and cost data relating to medical investigations, hospital and outpatient presentations were evaluated. Costs of healthcare utilisation were calculated, and the potential cost savings of implementing Gastric Alimetry within a diagnostic decision-tree model were estimated. RESULTS: Overall, 31 consecutive patients (mean age 36.1 years; 83.9% female; predominant symptoms: nausea [83.9%], pain [61.3%], vomiting [67.7%] and bloating [35.5%]) completed Gastric Alimetry testing. Repeat gastroscopy and abdominal CT rates were 29% (8/28) and 85% (11/13), respectively. Gastric Alimetry testing identified spectral abnormalities in 45.2% of patients, and symptom profiling classified a further 29.1% of patients. Median annualised cost difference after test introduction was NZ$-12,032. Estimated reductions in investigation-related costs when incorporating Gastric Alimetry into the diagnostic workflow model were approximately NZ$1,300 per patient. CONCLUSIONS: Healthcare utilisation and confirmatory testing rates remain high in nausea and vomiting syndromes. This study presents real-world data, together with a decision-tree analysis, showing Gastric Alimetry can streamline clinical care pathways, resulting in reduced healthcare utilisation and cost.

Translation and Psychometric Evaluation of the Hindi Language Version of the Pediatric Nausea Assessment Tool (PeNAT) in the Indian Population.

OBJECTIVES: To translate the Pediatric Nausea Assessment Tool (PeNAT) into Hindi and validate it in Indian pediatric cancer patients and survivors. METHODS: The PeNAT-Hindi was finalized by forward and backward translations, and pilot testing. The PeNAT-Hindi was administered to 200 Hindi-speaking pediatric (4-18 y) cancer patients/survivors, in three groups. These included pediatric cancer patients who had recently received chemotherapy (n = 150); who received no chemotherapy within 5 d (n = 25) and survivors (n = 25). Construct validity was tested by comparing scores among the three groups. Test-retest reliability and criterion validity were estimated by the correlation of the first PeNAT score with the second (taken 1 h later) PeNAT score and the number of vomiting/retching episodes, respectively. Convergent validity and discriminant validity were estimated by correlating PeNAT scores with parent-assessed nausea severity, and pain, respectively. The responsiveness was tested by comparing second PeNAT scores with subsequent divergent PeNAT scores among patients reporting subjective change (improvement and worsening, respectively) in nausea severity. RESULTS: Test-retest reliability of PeNAT-Hindi was good (intraclass correlation = 0.791). The initial PeNAT score had moderate correlation with the number of vomiting/retching episodes (Spearman ρ = 0.401). Median PeNAT scores in group 1 versus groups 2 and 3 were significantly different (p < 0.001). Initial PeNAT scores showed a moderate correlation with parent-assessed nausea (Spearman ρ = 0.657) and a weak correlation with parent-assessed pain (Spearman ρ = 0.319). The responsiveness (standardized response mean) of PeNAT-Hindi to the change in nausea severity was -1.79 (improvement) and 2.19 (worsening), respectively. CONCLUSION: PeNAT-Hindi showed good reliability and acceptable validity. It may be used among Hindi-speaking children for measuring nausea. The responsiveness of PeNAT-Hindi needs further evaluation.

Evaluation of a nausea assessment tool in the pediatric oncology population.

PURPOSE: Nausea is a symptom that is often experienced but misunderstood. Its impact is amplified in pediatric oncology patients. Nausea assessments in pediatric oncology are few and not yet widely used. The Baxter Retching Faces (BARF) scale holds promise and is used in some pediatric oncology units. The purpose of this evidence-based practice project was to evaluate the impact of the BARF scale on nursing assessments in inpatient pediatric hematology/oncology and stem cell transplant settings. CONCLUSIONS: Project work took place on one hematology/oncology unit and one stem cell transplant unit. Thirty nurses completed the acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM) to provide initial feedback on the BARF scale. Nurses used the BARF scale over an 8-week period. Patient demographics and BARF scores were collected during nausea assessments. Twenty nurses completed AIM/IAM/FIM scores postintervention. There were no significant changes in scores, though nurses stated that the tool was easy to use and provided valuable symptom feedback. PRACTICE IMPLICATIONS: Symptom management will continue to be a challenge in the pediatric setting given developmental and disease-specific considerations inherent to the specialty. While this small-scale project did not achieve statistical significance, the evidence and feedback from nursing staff present a compelling case that efforts to investigate and integrate improved methods of assessing nausea and other problematic symptoms are needed to enhance nursing practice and impact patient-centered outcomes.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment.

OBJECTIVES: Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care. DATA SOURCES: Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer. CONCLUSION: Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care. IMPLICATIONS FOR NURSING PRACTICE: Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

The preferences of women with ovarian cancer for oral versus intravenous recurrence regimens.

OBJECTIVE: To assess preferences of women with ovarian cancer regarding features of available anti-cancer regimens for platinum-resistant, biomarker-positive disease, with an emphasis on oral PARP inhibitor and standard intravenous (IV) chemotherapy regimens. METHODS: A discrete-choice-experiment preferences survey was designed, tested, and administered to women with ovarian cancer, with 11 pairs of treatment profiles defined using seven attributes (levels/ranges): regimen (oral daily, IV weekly, IV monthly); probability of progression-free (PFS) at 6 months (40%-60%); probability of PFS at 2 years (10%-20%); nausea (none, moderate); peripheral neuropathy (none, mild, moderate); memory problems (none, mild); and total out-of-pocket cost ($0 to $10,000). RESULTS: Of 123 participants, 38% had experienced recurrence, 25% were currently receiving chemotherapy, and 18% were currently taking a PARP inhibitor. Given attributes and levels, the relative importance weights (sum 100) were: 2-year PFS, 28; cost, 27; 6-month PFS, 19; neuropathy,14; memory problems, nausea, and regimen, all ≤5. To accept moderate neuropathy, participants required a 49% (versus 40%) chance of PFS at 6 months or 14% (versus 10%) chance at 2 years. Given a 3-way choice where PFS and cost were equal, 49% preferred a monthly IV regimen causing mild memory problems, 47% preferred an oral regimen causing moderate nausea, and 4% preferred a weekly IV regimen causing mild memory and mild neuropathy. CONCLUSIONS: These findings challenge the assumption that oral anti-cancer therapies are universally preferred by patients and demonstrate that there is no "one size fits all" regimen that is preferable to women with ovarian cancer when considering recurrence treatment regimens.

Routine assessment of gastrointestinal symptom using a validated questionnaire in the clinical setting to assess the probability of organic or functional gastrointestinal diseases.

BACKGROUND: Patients presenting with gastrointestinal symptoms can be challenging in terms of determining etiology and management strategies. Identifying likely organic pathology is important since it can be treated and may result in further, long-term harm to the patient if not treated. Currently, organic pathology is often identified via invasive procedures such as endoscopy or referral to a medical imaging service. We report on an approach that offers a first step at identifying patients with an organic gastrointestinal disease based on the SAGIS, a validated symptom questionnaire. METHODS: 8,922 patients referred to a tertiary care hospital were classified as having either functional gastrointestinal disease or an organic gastrointestinal disease. A model was developed to distinguish organic from functional symptoms on one random split half of the sample and validated on the other half. The incremental benefit of including psychological conditions and extra-gastrointestinal conditions was also evaluated. KEY RESULTS: Functional gastrointestinal patients scored higher on average than organic patients on all dimensions of the SAGIS and reported higher rates of psychological and extra-gastrointestinal conditions. All five dimensions of the SAGIS provided statistically independent discrimination of organic from functional diagnoses with good overall discrimination (AUC = 0.75). However, there was no noticeable incremental benefit of adding either psychological or extra-gastrointestinal conditions. Model performance was highly reproducible. CONCLUSIONS AND INFERENCES: The proposed algorithm for identifying likely organic gastrointestinal disease applied to symptoms as recorded in the SAGIS questionnaire provides a useful tool for the clinician in deciding what or if further diagnostic testing is required.

Chemotherapy-induced nausea in a sample of gynaecological cancer patients: assessment issues and personal risk factors evaluation.

PURPOSE: Chemotherapy-induced nausea (CIN) is a relevant problem for gynaecological cancer patients. The evaluation of CIN is a key aspect in its management, along with the identification of associated risk factors. The objective of the study was to compare different measurements of nausea and to investigate personal risk factors in CIN development. METHOD: Eighty-one women treated for gynaecological cancers took part. The presence of CIN was evaluated using the MASCC Antiemesis Tool (MAT) and a patient's report to clinicians at the subsequent chemotherapy cycle. Personal risk factors were assessed using the State-Trait Anxiety Inventory and a self-report questionnaire. RESULTS: The study shows that the agreement between patients' assessment of CIN with MAT and what they referred to clinicians was only moderate for acute nausea (Cohen's Kappa = 0.55; p < 0.001), while good for delayed nausea (Cohen's Kappa = 0.68; p < 0.001). At multiple logistic regression analysis, younger age, anticipatory nausea, patient medium-high expectations of CIN, and parity emerged as risk factors for the development of acute nausea (p = 0.0087, 0.0080, 0.0122 and 0.0021, respectively). Patient medium-high expectations of CIN and being single resulted to be risk factors for delayed nausea (p = 0.0397 and 0.0024, respectively). CONCLUSIONS: Our findings confirm that personal factors contribute to individual differences in the development of CIN; moreover, we highlight the importance of CIN evaluation by clinicians, underlining the need to use reliable instruments.

Integration of a nausea and vomiting assessment tool into antineoplastic management of pediatric oncology patients.

BACKGROUND: Antineoplastic-induced nausea and vomiting (AINV) is a treatment-related issue that can have significant negative influences on the cancer patient's quality of life. Assessment of nausea is challenging in children as few studies include the perception of nausea as an outcome, and the severity is rarely evaluated with the use of a validated instrument. We describe our experience of integrating an AINV tool into patient care at the Alberta Children's Hospital.Procedure: The Pediatric Nausea Assessment Tool (PeNAT) was adapted to create a standardized tool that could be used by the clinical pharmacists for AINV assessment. From February to August 2017, 74 patients receiving 217 cycles of highly or moderately emetogenic chemotherapy (HEC or MEC) were eligible to use the AINV tool. Patients that completed the AINV tool were contacted to complete a satisfaction survey. RESULTS: AINV tool uptake was low: 47 (22%) eligible chemotherapy cycles utilized the tool (24 (32%) and 23 (16%) cycles of HEC and MEC, respectively, (p < 0.01)). Ifosfamide-containing cycles received the highest nausea ratings, with nausea severity correlated with agent emetogenicity. Mean nausea rating was 2.07 versus 1.76 for patients receiving HEC or MEC, respectively. Clinical pharmacists performed 1.24 AINV interventions per day. Patient satisfaction with AINV care overall was high; however, 51% of patients indicated that the tool led to no changes in nausea symptoms. CONCLUSIONS: AINV tool uptake was low with limited value in improving outcomes. Incorporation of nausea assessment into the electronic health record and potential use of a mobile application may improve uptake.

Prospective assessment of taste impairment and nausea during radiotherapy for head and neck cancer.

Dysgeusia and nausea are common side effects observed in head and neck cancer patients treated with either exclusive radiotherapy or combined modality treatment. The aim of the present study was to prospectively evaluate dysgeusia, during treatment and follow-up, using the chemotherapy-induced taste alteration scale (CiTAS), a metrics based on 18-items exploring three dimensions (quantitative and qualitative changes in taste perception, and diet-related issues) identified through a four-factor analysis: decline in basic taste, discomfort, phantogeusia-parageusia, and general taste alterations. Moreover, we scored, according to Common Toxicity Criteria Adverse Events, nausea and other treatment-related toxicities. Since, ginger is traditionally used to prevent and/or treat nausea and vomiting, we prophylactically employed a ginger-based supplement named Naumix/Naugin (Gamfarma, Milan, Italy), to potentially mitigate both nausea and taste impairment. Using the CiTAS scale, we highlighted a progressive increase in all dysgeusia dimensions, peaking at the VII week of treatment and a subsequent partial late recovery. In particular, we observed a recovery for discomfort, phantogeusia-parageusia, and general taste alterations at 6 months. Grade 2 nausea, observed to be as low as 12.9% potentially due to the use of ginger, peaked at the III week of treatment. Finally, for patients experiencing nausea, the dysgeusia dimension of discomfort was also relevant.

Development and preliminary testing of a brief clinical tool to enable daily monitoring of chemotherapy toxicity: The Daily Chemotherapy Toxicity self-Assessment Questionnaire.

Close monitoring of chemotherapy toxicity can be instrumental in ensuring prompt symptom management and quality care. Our aim was to develop a brief clinical tool to enable daily assessment of chemotherapy toxicity and investigate/establish its content validity, feasibility/applicability, internal consistency and stability. Development of the Daily Chemotherapy Toxicity self-Assessment Questionnaire (DCTAQ) was based on an initial item pool created from two scoping reviews. Expert panel review (n = 15) and cognitive debriefing with patients with cancer (n = 7) were used to establish content validity. Feasibility/acceptability, applicability (self-report vs. interview-like administration), internal consistency (KR-20) and test-retest reliability (at 1-hr intervals) of the DCTAQ were field-tested with 82 patients with breast or colorectal cancer receiving active chemotherapy at eight hospitals. Initial development/content validity stages enabled item revisions and re-wording that led to a final, 11-item DCTAQ version with 10 core symptom items plus one open-ended "any other symptom" item. Feasibility and acceptability were demonstrated through the absence of participant withdrawals, absence of missing data and no complaints about tool length. The DCTAQ was found to have modest internal consistency (KR-20 = 0.56), but very good test-retest reliability. The DCTAQ is a brief clinical tool that allows for rapid and accurate daily assessments of chemotherapy toxicity in clinical practice.

The Optimal Cutoff Point for Expressing Revised Edmonton Symptom Assessment System Scores as Binary Data Indicating the Presence or Absence of Symptoms.

CONTEXT: Terminally ill patients with cancer experience various physical and emotional symptoms that have a negative impact on quality of life and activities of daily living. Recently, revised Edmonton Symptom Assessment System (ESAS-r) scores have been proposed for assessing symptoms in terminally ill patients with cancer. OBJECTIVE: To determine the optimal cutoff point for expressing ESAS-r scores as binary data, indicating the presence or absence of symptoms. METHODS: We conducted a retrospective study of patients hospitalized in the palliative care unit of our hospital between September 1, 2014 and May 31, 2015. To determine the optimal cutoff point for expressing ESAS-r scores as binary data, indicating the presence or absence of 6 physical symptoms ("pain," "tiredness," "drowsiness," "nausea," "lack of appetite," and "dyspnea"), the sensitivity and specificity of each measurement were calculated. Cutoff points were estimated using receiver operating characteristic curve analysis. RESULTS: Data from 157 patients who performed the self-assessment in ESAS-r scores were analyzed. The mean age was 66.5 years. Approximately 60.0% of patients were male. The optimal cutoff point for pain, tiredness, drowsiness, nausea, lack of appetite, and dyspnea was 4, 4, 4, 2, 5, and 4, respectively. The area under the curve for tiredness, nausea, and dyspnea was >0.70, followed in order by pain, lack of appetite, and drowsiness. The area under the curve for drowsiness was 0.55. CONCLUSION: Our results suggest that physical symptoms other than drowsiness could potentially predict ESAS-r score severity.

Chronic nausea and vomiting: evaluation and treatment.

Nausea is an uneasy feeling in the stomach while vomiting refers to the forceful expulsion of gastric contents. Chronic nausea and vomiting represent a diverse array of disorders defined by 4 weeks or more of symptoms. Chronic nausea and vomiting result from a variety of pathophysiological processes, involving gastrointestinal and non-gastrointestinal causes. The prevalence of chronic nausea and vomiting is unclear, although the epidemiology of specific conditions, such as gastroparesis and cyclic vomiting syndrome, is better understood. The economic impact of chronic nausea and vomiting and effects on quality of life are substantial. The initial diagnostic evaluation involves distinguishing gastrointestinal causes of chronic nausea and vomiting (e.g., gastroparesis, cyclic vomiting syndrome) from non-gastrointestinal causes (e.g., medications, vestibular, and neurologic disorders). After excluding anatomic, mechanical and biochemical causes of chronic nausea and vomiting, gastrointestinal causes can be grouped into two broad categories based on the finding of delayed, or normal, gastric emptying. Non-gastrointestinal disorders can also cause chronic nausea and vomiting. As a validated treatment algorithm for chronic nausea and vomiting does not exist, treatment should be based on a thoughtful discussion of benefits, side effects, and costs. The objective of this monograph is to review the evaluation and treatment of patients with chronic nausea and vomiting, emphasizing common gastrointestinal causes.

Symptom burden in chronic kidney disease; a population based cross sectional study.

BACKGROUND: Physical and psychological symptoms are among main manifestations of Chronic Kidney Disease (CKD). This study aimed to assess the symptom burden and self-perceived severity of symptoms among CKD patients living in a district in Sri Lanka. METHOD: A community based cross-sectional study included a sample of randomly selected 1174 CKD patients from all 19 Medical Officer of Health areas in the district of Anuradhapura. Trained para-medical staff visited the households and administered the locally validated questionnaire to assess the presence and severity of symptoms. The inquiry was on 25 symptoms in a 5 point Likert scale indicating the severity during the previous week. Symptom burden score was constructed by summing each symptom severity score which ranged from 0 to 125. RESULTS: A total of 1118 CKD patients participated with a response rate of 95.2%. The mean age was 58.3 (SD 10.8) years and 62.7% were males. A majority were in CKD stage 4 (58.3%). Bone/joint pain was the most experienced symptom (87.6%; 95%CI 85.6-89.5). Loss of libido was the most severe symptom. The median symptom burden score was 35.0 (IQR 20.0-50.0). Multiple linear regression revealed education up to Advanced Level (ß -9.176), CKD stage V (ß 3.373), being dialyzed (ß 20.944), comorbidities (ß 4.241) and being employed (ß -9.176) to be significant predictors of symptom burden. CONCLUSIONS: Patients in all stages of CKD experience high symptom burden warranting rigorous measures to relieve symptoms and to improve the well-being of CKD patients.

Psychometric assessment of the Chinese version of the MASCC Antiemesis Tool (MAT) for measuring chemotherapy-induced nausea and vomiting.

PURPOSE: This paper aims to assess the psychometric properties of the Chinese version of the MASCC Antiemesis Tool (MAT) for measuring chemotherapy-induced nausea and vomiting (CINV). METHODS: This was a psychometric study using a panel of experts and a prospective observational design. Six experts were invited to identify the content validity and face validity of the MAT, and 115 cancer patients were then recruited from three provincial medical centers in Fuzhou, China. The MAT was self-completed by the patients on the first and the fifth day after receiving the most recent chemotherapy, and patients also rated daily the Index of Nausea, Vomiting, and Retching (INVR) during the first 5 days after chemotherapy. Content validity was measured by the index of the content validity (CVI). Construct validity was estimated by the contrasted groups approach. Concurrent validity was measured by exploring the correlations between the INVR and MAT scores. The reliability of the MAT was examined by Cronbach's alpha and item-to-total correlations. RESULTS: One hundred and eleven subjects returned the completed measures. High content validity was determined. Contrasted groups analysis clearly discriminated the differences on the CINV symptom experiences between different age and gender groups. Excellent concurrent validity was identified, with the Spearman's correlation coefficient between the MAT total score and the INVR overall total score of 0.94 (P < 0.001). Cronbach's alpha for the MAT was 0.73, and the item-to-total correlations ranged from 0.50 to 0.71. CONCLUSIONS: The MAT Chinese version is a valid, reliable, and convenient instrument for measuring CINV in Chinese cancer patients.

Using Markov Multistate Models to Examine the Progression of Symptom Severity Among an Ambulatory Population of Cancer Patients: Are Certain Symptoms Better Managed Than Others?

CONTEXT: Patient-reported assessments of symptom severity can assist providers in monitoring and managing symptoms for cancer patients, which is important for offering patients optimal cancer care. Understanding which symptoms deteriorate at a faster rate over time can help identify areas for improving symptom management. OBJECTIVES: This article aimed to longitudinally examine the transitions in symptom severity over time and determine which symptoms deteriorate most rapidly. METHODS: This was an Ontario-wide cohort study from 2007 to 2011 of adult outpatients diagnosed with cancer. During every symptom assessment at the cancer center, patients reported their level of severity for each of nine symptoms. A Markov multistate model under an intermittent observation scheme was implemented to examine the progression of symptom severity over time among cancer patients. RESULTS: This study included 55,883 patients with over 280,000 symptom assessments. The median time between assessments was 29 days, and the majority of patients had at least three assessments. The symptoms deteriorating most rapidly over time were fatigue and well-being, whereas the symptom deteriorating least rapidly over time was nausea. CONCLUSION: The availability of numerous medications for treating nausea, compared to fatigue and well-being, may be a reasonable explanation for our findings. Alternate management for these symptoms, such as exercise for reducing fatigue, should be investigated to improve patients' quality of life. The use of multistate modeling methods is also unique in the study of symptom progression and provides a more in-depth understanding of the likelihood of symptom deterioration and improvement over time.

Evaluation of the validity of chemotherapy-induced nausea and vomiting assessment in outpatients using the Japanese version of the MASCC antiemesis tool.

PURPOSE: The Multinational Association of Supportive Care in Cancer (MASCC) developed the MASCC antiemesis tool (MAT) as a tool for chemotherapy-induced nausea and vomiting (CINV) assessment and subsequently published its Japanese version in 2010. We evaluated the validity of CINV assessment in outpatients using the Japanese version of MAT. METHODS: Patients administered highly or moderately emetogenic chemotherapy in the outpatient chemotherapy unit of our hospital were included in the study. The study was designed as a prospective two-period crossover observational study to evaluate the correlation between the daily patient diary and the Japanese version of MAT in terms of CINV onset. We examined with a focus on reliability of the Japanese version of MAT particularly in the description of the delayed phase of nausea and vomiting. RESULTS: Patient descriptions of CINV onset in a total of 116 cycles in 58 patients (two cycles/patient) were analyzed. The CINV incidence indicated by the patient diary was similar to that by the Japanese version of MAT. The concordance rate between the two tools in the same patients was 86.2 % for CINV onset in the delayed phase. The nausea score was also similar between the two tools regarding the mean and variance, showing a strong correlation with a correlation coefficient of 0.71. CONCLUSIONS: The results of the study showed that the Japanese version of MAT is a highly reliable tool for CINV assessment, indicating that it is valid for assessing CINV in outpatients.

Náuseas y vómitos: evaluación y manejo / Nausea and vomiting: assessment and management

Vomiting is a reflex action of motor and autonomous responses, resulting in violent expulsion of gastric contents through the mouth, triggered by humoral and neural stimuli. It must be distinguished from regurgitation or gagging. Nausea, on the other hand, is a subjective uncomfortable feeling that most people have experienced and is generally described as an imminent need to vomit, felt in the epigastrium and throat. These can be symptoms of a series of pathologies, and represent a reason for frequent consultation at emergency health care units. Both acute and chronic occurrence must be assessed carefully to identify its etiological agent in order to administer proper treatment focused on the symptoms. Nausea and vomiting during pregnancy, after chemotherapy, and cyclic vomiting syndrome will be further developed. In addition, nausea and vomiting treatment in the emergency room is reviewed.

El vómito es un reflejo coordinado de respuestas motoras y autonómicas que resulta en la expulsión violenta del contenido gástrico por la boca, activado por estímulos humorales o neuronales. Debe distinguirse de regurgitación o arcadas. La náusea, por otro lado, es una sensación subjetiva desagradable que la mayoría de las personas han experimentado en algún momento de su vida y, por lo general, reconocen como una sensación de inminente vómito, en el epigastrio o garganta. Son un síntoma de una pléyade de diversas patologías, y corresponde a un motivo de consulta frecuente en servicios de urgencia. Tanto su presentación aguda, como crónica deben ser evaluadas en forma integral de modo de identificar la etiología y poder brindar un tratamiento, tanto sintomático como dirigido. Las náuseas y vómitos en el embarazo, en relación a quimioterapia, y el síndrome de vómito cíclico serán abordados en profundidad. Del mismo modo se realiza una revisión del tratamiento de náuseas y vómitos indiferenciados, en el servicio de urgencia.

Activity-based cost analysis of opioid-related nausea and vomiting among inpatients.

OBJECTIVE: Nausea and/or vomiting (N/V) are frequent side effects of opioid drugs. These are of major concerns to patients and caregivers and only few studies have focused on their economical costs. DESIGN: This is a prospective, nonproduct-related, activity-based evaluation of personnel and material costs of opioid-related N/V among inpatients. SETTING: Data were obtained from surgical, general medicine, and palliative care wards at 16 German hospitals of different size, healthcare mandate, and ownership. PATIENTS, PARTICIPANTS: According to predefined criteria, of 462 documented N/V events, 340 were diagnosed as opioid related. INTERVENTIONS: Elicited activities and pharmacological interventions for N/V episodes followed local standards. MAIN OUTCOME MEASURE: Both materials used and the time engaged to treat patients with N/V were documented on an "ad hoc" activity recording form. The total cost of an opioid-related N/V episode was calculated based on standard wages of the involved personnel and standard costs of the inherent materials used. RESULTS: Mean staff tenure time for handling an episode of N/V was 26.2 ± 19.8 minutes (nausea 16.9 ± 28.7 minutes; nausea + vomiting: 33.4 ± 26.8 minutes). In the German context, this corresponds to average personnel costs of €18.06 ± 13.64. Material cost contributes to another €13.49 ±13.38 of costs mainly depending on acquisition costs of antiemetic drugs. CONCLUSIONS: N/V showed to have impact on workload of nurses and (to lesser extent) physicians and economic burden of €31 ± 22 for each N/V episode. In view of these results, the potential costs of strategies to minimize the incidence of N/V (use of antiemetics and/or the use of new analgesics) should be outweighed against the incurred costs of N/V.