Ginger-Mechanism of action in chemotherapy-induced nausea and vomiting: A review

Despite advances in antiemetic therapy, chemotherapy-induced nausea and vomiting (CINV) still poses a significant burden to patients undergoing chemotherapy. Nausea, in particular, is still highly prevalent in this population. Ginger has been traditionally used as a folk remedy for gastrointestinal complaints and has been suggested as a viable adjuvant treatment for nausea and vomiting in the cancer context. Substantial research has revealed ginger to possess properties that could exert multiple beneficial effects on chemotherapy patients who experience nausea and vomiting. Bioactive compounds within the rhizome of ginger, particularly the gingerol and shogaol class of compounds, interact with several pathways that are directly implicated in CINV in addition to pathways that could play secondary roles by exacerbating symptoms. These properties include 5-HT3, substance P, and acetylcholine receptor antagonism; antiinflammatory properties; and modulation of cellular redox signaling, vasopressin release, gastrointestinal motility, and gastric emptying rate. This review outlines these proposed mechanisms by discussing the results of clinical, in vitro, and animal studies both within the chemotherapy context and in other relevant fields. The evidence presented in this review indicates that ginger possesses multiple properties that could be beneficial in reducing CINV.

Nausea and vomiting of pregnancy - What's new?

Nausea and vomiting of pregnancy (NVP) is one of the most common disorders of pregnancy. The symptoms occur predominantly during the first trimester, although in a subgroup of patients they can continue throughout the entire pregnancy and can affect the woman's quality of life. A small percentage of women develop a severe form of NVP called hyperemesis gravidarum (HG) that if left untreated may lead to significant maternal morbidity and adverse birth outcomes. Overall, the morbidity in pregnant women with NVP is significant, although it tends to be underestimated. The pathogenesis of NVP remains unclear, but there is consensus that the disorder is multifactorial and that various genetic, endocrine and infectious factors may be involved. The treatment of NVP can be challenging as the optimal targets for therapy are not known. Currently, the therapy used depends on the severity of the disorder and it is focused on improving the symptoms while minimizing risks to mother and fetus. Therapies range from dietary changes, pharmacologic treatment or hospitalization with intravenous fluid replacement and nutrition therapy. The aims of this review are 1) to provide an overview of NVP, 2) to present possible links between the most important factors associated with the pathogenesis of NVP and 3) to discuss the effectiveness and safety of the pharmacologic and non-pharmacologic options available to treat this disorder.

Surveillance of adverse events following immunisation in Australia annual report, 2014

This report summarises Australian passive surveillance data for adverse events following immunisation (AEFI) for 2014 reported to the Therapeutic Goods Administration for 2014 and describes reporting trends over the 15-year period 1 January 2000 to 31 December 2014. There were 3,087 AEFI records for vaccines administered in 2014; an annual AEFI reporting rate of 13.2 per 100,000 population. There was a decline of 5% in the overall AEFI reporting rate in 2014 compared with 2013. This decline in reported adverse events in 2014 compared with the previous year was mainly attributable to fewer reports following the human papillomavirus (HPV) vaccine as it was the 2nd year of the extension of the National HPV Vaccination Program to males. AEFI reporting rates for most vaccines were lower in 2014 compared with 2013. The most commonly reported reactions were injection site reaction (27%), pyrexia (18%), rash (16%), vomiting (9%), headache (7%), and syncope (5%). The majority of AEFI reports described non-serious events while 7% (n=211) were classified as serious. There were 5 deaths reported with no clear causal relationship with vaccination found.

Radiation-induced nausea and vomiting: Is ABO blood group as important as radiation and patient-related factors? An observational study

Despite the improvements in cancer screening and treatment, it still remains as one of the leading causes of mortality worldwide. Nausea and vomiting as the side effects of different cancer treatment modalities, such as radiotherapy, are multifactorial and could affect the treatment continuation and patient quality of life. Therefore, the aim of this study was to assess the possible linkage between ABO blood groups and radiation-induced nausea and vomiting (RINV), also its incidence and affecting factors.One hundred twenty-eight patients referring to Tohid hospital of Sanandaj, Iran, were selected and the patients and treatment-related factors were determined in a cross-sectional study. Patients' nausea and vomiting were recorded from the onset of treatment until 1 week after treatment accomplishment. Also, previous possible nausea and vomiting were recorded. The frequencies of nausea and vomiting and their peak time were examined during the treatment period.The association between ABO blood group and the incidence of radiotherapy-induced nausea and vomiting (RINV) were significant and it seems that A blood group patients are the most vulnerable individuals to these symptoms. The association between Rhesus antigen and the time of maximum severity of RINV may indicate that Rhesus antigen affects the time of maximum severity of RINV. The incidence of RINV was not affected by karnofsky performance status, but it was related to the severity of RINV. Furthermore, among the factors affecting the incidence of nausea and vomiting, nausea and vomiting during patient's previous chemotherapy, radiotherapy region, and background gastrointestinal disease were shown to be three important factors.In addition to familiar RINV-affecting factors, ABO blood group may play an important role and these results address the needs for further studies with larger sample size.

Effect of endoscopic pyloric therapies for patients with nausea and vomiting and functional obstructive gastroparesis

Gastroparesis (GP) is associated with loss of interstitial cells of Cajal (ICCs) and gastric dysrhythmias such as tachygastria. We hypothesized that a subset of patients with GP, normal 3cycles per minute (cpm) gastric myoelectrical activity (GMA), and normal upper endoscopy may respond to pyloric therapies.

AIMS

To determine the effect of botulinum toxin A (btA) injection or balloon dilation (BD) of the pylorus on symptoms and body weight in patients with GP and 3cpm GMA.

METHODS

Patients were identified who had GP, normal 3cpm GMA, and normal endoscopy that excluded mechanical obstruction of the pylorus. Electrogastrograms (EGG) with water load tests (WLT) were recorded to determine GMA. Gastric emptying was measured with 4h scintigraphy. Each patient underwent up to three pyloric treatments with btA or BD.

RESULTS

Thirty-three patients (29 women) with an average age of 42years were studied. Seventy-nine percent had idiopathic GP and 21% had diabetic GP. The average percent meal retained at 4h was 42% and each EGG test showed normal 3cpm GMA. Nausea was the major symptom in 76% of patients. Complete or partial symptom response occurred in 75%, 72%, and 88% of patients after the first, second, or third endoscopic pyloric treatment, respectively. Overall, 78% of the 33 patients reported improvement in symptoms and average weight gain was 1.54lb from baseline to final treatment (p<0.04).

CONCLUSION

Pyloric therapies appear to be effective treatments in symptomatic patients with GP and 3cpm GMA and controlled trials are warranted.

Role of the abdominal vagus and hindbrain in inhalational anesthesia-induced vomiting

The incidence of postoperative nausea and vomiting (PONV) can be as high as 80% in patients with risk factors (e.g., females, history of motion sickness). PONV delays postoperative recovery and costs several hundred million dollars annually. Cell-based assays show that halogenated ethers (e.g., isoflurane) activate 5-HT₃ receptors, which are found on gastrointestinal vagal afferents and in the hindbrain - key pathways for producing nausea and vomiting. This project evaluated the role of the vagus and activation of the hindbrain in isoflurane-induced emesis in musk shrews, a small animal model with a vomiting reflex, which is lacking in rats and mice. Sham-operated and abdominal vagotomized shrews were exposed to 1 to 3% isoflurane to determine effects on emesis; vagotomy was confirmed by lack of vagal transport of the neuronal tracer Fluoro-Gold. In an additional study, shrews were exposed to isoflurane and hindbrain c-Fos was measured at 90min after exposure using immunohistochemistry. There were no statistically significant effects of vagotomy on isoflurane-induced emesis compared to sham-operated controls. Isoflurane exposure produced a significant increase in c-Fos-positive cells in the nucleus of the solitary tract and vestibular nuclei but not in the area postrema or dorsal motor nucleus. These results indicate that the abdominal vagus plays no role in isoflurane-induced emesis and suggest that isoflurane activates emesis by action on the hindbrain, as shown by c-Fos labeling. Ultimately, knowledge of the mechanisms of inhalational anesthesia-induced PONV could lead to more targeted therapies to control PONV.

Optical Coherence Tomography Evaluation of Valsalva-Induced Suprachoroidal Hemorrhage

Suprachoroidal hemorrhage is typically observed in patients with hypotony in the context of intraocular surgery and trauma. We report a rare presentation of suprachoroidal hemorrhage associated with emesis (Valsalva maneuver) in a myopic patient with few other identifiable risk factors. This diagnosis was confirmed with wide-field fundus photography and B-scan ultrasound and was localized to the suprachoroidal space using both enhanced depth and swept-source optical coherence tomography imaging. This case is unique in its presentation and demonstrates the utility of newer imaging techniques to localize hemorrhages using a multimodal approach. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:674-676.].

[The developmental characteristics of locomotion and sleep in cyclic vomiting syndrome and the effects of drug therapy]

Objective: To evaluate the characteristics of patients with cyclic vomiting syndrome (CVS) and the efficacy of prophylaxis therapy. Methods: We defined the patients as “CV (+) ” if they had multiple neuromuscular diseases and as “CV (−) ” if they did not. We compared the two groups according to their background and the type of medications and their effects. We also evaluated their locomotion and sleep pattern. Results: There was no significant difference between CV (+) and CV (−) with regard to the association with migraine. Pharmacotherapy with cyproheptadine and valproate had high success rate for both CV (−) and CV (+). The rate of delayed locomotion development and atonia during non-REM sleep was high in both CV (+) and CV (−). Conclusions: We postulate that the association of serotonergic neurons is one of the important factors in both CV (+) and CV (−).

A Case Report and Literature Review of Spontaneous Perforation of Pyometra

BACKGROUND

Pyometra is defined as an accumulation of purulent material in the uterine cavity. Spontaneous perforation is a very rare complication of pyometra. The clinical findings of perforated pyometra are similar to perforation of the gastrointestinal tract and other causes of acute abdomen.

CASE REPORT

We report a rare and difficult case of peritonitis in an elderly female that was caused by a spontaneous perforation of pyometra. A 90-year-old postmenopausal woman was referred to our hospital with complaints of vomiting, fever, and abdominal pain. Computed tomography revealed a large amount of ascites, cystic mass in the uterus, and intraperitoneal and intrauterine air. Transvaginal ultrasound demonstrated a thin area around the fundus. An emergency laparotomy was performed for the suspected gastrointestinal perforation or perforation of pyometra. At laparotomy, copious purulent fluid was present in the peritoneal cavity; however, no perforation of the gastrointestinal tract was observed. We identified a perforation site over the uterine fundus and purulent material exuding from the cavity. Subsequently, hysterectomy and bilateral salpingo-oophorectomy were performed. The patient was discharged on postoperative day 13 with no complications. Histopathologic studies revealed endometritis and myometritis with no evidence of malignancy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With diffuse peritonitis, ruptured pyometra should be considered, even in elderly female patients. This case illustrates the importance of clinical knowledge of acute gynecologic diseases. Here we also review the perforation of pyometra with no evidence of malignancy.

An Evidenced-Based Scale of Disease Severity following Human Challenge with Enteroxigenic Escherichia coli

Background

Experimental human challenge models have played a major role in enhancing our understanding of infectious diseases. Primary outcomes have typically utilized overly simplistic outcomes that fail to entirely account for complex illness syndromes. We sought to characterize clinical outcomes associated with experimental infection with enterotoxigenic Escherichia coli (ETEC) and to develop a disease score.

Methods

Data were obtained from prior controlled human ETEC infection studies. Correlation and univariate regression across sign and symptom severity was performed. A multiple correspondence analysis was conducted. A 3-parameter disease score with construct validity was developed in an iterative fashion, compared to standard outcome definitions and applied to prior vaccine challenge trials.

Results

Data on 264 subjects receiving seven ETEC strains at doses from 1x10⁵ to 1x10¹⁰ cfu were used to construct a standardized dataset. The strongest observed correlation was between vomiting and nausea (r = 0.65); however, stool output was poorly correlated with subjective activity-impacting outcomes. Multiple correspondence analyses showed covariability in multiple signs and symptoms, with severity being the strongest factor corresponding across outcomes. The developed disease score performed well compared to standard outcome definitions and differentiated disease in vaccinated and unvaccinated subjects.

Conclusion

Frequency and volumetric definitions of diarrhea severity poorly characterize ETEC disease. These data support a disease severity score accounting for stool output and other clinical signs and symptoms. Such a score could serve as the basis for better field trial outcomes and gives an additional outcome measure to help select future vaccines that warrant expanded testing in pivotal pre-licensure trials.

Appendicitis in the Infant Population: A Case Report and Review of a Four-Month Old With Appendicitis

BACKGROUND

Appendicitis is uncommon in children <6 months old, with few observational studies reporting cases of children younger than 5 years old with the diagnosis. The classic periumbilical pain that migrates to the right lower quadrant, followed by the onset of fever and vomiting, is present in approximately 40% of pediatric patients under 12 years of age with appendicitis.

CASE REPORT

A 4-month-old girl presented to the Emergency Department (ED) with acute onset of grunting, pallor, fussiness, emesis, and diarrhea. The patient was initially afebrile, tachycardic, and tachypneic with a soft, nondistended, nontender abdomen and active bowel sounds. The patient became febrile, with a maximum temperature of 39.3°C (102.7°F), and remained tachycardic despite receiving fluids and antipyretics. Laboratory studies were notable for mild dehydration and sterile pyuria. Chest x-ray study was negative for infectious etiologies. Initial abdominal ultrasound found no clear etiology of the patient's symptoms. The patient was admitted to inpatient pediatrics for dehydration, fever, and presumed pyelonephritis. Twenty-four hours later the patient's abdomen became distended and diffusely tender to palpation, with obstipation and increasing episodes of emesis. Abdominal x-ray study demonstrated mild gaseous distension of multiple bowel loops with repeat abdominal ultrasound notable for a focal 8-mm, noncompressible hyperemic structure in the right lower quadrant. The patient was taken to the operating room for a laparoscopic appendectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Appendicitis is a potentially life-threatening condition. In the infant population it frequently presents without the features typically seen in older children.

PATTERNS AND SEASONAL VARIATION OF INTUSSUSCEPTION IN CHILDREN: A RETROSPECTIVE ANALYSIS OF CASES OPERATED IN A TERTIARY HOSPITAL IN ETHIOPIA

BACKGROUND

Intussusception is one of the frequent causes of bowel obstruction in infants and toddlers (1). It involves invagination of a portion of intestine into another(2-4). The peak age of occurrence is between the age of 4 and 8 months. The aim of this study is to review the pattern of clinical presentation and seasonal variation of intussusception in our hospital, and to analyze the mode and outcomes of treatment.

PATIENTS AND METHODS

This is a four-year retrospective study of children aged 13 years and below who were admitted and treated for intussusception between January 2011 and December 2014 at the pediatric surgery unit of Tikur Anbesa Specialized Hospital (TAH) in Ethiopia. Information on the patients' demographic characteristics, clinical presentation, and month of occurrence as well as the operative findings and outcome were obtained from the pediatric surgery unit record book, patient charts, and the operating theatre registry.

RESULTS

One hundred and thirty six cases of intussusception were admitted to TAH, Addis Ababa over a four year period, of which 130 charts were retrieved and analyzed. Males dominated in the series. Age distribution showed that 59.2% of the cases were ≤ one year old, and 77.7 % were ≤ two years old. Abdominal pain, vomiting, bloody mucoid diarrhea and a mass palpated abdominally and/or rectally were the most common modes of presentations, with the classic triad of abdominal pain, vomiting and bloody mucoid diarrhea occurring in nearly two third of cases. The highest peak of presentation was in the month of June with 18 (13.9%) cases. The mean duration of symptoms before presentation to our hospital was 5.2 days with a range of 1-21 days. Intraoperatively, it was found that ileocolic intussusception was the most common type. Simple reduction without bowel resection was possible in 70.8% of cases. There were 44 (33.9 %) complications, wound site infection being the most common occurring in 20 (15.4%) cases and there were 6 deaths.

CONCLUSION

Intussusception was more common in the wet season. There was delayed presentation with a higher rate of operative management and bowel resection. The mortality rate has decreased significantly compared with a previous study from this institution.

Management of Chemotherapy Induced Nausea and Vomiting in Patients on Multiday Cisplatin Based Combination Chemotherapy

Introduction of cisplatin based chemotherapy has revolutionized the treatment of germ cell tumors. A common side effect of multiday cisplatin chemotherapy is severe nausea and vomiting. Considerable progress has been made in the control of these side effects since the introduction of cisplatin based chemotherapy in the 1970s. Germ cell tumor which is a model for a curable neoplasm has also turned into an excellent testing ground to develop effective strategies to prevent chemotherapy induced nausea and vomiting (CINV) in multiday cisplatin based regimens. The use of combination of a 5-hydroxytryptamine (HT)3 receptor antagonist, a neurokinin-1 (NK1) antagonist, and dexamethasone has greatly improved our ability to prevent and control acute and delayed CINV. Mechanism and pattern of CINV with multiday chemotherapy may differ from those in single day chemotherapy and therefore efficacy of antiemetic drugs as observed in single day chemotherapy may not be applicable. There are only few randomized clinical trials with special emphasis on multiday chemotherapy. Further studies are essential to determine the efficacy, optimal dose, and duration of the newer agents and combinations in multiday cisplatin based chemotherapy.

Severe Quetiapine Withdrawal Syndrome with Nausea and Vomiting in a 65-year-old Patient with Psychotic Depression

A 65-year old patient suffering from severe psychotic depression obtained quetiapine for roughly one year. Several attempts to discontinue quetiapine by tapering the dose provoked severe withdrawal symptoms with nausea and vomitus. Pretreatment with domperidone largely prevented withdrawal so that he finally could successfully discontinue quetiapine administration.

[COMPARISON OF THE OCCURRENCE RATE OF NAUSEA AND VOMITING AFTER TRANSCUTANEOUS NEPHROLITHOTRIPSY: SEVOFLURANE OR PROPOFOL]

Impact of various kinds of general anesthesia while performing transcutaneous endoscopic interventions on kidneys on postoperative occurrence and rate of nausea and vomiting were studied. Propofol and sevofluran were used for support of general anesthesia conduction. There was established, that if optimal depth of anesthesia is maintained (bispectral index 40 - 60 units), the rate of nausea and vomiting occurrence do not depend on the kind of anesthesia applied--total intravenous or the inhalation one.

[THE TOXIC EFFECTS OF CHEMOTHERAPY ON THE GASTROINTESTINAL TRACT]

Chemotherapy in modern oncology is one of the main methods of treatment, along with surgery and radiotherapy techniques. More than 60% of patients receiving chemotherapy at different stages of treatment. Recently, modern chemotherapy has become more urgent personal approach to the choice of drugs and their doses, aimed at reducing the toxicity of chemotherapy. Complications of chemotherapy significantly degrade the effectiveness of the treatment of patients with malignant tumors, because they require lower doses of anticancer drug, or lengthening the intervals between cycles of chemotherapy, which affects treatment outcomes and quality of life.

Evaluation of the toxicity of anticancer chemotherapy in patients with colon cancer

BACKGROUND

Modern anticancer chemotherapy can cause numerous adverse effects in the organism, whose functioning has already been disrupted by the neoplastic process itself.

OBJECTIVES

The aim of the study was to evaluate and compare the frequency and severity of the toxicity of FOLFOX-4 and CLF-1 anticancer therapy in patients with colon cancer, and to analyze certain factors that might have increased the toxicity of the chemotherapy.

MATERIAL AND METHODS

The study involved 64 patients suffering from generalized colon cancer, including 48 patients treated according to the FOLFOX-4 regimen and 16 patients treated according to the CLF-1 regimen. The toxicity of each regimen was analyzed on the basis of a confidential questionnaire formulated by the authors and laboratory research according to the extended WHO toxicity criteria.

RESULTS

The analysis of the symptoms of toxicity symptoms associated with the use of the FOLFOX-4 and CLF-1 therapeutic regimens revealed that the most common side effects included nausea and vomiting, despite ondansetron premedication, and neurotoxicity. Disruption of the functioning of the nervous system under the FOLFOX-4 regimen statistically significant exacerbation that increased with the number of chemotherapy cycles administered; this was more common and more severe in women. Paresthesia was also revealed to be a neurotoxic effect of the FOLFOX-4 regimen after termination of therapy. A statistically significant relationship was observed between the use of vitamin supplements and the incidence and severity of the toxicity of the FOLFOX-4 regimen.

CONCLUSIONS

The findings of the current study regarding the toxicity of the FOLFOX-4 and CLF-1 therapy regimens should be taken into consideration when monitoring chemotherapy safety in colon cancer. The patients' tolerance of the administered medication and the side effects reported by patients should be constantly evaluated, which will help prevent these side effects, apply appropriate therapy and contribute to the improvement of the patients' quality of life. The functioning of the central nervous system should be carefully evaluated when planning the anticancer therapy, especially if repeated administration of neurotoxic drugs is necessary in cases of a recurrence of the disease. Chemotherapy should be thoroughly monitored for safety, especially in women over 65 years of age suffering from coexisting diseases. Colon cancer patients and their families should be informed of the risks of nutritional supplements before the start of the anticancer chemotherapy, and may need to dispense with their use.

Mechanism of gastrointestinal abnormal motor activity induced by cisplatin in conscious dogs

AIM: To investigate whether 5-hydroxytryptamine (serotonin; 5-HT) is involved in mediating abnormal motor activity in dogs after cisplatin administration.

METHODS: After the dogs had been given a 2-wk recovery period, all of them were administered cisplatin, and the motor activity was recorded using strain gauge force transducers. Blood and intestinal fluid samples were collected to measure 5-HT for 24 h. To determine whether 5-HT in plasma or that in intestinal fluids is more closely related to abnormal motor activity we injected 5-HT into the bloodstream and the intestinal tract of the dogs.

RESULTS: Cisplatin given intravenously produced abnormal motor activity that lasted up to 5 h. From 3 to 4 h after cisplatin administration, normal intact dogs exhibited retropropagation of motor activity accompanied by emesis. The concentration of 5-HT in plasma reached the peak at 4 h, and that in intestinal fluids reached the peak at 3 h. In normal intact dogs with resection of the vagus nerve that were administered kytril, cisplatin given intravenously did not produce abnormal motor activity. Intestinal serotonin administration did not produce abnormal motor activity, but intravenous serotonin administration did.

CONCLUSION: After the intravenous administration of cisplatin, abnormal motor activity was produced in the involved vagus nerve and in the involved serotonergic neurons via another pathway. This study was the first to determine the relationship between 5-HT and emesis-induced motor activity.

[Gastrointestinal disorders in patients with renal impairment]

In the study the most common gastroenterological disorders among patients with CRF are reviewed. It was shown two main types of such disorders: as a manifestation of the underlying disease (CKD) or as an associated disease. It was determined that anorexia, nausea, vomiting, constipation, gastrointestinal bleeding, and acute abdominal pain are the most common gastroenterological symptoms. The necessity of further studying of the pathogenetic mechanisms of gastroenterological disorders in the case of presence of CRF and the importance of an integrated approach to the screening and management of patients with CRF was shown.

A randomized trial of the effectiveness of topical "ABH Gel" (Ativan(®), Benadryl(®), Haldol(®)) vs. placebo in cancer patients with nausea

CONTEXT

The topical gel known as "ABH gel," comprising lorazepam (Ativan(®)), diphenhydramine (Benadryl(®)), and haloperidol (Haldol(®)), is frequently used to treat nausea because of its perceived efficacy, relatively low cost, and ease of use in the home setting. There are limited scientific data on this medication, however. Recent pilot studies showed no absorption of the active ingredients of the gel, prompting further prospective studies into the cause of the perceived efficacy in the clinical setting.

OBJECTIVES

To determine any difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea.

METHODS

A randomized, double-blind, placebo-controlled, crossover, noninferiority clinical trial was developed to test the hypothesis that there is no difference in the effectiveness of ABH gel compared with placebo in cancer patients with nausea. The primary outcome was the difference in nausea score (on a 0-10 scale) at baseline and at 60 minutes in each treatment group. The difference in the ABH gel-treated group compared with placebo was evaluated for noninferiority. Secondary outcomes included the number of vomiting episodes and side effects over time.

RESULTS

The mean change in nausea score from baseline to 60 minutes after treatment in the ABH gel group was 1.7 ± 2.05 and 0.9 ± 2.45 for the placebo group (P = 0.42). The placebo group was found to be noninferior to the ABH gel group in reducing the nausea score. ABH gel also did not decrease vomiting events better than placebo (P = 0.34). Only one patient reported any side effects from the treatments in either arm of the study.

CONCLUSION

ABH gel in its current formulation should not be used in cancer patients experiencing nausea.

Serotonin 5-HT3 receptor-mediated vomiting occurs via the activation of Ca2+/CaMKII-dependent ERK1/2 signaling in the least shrew (Cryptotis parva)

Stimulation of 5-HT₃ receptors (5-HT₃Rs) by 2-methylserotonin (2-Me-5-HT), a selective 5-HT₃ receptor agonist, can induce vomiting. However, downstream signaling pathways for the induced emesis remain unknown. The 5-HT₃R channel has high permeability to extracellular calcium (Ca²⁺) and upon stimulation allows increased Ca²⁺ influx. We examined the contribution of Ca²⁺/calmodulin-dependent protein kinase IIα (Ca²⁺/CaMKIIα), interaction of 5-HT₃R with calmodulin, and extracellular signal-regulated kinase 1/2 (ERK1/2) signaling to 2-Me-5-HT-induced emesis in the least shrew. Using fluo-4 AM dye, we found that 2-Me-5-HT augments intracellular Ca²⁺ levels in brainstem slices and that the selective 5-HT₃R antagonist palonosetron, can abolish the induced Ca²⁺ signaling. Pre-treatment of shrews with either: i) amlodipine, an antagonist of L-type Ca²⁺ channels present on the cell membrane; ii) dantrolene, an inhibitor of ryanodine receptors (RyRs) Ca²⁺-release channels located on the endoplasmic reticulum (ER); iii) a combination of their less-effective doses; or iv) inhibitors of CaMKII (KN93) and ERK1/2 (PD98059); dose-dependently suppressed emesis caused by 2-Me-5-HT. Administration of 2-Me-5-HT also significantly: i) enhanced the interaction of 5-HT₃R with calmodulin in the brainstem as revealed by immunoprecipitation, as well as their colocalization in the area postrema (brainstem) and small intestine by immunohistochemistry; and ii) activated CaMKIIα in brainstem and in isolated enterochromaffin cells of the small intestine as shown by Western blot and immunocytochemistry. These effects were suppressed by palonosetron. 2-Me-5-HT also activated ERK1/2 in brainstem, which was abrogated by palonosetron, KN93, PD98059, amlodipine, dantrolene, or a combination of amlodipine plus dantrolene. However, blockade of ER inositol-1, 4, 5-triphosphate receptors by 2-APB, had no significant effect on the discussed behavioral and biochemical parameters. This study demonstrates that Ca²⁺ mobilization via extracellular Ca²⁺ influx through 5-HT₃Rs/L-type Ca²⁺ channels, and intracellular Ca²⁺ release via RyRs on ER, initiate Ca²⁺-dependent sequential activation of CaMKIIα and ERK1/2, which contribute to the 5-HT₃R-mediated, 2-Me-5-HT-evoked emesis.

Adolescent rumination syndrome

Rumination syndrome is the non-purposeful regurgitation of recently ingested food from the stomach to the mouth, where it is either expelled or reswallowed. Adolescent rumination syndrome (ARS) is a rare condition of which many physicians are unaware. Patients often are misdiagnosed or undergo costly testing, and as a result, diagnosis and treatment are often delayed. While ARS is not life-threatening, it does have medical and emotional effects on the patient and the patient's family. Diagnosis of ARS is based upon the Rome III diagnostic criteria. Antroduodenal manometry, while not required for a diagnosis, can be helpful to confirm the diagnosis. The pathogenesis of this disorder is complex and not well understood. However, because of its behavioral component, treatment of ARS requires a multidisciplinary approach that includes both medical management of symptoms and implementation of strategies that address behavioral, psychological, and general quality-of-life components of the disorder.

Motion sickness: more than nausea and vomiting

Motion sickness is a complex syndrome that includes many features besides nausea and vomiting. This review describes some of these factors and points out that under normal circumstances, many cases of motion sickness go unrecognized. Motion sickness can occur during exposure to physical motion, visual motion, and virtual motion, and only those without a functioning vestibular system are fully immune. The range of vulnerability in the normal population varies about 10,000 to 1. Sleep deprivation can also enhance susceptibility. Systematic studies conducted in parabolic flight have identified velocity storage of semicircular canal signals-velocity integration-as being a key factor in both space motion sickness and terrestrial motion sickness. Adaptation procedures that have been developed to increase resistance to motion sickness reduce this time constant. A fully adequate theory of motion sickness is not presently available. Limitations of two popular theories, the evolutionary and the ecological, are described. A sensory conflict theory can explain many but not all aspects of motion sickness elicitation. However, extending the theory to include conflicts related to visceral afferent feedback elicited by voluntary and passive body motion greatly expands its explanatory range. Future goals should include determining why some conflicts are provocative and others are not but instead lead to perceptual reinterpretations of ongoing body motion. The contribution of visceral afferents in relation to vestibular and cerebellar signals in evoking sickness also deserves further exploration. Substantial progress is being made in identifying the physiological mechanisms underlying the evocation of nausea, vomiting, and anxiety, and a comprehensive understanding of motion sickness may soon be attainable. Adequate anti-motion sickness drugs without adverse side effects are not yet available.

Use of antiemetics in the prevention of chemotherapy-induced nausea and vomiting: review and focus on the Belgian situation

Chemotherapy-induced nausea and vomiting (CINV) is a common, distressing, debilitating and costly side effect, experienced by up to 90% of patients receiving highly emetogenic drugs. During the last 20 years great advances have been made in the prevention and treatment of CINV. Aprepitant (a neurokinin-1 antagonist) and palonosetron (a 5-HT3 antagonist) are the most recent additions to the available armamentarium. The aim of this paper is to review the most recent findings concerning the pathophysiology and prevention of CINV, and the international guidelines currently in place for its prevention and treatment. Among the treatments available, 5-HT3 antagonists and NK-1 antagonists are compared. In a large meta-analysis (8 studies in 3 592 patients) statistically significant differences in favour of palonosetron compared with first-generation 5-HT3 antagonists have been demonstrated in the prevention of acute, delayed and overall CINV. A recent, large phase III randomized, gender-stratified, double-blind trial in 848 patients receiving a broad range of moderately emetogenic chemotherapy regimens with a variety of tumour types showed superiority of an aprepitant triple regimen compared to a control regimen of ondansetron and dexamethasone. A new combined 5-HT3/ NK-1 treatment, called NEPA (palonosetron/netupitant), has provided very promising preliminary data and is awaited with great anticipation by clinicians. The specific Belgian situation in terms of Health Authorities recommendations and reimbursement policies is also presented. It is concluded that further improvements are still desirable, particularly in the prevention and treatment of delayed emesis.

Migraine-related symptoms in childhood

Periodic disorders of childhood often represent precursors of migraine. As we advance our knowledge of migraine and its complicated phenotypic presentation in childhood, we have noted the similarities in overlapping symptoms of children presenting with childhood periodic syndromes. There is often a positive family history of migraine in children that present with periodic syndromes. There is a known transformation of periodic syndromes from childhood into adult migraine with and without aura phenotype. There has been an evolution of our understanding of what was initially referred to as periodic symptoms of childhood and more recently been called childhood periodic syndromes and is now evolving into the terminology of episodic symptoms that are associated with migraine. International classification of headache disorders has been instrumental in the evolution of the classification of headache and children adults. The most recent classification utilizes and replaces the periodic symptom terminology with episodic symptoms that will no longer be limited to just childhood. This article will address the evolution of our understanding of the diagnostic criteria, pathophysiology and management of the episodic syndromes that may be associated with migraine.

Regulation of nausea and vomiting by cannabinoids and the endocannabinoid system

Nausea and vomiting (emesis) are important elements in defensive or protective responses that animals use to avoid ingestion or digestion of potentially harmful substances. However, these neurally-mediated responses are at times manifested as symptoms of disease and they are frequently observed as side-effects of a variety of medications, notably those used to treat cancer. Cannabis has long been known to limit or prevent nausea and vomiting from a variety of causes. This has led to extensive investigations that have revealed an important role for cannabinoids and their receptors in the regulation of nausea and emesis. With the discovery of the endocannabinoid system, novel ways to regulate both nausea and vomiting have been discovered that involve the production of endogenous cannabinoids acting centrally. Here we review recent progress in understanding the regulation of nausea and vomiting by cannabinoids and the endocannabinoid system, and we discuss the potential to utilize the endocannabinoid system in the treatment of these frequently debilitating conditions.

Looking beyond 5-HT(3) receptors: a review of the wider role of serotonin in the pharmacology of nausea and vomiting

The concept that 5-hydroxytryptamine (5-HT; serotonin) is involved in the emetic reflex was revealed using drugs that interfere with its synthesis, storage, release and metabolism ahead of the discovery of selective tools to modulate specific subtypes of receptors. This review comprehensively examines the fundamental role of serotonin in emesis control and highlights data indicating association of 5-HT1-4 receptors in the emetic reflex, whilst leaving open the possibility that 5-HT5-7 receptors may also be involved. The fact that each receptor subtype may mediate both emetic and anti-emetic effects is discussed in detail for the first time. These discussions are made in light of known species differences in emesis control, which has sometimes affected the perception of the translational value of data in regard to the development of novel anti-emetic for use in man.

From heave to leave: understanding cyclic vomiting syndrome

Cyclic vomiting syndrome (CVS) is an idiopathic functional gastrointestinal disorder that has been underrecognized in the adult population. Nausea, vomiting, and abdominal pain are common presentations to gastrointestinal nursing. There are multiple differential diagnoses the clinician must consider prior to a diagnosis of CVS to recognize the disorder. CVS occurs in 4 phases: (a) interepisodic, (b) prodromal, (c) vomiting, and (d) recovery. Each phase has specific treatment guidelines. There is no specific "cure" for CVS; proper management is key. Increasing awareness of CVS is paramount to its detection. CVS has been examined in the pediatric population and has often been considered a pediatric disorder. More recently, it has come to be recognized in the adult population. Proper care and management of these patients allow for better support for patients and their families who are often on the primary caregivers. Nurses are often on the front lines of care and knowledge of CVS from the beginning should lead to shortened hospital stays and optimal patient care.

The role of vagal neurocircuits in the regulation of nausea and vomiting

Nausea and vomiting are among the most frequently occurring symptoms observed by clinicians. While advances have been made in understanding both the physiological as well as the neurophysiological pathways involved in nausea and vomiting, the final common pathway(s) for emesis have yet to be defined. Regardless of the difficulties in elucidating the precise neurocircuitry involved in nausea and vomiting, it has been accepted for over a century that the locus for these neurocircuits encompasses several structures within the medullary reticular formation of the hindbrain and that the role of vagal neurocircuits in particular are of critical importance. The afferent vagus nerve is responsible for relaying a vast amount of sensory information from thoracic and abdominal organs to the central nervous system. Neurons within the nucleus of the tractus solitarius not only receive these peripheral sensory inputs but have direct or indirect connections with several other hindbrain, midbrain and forebrain structures responsible for the co-ordination of the multiple organ systems. The efferent vagus nerve relays the integrated and co-ordinated output response to several peripheral organs responsible for emesis. The important role of both sensory and motor vagus nerves, and the available nature of peripheral vagal afferent and efferent nerve terminals, provides extensive and readily accessible targets for the development of drugs to combat nausea and vomiting.

Effects of professional support on nausea, vomiting, and quality of life during early pregnancy

The purpose of this study was to examine the effectiveness of a professional support (PS) intervention (including individualized health education and supportive phone calls) in reducing the severity of nausea and vomiting (NV) and improving the quality of life (QOL) of women in early pregnancy. An experimental pretest/posttest design with a control group was used. Participants were recruited from a regional teaching hospital in southern Taiwan. The women in the experimental group (n = 40) received the PS intervention, while those in the control group (n = 39) only received routine nursing care. Analysis of covariance and mixed models were used to compare the experimental and control groups while adjusting for covariates. The severity of NV and the perceived level of symptom distress were significantly lower in the experimental group than in the control group during weeks 2 and 4, and the women in the experimental group showed a significant improvement in their QOL in week 4 (p < .05). However, there was no significant difference between the two groups in body weight at week 4 (p = .501). These findings provide empirical evidence in support of the effectiveness of PS in reducing the severity of NV and improving QOL for women during early pregnancy. This intervention could be routinely applied in prenatal nursing health education. Future studies could apply the concept of PS to different populations and health issues.

Nausea and vomiting in palliative care

Nausea and vomiting in patients with advanced disease are debilitating symptoms that reduce the quality of life for patients, their families and carers. These symptoms are common in patients with both malignant and non-malignant disease. Palliative care intervention has been shown to improve them significantly, thereby improving patient experience of end-of-life care. This article discusses systematic and thorough assessment of patients to identify possible causes, and how these can be corrected where possible. Simple measures to manage symptoms can be effective in improving nausea and vomiting without the need for medication, and these should be considered in the first instance. We give also explain the pathophysiology of nausea, including the neurotransmitters involved, to help guide appropriate prescribing.

Global T-wave inversions with isolated hypomagnesemia

BACKGROUND

The physiological actions of magnesium within the cardiac conduction system and myocytes have yet to be fully elucidated. Because concurrent hypocalcemia or hypokalemia were also present in previous human reports, specific electrocardiographic effects of isolated hypomagnesemia have not been clearly delineated.

OBJECTIVE

We report a case in which dynamic electrocardiogram (ECG) changes were demonstrated in isolated hypomagnesemia.

CASE REPORT

A 37-year-old man with history of heavy alcohol use was admitted for syncope. The ECG showed global T-wave inversions with prolonged corrected QT (QTc) duration on ECG. Extensive work-up including cardiac catheterization was unremarkable. His serum magnesium was noted to be low at 1.1 mg/dL, and his serum calcium and potassium were within normal limits. The patient received magnesium infusion with subsequent ECGs showing resolution of his global T-wave inversions and prolonged QTc.

CONCLUSION

This case is unique because it reports dynamic ECG changes in a patient with isolated hypomagnesemia. Although isolated hypomagnesemia is commonly believed to result in dysrhythmia, we were unaware of any previous cases of ECG abnormalities in humans. Clinically, we advise checking serum magnesium and correcting hypomagnesemia when prolonged QTc duration and global T-wave inversions are seen on ECG.

Evaluation of nausea and vomiting: a case-based approach

In the absence of acute abdominal pain, significant headache, or recent initiation of certain medications, acute nausea and vomiting is usually the result of self-limited gastrointestinal infections. Nausea and vomiting is also a common adverse effect of radiation therapy, chemotherapy, and surgical anesthesia. Other potential diagnoses include endocrine conditions (including pregnancy), central nervous system disorders, psychiatric causes, toxin exposure, metabolic abnormalities, and obstructive or functional gastrointestinal causes. The likely cause of acute nausea and vomiting can usually be determined by history and physical examination. Alarm signs such as dehydration, acidosis caused by an underlying metabolic disorder, or an acute abdomen warrant additional evaluation. Based on the suspected diagnosis, basic laboratory testing may include urinalysis, urine pregnancy testing, complete blood count, comprehensive metabolic panel, amylase and lipase levels, thyroid-stimulating hormone level, and stool studies with cultures. Imaging studies include abdominal radiography, ultrasonography, and computed tomography. Computed tomography of the head should be performed if an acute intracranial process is suspected. Chronic nausea and vomiting is defined by symptoms that persist for at least one month. Patients with risk factors for gastric malignancies or alarm symptoms should be evaluated with esophagogastroduodenoscopy. If gastroparesis is suspected, a gastric emptying study is recommended. In addition to functional causes, it is also important to consider psychiatric causes when evaluating patients with chronic nausea and vomiting.

Getting the measure of the patient experience

Enhanced recovery uses evidence-based interventions to improve the perioperative care of patients undergoing major surgery. Due to the relative lack of research into patient experience, Central Manchester Foundation Trust distributed a questionnaire to measure the experience of patients cared for on a colorectal ER pathway. Overall, results were favourable, and described good pain management and high-quality care provided by the enhanced recovery team. This article describes how the results will be used to shape services in the future.

Chest pain and an abnormal chest X-ray--a case report

Chest pain is a common symptom amongst patients presenting to the acute medical unit, and presents a diagnostic challenge. We present the case of a previously healthy 65 year old year old gentleman with chest pain and subsequent vomiting, treated initially as an acute coronary syndrome, despite normal ECG and troponin. Chest radiograph revealed left basal consolidation with an effusion, suggesting pneumonia. The absence of symptoms of respiratory infection along with a normal C-reactive protein level led to further investigation with CT. This revealed evidence of oesophageal rupture (Boerhaave's syndrome). Despite early surgical intervention our patient suffered a number of complications and continues his recovery in hospital three months post presentation.

Crying and spilling--time to stop the overmedicalisation of normal infant behaviour

Many infants have periods of unsettledness, or irritability, over the first months of life. Spilling (or posseting) due to reflux of gastric contents is also seen very frequently. Almost universally, these are normal patterns of infancy (the first 12 months of life) that resolve with the passage of time. In recent years, these normal developmental processes have increasingly been ascribed to pathology and treated with medical therapies, including acid suppressants. There is clear evidence, however, that acid suppression has no role in the management of these behaviours. In addition, recent data illustrate increased risk of adverse effects of these drugs in infants.

Emesis in diabetes mellitus

It is estimated that 20-40% of patients with diabetes, particularly those with prolonged duration of type 1 diabetes mellitus with other complications develop gastroparesis .We present in a picture quiz format the interesting case of an elderly lady presenting with diabetic gastroparesis in a tertiary care hospital in India.

Radiology case of the month. Nausea, vomiting, and diarrhea in a patient with hepatitis C and acquired immunodeficiency syndrome (AIDS). Diffuse, severe gastric-wall thickening, consistent with edema

The patient is a 42-year-old male with a past medical history of HIV/AIDS (his most recent CD4 count, four months before admission, was 19) and hepatitis C who presented to the Emergency Department complaining of one week of persistent nausea, vomiting, and diarrhea. His admit labs were as follows: hemoglobin of 11.8, hematocrit of 35, total protein of 6.0, albumin of 1.6, total bilirubin of 2.3, aspartate aminotransferase (AST) of 141, alkaline phosphatase (ALP) of 146, and alanine aminotransferase (ALT) of 31. Computed tomography (CT) images of the abdomen and pelvis with contrast were obtained (Figures 1 - 4).

Cannabidiol, a non-psychotropic component of cannabis, attenuates vomiting and nausea-like behaviour via indirect agonism of 5-HT(1A) somatodendritic autoreceptors in the dorsal raphe nucleus

BACKGROUND AND PURPOSE

To evaluate the hypothesis that activation of somatodendritic 5-HT(1A) autoreceptors in the dorsal raphe nucleus (DRN) produces the anti-emetic/anti-nausea effects of cannabidiol (CBD), a primary non-psychoactive cannabinoid found in cannabis.

EXPERIMENTAL APPROACH

The potential of systemic and intra-DRN administration of 5-HT(1A) receptor antagonists, WAY100135 or WAY100635, to prevent the anti-emetic effect of CBD in shrews (Suncus murinus) and the anti-nausea-like effects of CBD (conditioned gaping) in rats were evaluated. Also, the ability of intra-DRN administration of CBD to produce anti-nausea-like effects (and reversal by systemic WAY100635) was assessed. In vitro studies evaluated the potential of CBD to directly target 5-HT(1A) receptors and to modify the ability of the 5-HT(1A) agonist, 8-OH-DPAT, to stimulate [(35) S]GTPγS binding in rat brainstem membranes.

KEY RESULTS

CBD suppressed nicotine-, lithium chloride (LiCl)- and cisplatin (20 mg·kg(-1) , but not 40 mg·kg(-1) )-induced vomiting in the S. murinus and LiCl-induced conditioned gaping in rats. Anti-emetic and anti-nausea-like effects of CBD were suppressed by WAY100135 and the latter by WAY100635. When administered to the DRN: (i) WAY100635 reversed anti-nausea-like effects of systemic CBD, and (ii) CBD suppressed nausea-like effects, an effect that was reversed by systemic WAY100635. CBD also displayed significant potency (in a bell-shaped dose-response curve) at enhancing the ability of 8-OH-DPAT to stimulate [(35) S]GTPγS binding to rat brainstem membranes in vitro. Systemically administered CBD and 8-OH-DPAT synergistically suppressed LiCl-induced conditioned gaping.

CONCLUSIONS AND IMPLICATIONS

These results suggest that CBD produced its anti-emetic/anti-nausea effects by indirect activation of the somatodendritic 5-HT(1A) autoreceptors in the DRN.

LINKED ARTICLES

This article is part of a themed section on Cannabinoids in Biology and Medicine. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2012.165.issue-8. To view Part I of Cannabinoids in Biology and Medicine visit http://dx.doi.org/10.1111/bph.2011.163.issue-7.

Cyclic vomiting syndrome and functional vomiting in adults: association with cannabinoid use in males

BACKGROUND

Cyclic vomiting syndrome (CVS) is characterized by stereotypical episodes of vomiting separated by symptom-free intervals. However, the difficulty encountered in the management of patients with CVS may be a reflection of a deficiency in our understanding of the disorder. We aimed to evaluate whether clinical or gastric emptying (GE) data discriminate patients labeled as having CVS from functional vomiting (FV) or irritable bowel syndrome (IBS).

METHODS

The medical records of patients diagnosed with any vomiting (including CVS, FV) over a 13-year period (1993-2006) at our institution were carefully reviewed. Disease controls were age and gender matched subjects with IBS. Gastric emptying was performed by scintigraphy (99mTc-egg meal). The associations of clinical factors and GE data with patient status (CVS vs FV or IBS) were analyzed.

KEY RESULTS

A total of 82 patients with CVS and 62 FV patients were identified. Younger age [per 10 years, OR = 0.7 (0.5, 0.9)], male gender [OR = 0.4 (0.2, 0.9)], and cannabinoid use [OR = 2.9 (1.2, 7.2)] were significantly associated with CVS compared with FV. However, there were no significant associations between patient status (CVS vs FV) and age, BMI, smoking, alcohol use, gastrointestinal symptoms, or GE. The proportion of cannabinoid users was significantly higher in patients with CVS compared with patients with IBS, whereas proportions for headaches and psychiatric disease were higher in subjects with IBS.

CONCLUSIONS & INFERENCES

Cyclic vomiting syndrome (vs FV) was not associated with clinical factors, but was associated with younger age, male gender and cannabinoid use. A larger proportion of CVS (vs IBS) patients had used cannabinoids.