Situation: Margaret, age 68, was brought to the emergency department of a large regional medical center by her sister-in-law who stated, "She does nothing but sit and stare into space. I can't get her to eat or anything!" Upon assessment, it was found that 6 months ago Margaret's husband of 45 years had died of a massive myocardial infarction. They had no children and had been inseparable. Since her husband's death, Margaret has visited the cemetery every day, changing the flowers often on his grave. She has not removed any of his clothes from the closet or chest of drawers. His shaving materials still occupy the same space in the bathroom. Over the months, Margaret has become more and more socially isolated. She refuses invitations from friends, preferring instead to make her daily trips to the cemetery. She has lost 15 pounds and her sister-in-law reports that there is very little food in the house. Today she said to her sister-in-law, "I don't really want to live anymore. My life is nothing without Frank." Her sister-in-law became frightened and, with forceful persuasion, was able to convince Margaret she needed to see a doctor. Margaret is admitted to the psychiatric unit. Review articles Drugs. 2000 Feb; 59 2 ; : 213-43. Prevention and treatment of postoperative nausea and vomiting. Kovac AL. Department of Anaesthesiology, University of Kansas Medical Center, Kansas City 66160-7415, USA. akovac kumc Pain, nausea and vomiting are frequently listed by patients as their most important perioperative concerns. With the change in emphasis from an inpatient to outpatient hospital and office-based medical surgical environment, there has been increased interest in the 'big little problem' of postoperative nausea and vomiting PONV ; . Currently, the overall incidence of PONV is estimated to be 25 30%, with severe, intractable PONV estimated to occur in approximately 0.18% of all patients undergoing surgery. PONV can lead to delayed postanaesthesia care unit PACU ; recovery room discharge and unanticipated hospital admission, thereby increasing medical costs. The aetiology and consequences of PONV are complex and multifactorial, with patient-, medical- and surgery-related factors. A thorough understanding of these factors, as well as the neuropharmacology of multiple emetic receptors [dopaminergic, muscarinic, cholinergic, opioid, histamine, serotonin 5hydroxy-tryptamine; 5-HT ; ] and physiology [cranial nerves VIII acoustic-vestibular ; , IX glossopharyngeal ; and X vagus ; , gastrointestinal reflex] relating to PONV are necessary to most effectively manage PONV. Commonly used older, traditional antiemetics for PONV include the anticholinergics scopolamine ; , phenothiazines promethazine ; , antihistamines diphenhydramine ; , butyrophenones droperidol ; and benzamides metoclopramide ; . These antiemetics have adverse effects such as dry mouth, sedation, hypotension, extrapyramidal symptoms, dystonic effects and restlessness. The newest class of antiemetics used for the prevention and treatment of PONV are the serotonin receptor antagonists ondansetron, granisetron, tropisetron, dolasetron ; . These antiemetics do not have the adverse effects of the older, traditional antiemetics. Headache and dizziness are the main adverse effects of the serotonin receptor antagonists in the dosages used for PONV. The serotonin receptor antagonists have improved antiemetic effectiveness but are not as completely efficacious for PONV as they are for chemotherapy-induced nausea and vomiting. Older, traditional antiemetics such as droperidol ; compare favourably with the serotonin receptor antagonists regarding efficacy for PONV prevention. Combination antiemetic therapy improves efficacy for PONV prevention and treatment. In the difficult-to-treat PONV patient as in the chemotherapy patient ; , suppression of numerous emetogenic peripheral stimuli and central neuroemetic receptors may be necessary. This multimodal PONV management approach includes use of: i ; multiple different antiemetic medications double or triple combination antiemetic therapy acting at different neuroreceptor sites ii ; less emetogenic anaesthesia techniques; iii ; adequate intravenous hydration; and iv ; adequate pain control. Eur J Anaesthesiol. 1998 Sep; 15 5 ; : 595-9. The impact of audit in a district general hospital on post-operative nausea and vomiting after major gynaecological surgery. Hadji F, Eastwood D, Fear S, Corfield HJ. Arrowe Park Hospital, Upton, Wirral, UK. An audit of post-operative nausea and vomiting PONV ; was undertaken in 935 female patients who used morphine patientcontrolled analgesia PCA ; for pain relief after major gynaecological operations in a district general hospital. We investigated retrospectively five different antiemetic policies and a reference group without policy from January 1993 to July 1995. The department's computerized audit system was used to analyse the observations. At the beginning of the audit, the incidence of nausea and vomiting was as high as 71.5%. But as a consequence of this audit, a departmental policy was adopted 3 years later, which had an incidence of PONV of only 51.7%. During this time the compliance with antiemetic protocols increased from 41% to 76%. There was significantly less PONV if an antiemetic protocol was followed P 0.002 ; . This emphasizes the importance of corporate involvement in the development, formulation and evaluation of departmental protocols if compliance is to be high. We conclude that audit as a corporate effort improves the acceptance of departmental protocols. This reduces PONV significantly irrespective of the type of antiemetic drug used. Eur J Cancer. 1994; 30A 9 ; : 1223-7. Comment in: Eur J Cancer. 1994; 30A 9 ; : 1217. The roles of patient and observer assessments in anti-emetic trials. Olver IN, Matthews JP, Bishop JF, Smith RA. Medical Oncology Department, Royal Adelaide Hospital, Australia. The endpoints assessed by both patients and nurses were compared in three anti-emetic studies. In a parallel subjects study, there was no significant difference between the patients' and nurses' assessment of the number of vomiting episodes, but the duration of vomiting, the severity and duration of nausea, and the side-effects of the anti-emetic were given higher scores by the nurses. In two cross-over studies, the patients recorded more vomiting episodes than the nurses, while the nurses recorded more anxiety and sedation than the patients. This resulted in the patients detecting a difference between the side-effects of the anti-emetics being compared that was not apparent from the nurses' forms. Many of the differences reflect differences in the timing and frequency of data collection. Nurses collected data regularly during the assessment period whereas patients reported their experiences only at the completion of 24 h. Both assessments provide useful perspectives on the study outcomes.