148 PART THREE | DELIRIUM nausea as a primary endpoint [61]. Several assessment tools exist to measure nausea as a single endpoint (e.g. visual analog scale; VAS) or as part of a multiple symptom assessment tool (e.g. Functional Living Index-Emesis; FLIE) [62]. In the light of the above considerations, we have conducted the MEDEA study, which is described in chapter 4. In thismulticenter, open-label, randomized, phase III, noninferiority trial amongpatients receivingMEC,weusedtotal control (TC;definedasnoemeticepisodes, no use of rescuemedication, and no nausea) in the delayed phase as the primary endpoint. We demonstrated that dexamethasone-sparing regimens (single-dose dexamethasone plus palonosetron or single-dose dexamethasone plus ondansetron and metoclopramide 10 mg orally three times daily on days 2-3) are well tolerated and do not result in any significant loss in antiemetic protection against not only vomiting but also nausea during the delayed period after MEC. There were no statistically significant differences in impact of CINV on QoL, and side effects associated with the use of antiemetics between treatment arms. Our data should encourage clinicians to optimize the use of dexamethasone without compromising antiemetic efficacy during the planned cycles of MEC. Future antiemetic studies need to develop better tools to stratify a patient’s CINV risk based on validated predictive tools to optimize care. CINV study endpoints should be standardized to allow objective cross-trial comparisons and meta-analyses to better inform treatment guidelines and health policy. In these studies, nausea, particularly in the delayed phase, should be measured and reported as a separate outcome. Part Three: Delirium In Chapter 5, the incidence of delirium in a hospitalized population of 574 patients with cancer was studied in a single-center, retrospective, cohort study. In comparison with previous literature [63, 64], we found a low incidence rate of only 3.5 per 100 admittances. Nine percent of all patients admitted in this period developed delirium. One reason for the low incidence of delirium on this ward could be that 58% of the admittances were elective for administration of chemotherapy or scheduled medical procedures, as these patients are at low risk of developing delirium during their hospital stay. Realizing that age and cognitive functioning are predisposing risk factors for delirium [65, 66], another possible reason for the low incidence rate is that the mean age of the patients admitted to this ward was 60 years (only 21% of the patients were aged ≥70 years) and most elderly patients had a good cognitive performance status, as only 2.1 percent of all patients had a cognitive impairment. In addition, hypoactive presentations of delirium [67], which more common than the classically agitated, hyperactive forms of delirium in patients with advanced cancer [68, 69], may be overlooked by the oncology team [70, 71]. Combining the assessments of palliative care physicians and oncology nurses has been shown to improve the detection of delirium in terminal cancer patients [72]. Finally, a retrospective chart review study is subject to several layers of potential bias. For example, even if delirium is detected, the attending physician or nurse may fail to document it in the medical chart.
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