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## Complete Summary

#### GUIDELINE TITLE

Nausea and vomiting.

#### BIBLIOGRAPHIC SOURCE(S)

Editorial Board Palliative Care: Practice Guidelines. Nausea and
vomiting. Utrecht, The Netherlands: Association of Comprehensive Cancer
Centres (ACCC); 2006 Jan 12. 28 p. \[73 references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory and/or
warning information has been released.

-   [September 17, 2007, Haloperidol
    (Haldol)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Haloperidol):
    Johnson and Johnson and the U.S. Food and Drug Administration (FDA)
    informed healthcare professionals that the WARNINGS section of the
    prescribing information for haloperidol has been revised to include
    a new Cardiovascular subsection.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Nausea and vomiting in palliative care patients

#### GUIDELINE CATEGORY

Diagnosis\
Management\
Treatment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Nursing\
Oncology\
Pharmacology\
Psychology

#### INTENDED USERS

Allied Health Personnel\
Nurses\
Pharmacists\
Physician Assistants\
Physicians\
Psychologists/Non-physician Behavioral Health Clinicians

#### GUIDELINE OBJECTIVE(S)

To improve the quality of palliative care for the individual patient by
providing recommendations regarding diagnosis and treatment.
Secondarily, these guidelines can be used:

-   As an aid during consultations regarding palliative care

-   To increase knowledge regarding palliative care

-   For training and continuing education

#### TARGET POPULATION

Cancer patients who experience nausea and vomiting

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis**

1.  Patient history

2.  Physical examination (including dehydration and bowel obstruction
    assessment)

3.  Blood tests (renal and hepatic function, electrolytes, drug
    concentrations)

4.  Diagnostic imaging (x-ray, ultrasound, computed tomography (CT),
    magnetic resonance imaging, gastroscopy

**Management/Treatment**

1.  Integral approach to management

    -   Provision of information to patient

    -   Communication

    -   Supportive care

    -   Continuity of care

2.  Treatment of the underlying cause

3.  Nonpharmacological symptom management

    -   General and nutritional advice

    -   Administration of fluids and electrolytes

    -   Gastric tube

    -   Psychosocial techniques

4.  Pharmacological treatment of symptoms with antiemetics

    -   Dopamine antagonists (metoclopramide, haloperidol,
        levomepromazine)

    -   Prokinetic drugs (metoclopramide, domperidone, erythromycin

    -   Serotonin (5HT3) antagonists (ondansetron granisetron,
        tropisetron)

    -   Neurokinin antagonists (aprepitant)

    -   Corticosteroids (dexamethasone)

    -   Antihistamines (cyclizine, levomepromazine)

    -   Anticholinergic agents (cyclizine, butylscopolamine,
        levomepromazine)

    -   Octreotide/lanreotide

#### MAJOR OUTCOMES CONSIDERED

-   Rate of symptom relief

-   Quality of life

-   Side effects of pharmacological agents

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

**Level 1** = Based on a systematic review or at least two randomised
trials of sufficient quality

**Level 2** = Based on at least two comparative clinical trials of
moderate quality or insufficient size, or other comparative studies

**Level 3** = Based on one comparative trial or a non-comparative trial

**Level 4** = Based on expert opinion

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review with Evidence Tables

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The level of evidence was determined using a classification system that
conforms to that of the CBO (Centraal Begeleidings Orgaan). The levels
of evidence reflect the opinions of the authors and are open to
discussion.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

No pretence was made to create evidence-based guidelines in the same
sense that the CBO guidelines are evidence-based. The methods required
to develop evidence-based guidelines made the approach unfeasible given
the time and financial restrictions placed on the editorial staff

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Diagnosis**

**Patient History**

-   Medical history

-   Presence, duration, course, and severity of nausea

-   Frequency and amount of retching and/or vomiting; characteristics
    and odour; presence of food remnants and/or blood in vomit; relation
    to mealtimes

-   Relationship (or lack thereof) between nausea and vomiting;
    improvement of nausea after vomiting

-   Induction of nausea/vomiting by factors such as meals, change in
    position or movement, recent radiotherapy or chemotherapy

-   Use of antiemetics and their effects

-   Associated symptoms, such as anorexia, difficulty swallowing or
    digesting, stomach pain, early satiety, abdominal pain or cramps,
    swollen abdomen, stomach rumbling, constipation, thirst, polyuria,
    pain, cough, hiccups, dizziness, hearing impairment, headache, or
    neurological impairment

-   Changes in body weight

-   Anxiety, stress, or depression and their effect on symptoms

-   Alcohol use

-   (Changes in) medication

The history can provide important information regarding the cause of
nausea and/or vomiting:

-   Regurgitation of undigested, non-acidic food directly after
    swallowing indicates an oesophageal disorder

-   Vomit large amounts several hours after eating, often accompanied by
    hiccups, indicates delayed gastric emptying caused by partial
    obstruction of the pylorus or duodenum

-   Severe vomiting, which can lead to rapid dehydration, indicates a
    total pyloric or duodenal obstruction, which is uncommon

-   Small amounts of vomit with no signs of gastric retention are
    consistent with a filled gastric cavity caused by tumour or external
    compression

-   Small amounts of vomit with varying degrees of nausea and fluid
    associated with abdominal swelling indicates gastroparesis

-   Vomiting combined with increased abdominal girth and shortness of
    breath can indicate ascites

-   Position-dependent nausea and vomiting may be caused by fluid stasis
    in the stomach, infiltration of the mesenterium/peritoneum, or
    hypersensitivity of the vestibular apparatus (caused by tumours of
    the inner or middle ear or as a rare side effect of opioids)

-   Vomiting, often in the morning, in the absence of nausea, combined
    with headache and/or neurological defects, indicates increased
    intracranial pressure

-   Vomiting combined with thirst, polyuria, constipation, drowsiness,
    and/or confusion may indicate hypercalcaemia

**Physical Examination**

-   General: nutritional status, hydration status, mental condition

-   Inspection of the mouth and pharynx, particularly for candidiasis

-   Abdominal examination: surgical scars, peristalsis, signs of ascites
    (shifting dullness = position-dependent dullness during percussion,
    undulation = fluid wave induction in the flanks), distended stomach
    (clapotage = sloshing sound when the gastric region is pressed),
    liver enlargement, abnormal resistance, pain when pressure is
    applied, rectal examination

-   Fundoscopy/neurological examination if increased intracranial
    pressure is suspected

-   Vomit inspection. Large amounts of food remnants indicate pyloric or
    duodenal obstruction or bowel obstruction

**Additional Tests**

If desired, additional tests can be performed as indicated:

-   Blood analysis:

    -   Serum creatinine or serum potassium to determine the degree of
        dehydration, renal impairment, and/or potassium loss

    -   Total calcium (correct for low serum albumin using the formula
        Corrected Ca = serum calcium + 1.0 (0.025 x serum albumin) or
        Ca^2^+ (correction is not necessary for low serum albumin) to
        assess for hypercalcaemia

    -   Hepatic function (bilirubin, alkaline phosphatase \[AP\],
        gamma-glutamyl transpeptidase \[gamma-GT\], aspartate
        aminotransferase \[ASAT\], alanine aminotransferase \[ALAT\]):
        if liver metastases are suspected

    -   Sodium levels: if hyponatraemia is suspected

    -   Concentrations of digoxin, anti-epileptics, and theophylline if
        used

-   Diagnostic imaging:

    -   Abdominal X-ray if constipation or bowel obstruction is
        suspected

    -   Abdominal ultrasound or computed tomography (CT) scan if gastric
        obstruction, liver metastases, ascites, or carcinomatous
        peritonitis is suspected

    -   CT scan or magnetic resonance imaging (MRI) of the brain if
        metastases or meningitis carcinomatosa is suspected

-   Perform gastroscopy if gastritis, ulcer, or gastric compression or
    obstruction is suspected

**Management**

**Integral Approach**

*Information*

-   Provide information regarding the cause of nausea and vomiting,
    relevant factors, and the expected duration. The potential risks,
    symptoms, and consequences of dehydration should also be mentioned

-   Provide information regarding the goals, effects, and possible side
    effects of treatment with antiemetics

-   Advise on the (limited) role of administering parenteral fluids

*Communication*

-   Ascertain whether the patient is experiencing anxiety, stress, or
    other psychogenic factors

-   Discuss the changing role of nutrition (given its importance in
    relation to the prognosis) with the patient and his or her
    caregivers

-   Discuss the use of a symptom diary to aid in communication

*Supportive Care*

-   Ascertain whether nutritional advice from a dietician is needed

-   Discuss the value of relaxation and distraction techniques if
    anxiety is suspected to play a role. For treatment, contact can be
    made with a physiotherapist (relaxation and massage), psychologist
    (relaxation and hypnosis), or music therapist (relaxation and
    distraction)

-   Consider pharmacological support with anxiolytics for anxiety and
    stress

*Continuity of Care*

-   Ensure effective communication between various care providers

-   For complementary care, consider forms that the patient can receive
    or practice primarily at home (or in hospital), possibly with
    support from a volunteer aid

**Treating the Cause**

**Treating the Underlying Cause**

-   Targeted antitumour therapy (surgery, radiotherapy, or chemotherapy)
    should be considered only if there is a reasonable chance of
    response and a low risk of severe side effects

-   Dose modification or, if necessary, discontinuation; for opioids,
    consider opioid rotation or trying an alternative route of
    administration

-   For patients with obstruction of the gastric outlet or duodenum:

    -   If life expectancy is measured in weeks or months, stent
        placement may be considered

    -   If life expectancy is a few months or more, gastrojejunostomy
        can be considered

-   Treatment of peptic ulcer, gastritis, pancreatitis, cholelithiasis,
    nephrolithiasis, constipation, pain, or cough

-   Treatment of electrolyte disorders:

    -   Hypercalcaemia: zoledronic acid 4 mg intravenous (i.v.) or
        aminohydroxypropylidine bisphosphonate (APD) 90 mg i.v. + 3 to 4
        litres of 0.9% NaCl/24 hours (see guideline on hypercalcaemia);
        this often implies hospital admission for fluid administration

    -   Hyponatraemia: water restriction (for syndrome of inappropriate
        antidiuretic hormone secretion \[SIADH\]) or broth orally/0.9%
        NaCl i.v. (if there is concurrent dehydration)

-   For ascites, consider ascites puncture and drainage

-   For bowel obstruction (see also the Association of Comprehensive
    Cancer Centres (ACCC) guideline on bowel obstruction):

    -   Discuss the feasibility and desirability of surgery with the
        surgeon

    -   If surgery is not an option, consider conservative therapy:

        -   Gastric drainage (nasogastric tube) as needed during the
            acute phase, particularly for severe vomiting

        -   Somatostatin analogues: octreotide 100 to 300 microgram
            subcutaneous (s.c.) three times daily or 300 to 900
            microgram/24 hours continuous s.c. or i.v. infusion
            (particularly for severe vomiting); or, during the stable
            phase after the efficacy of octreotide has been confirmed,
            lanreotide PR 30 mg i.m. once every 2 weeks

        -   Butylscopolamine 60 to 120 mg/24 hours s.c. or i.v.

        -   For persistent nausea and vomiting despite pharmacological
            therapy, continuous gastric drainage with the use of
            nasogastric tube or percutaneous endoscopic gastrostomy
            (PEG) tube

-   For brain metastases, corticosteroids (dexamethasone 4 mg/day p.o.,
    s.c., or i.v.; if necessary higher doses can be given, see guideline
    on Brain Metastases) and possibly radiotherapy

**Non-pharmacological**

*Non-pharmacological Treatment of Symptoms*

[General and Nutritional Advice]{.underline}

-   Keep tissues and water to rinse the mouth nearby

-   Maintain a calm environment and fresh air

-   Wear loose clothing

-   Avoid strong perfumes

-   Avoid the sight and smell of food; immediately remove any food that
    the patient cannot or will not eat

-   Practice proper mouth care

-   Sit in an upright position for 30 to 45 minutes after eating

-   Take small, frequent meals; avoid foods that are greasy, warm,
    spicy, or aromatic; in some cases food is best served cold; allow
    the patient to eat what he or she finds appetising and tolerates
    well

-   Drink cola (not too cold!)

-   Suck on an ice cube, sorbet, or a piece of frozen fruit (pineapple,
    kiwi, or apple)

-   For patients with severe vomiting, try to ensure that the stomach is
    full, provided that gastric retention has been ruled out

-   Consider consulting a dietician

-   For malnourished patients, consider dietary supplements; however,
    these are often poorly tolerated and may sometimes exacerbate
    symptoms

[Administration of Fluids and Electrolytes]{.underline}

If there are indications of dehydration based on the patient history,
physical examination, and possibly laboratory assessment, parenteral
fluid administration can be considered, depending on the life expectancy
and the wishes of the patient; for cases of hypokalaemia, supplemental
potassium can be given intravenously.

[Gastric Tube]{.underline}

Gastric tubes have a limited role in the palliative phase, except in
cases of total pyloric or duodenal obstruction, bowel obstruction, or
untreatable gastroparesis. For non-responsive vomiting in these
situations, a nasogastric or percutaneous endoscopic gastrostomy (PEG)
tube can be used to drain off stomach contents, thereby preventing
vomiting.

[Psychological Techniques]{.underline}

Psychological techniques are used to manage nausea and vomiting
primarily when psychogenic factors (anxiety and stress) and conditioning
(anticipatory nausea and vomiting) are found to play an important role.
These types of nausea and vomiting respond poorly to antiemetics.
Psychological techniques act by inducing relaxation, distraction, and/or
a feeling of self-control. Instruction from a psychologist is necessary
the first time, after which a physician, nurse, or even the patient can
usually apply the technique on their own.

The following techniques can be applied:

-   Distraction

-   Relaxation techniques

-   Guided imagery

-   Systematic desensitisation

-   Self hypnosis

-   Biofeedback

-   Music therapy

The approach used must be attuned to the coping style of the patient.
Some patients will benefit more from a physical approach aimed at
relaxation, while others may respond to a more active approach involving
behavioural therapy.

**Pharmacological**

*Pharmacological Treatment of Symptoms*

Knowledge of the aetiology is essential for applying targeted antiemetic
therapy. Antiemetics can be administered by oral, rectal, transdermal,
or parenteral routes. For chronic nausea (which is often associated with
delayed gastric emptying and vomiting) antiemetics must be given
rectally or possibly parenterally.

Some agents have multiple mechanisms of action and interact with various
neurotransmitters.

Agents used as antiemetics are shown in Table 1 in the original
guideline document:

-   Dopamine antagonists: inhibit central dopamine (D2) receptors in the
    chemoreceptor trigger zone (metoclopramide, haloperidol,
    levomepromazine)

-   Prokinetic drugs: promote gastric emptying by inhibiting dopamine
    receptors in the stomach (metoclopramide, domperidone,
    erythromycin); metoclopramide also stimulates peripheral 5HT4
    receptors, which increases acetylcholine secretion from the
    myenteric plexus and promotes peristalsis

-   Serotonin (5HT3) antagonists (ondansetron, granisetron, tropisetron)

-   Neurokinin antagonists (aprepitant)

-   Corticosteroids (dexamethasone)

-   Antihistamines (cyclizine, levomepromazine)

-   Anticholinergic agents (cyclizine, butylscopolamine,
    levomepromazine)

-   Octreotide/lanreotide (analogues of somatostatin, a gastrointestinal
    hormone that inhibits secretion in the gastrointestinal tract)

The choice of antiemetic depends on the mechanism that lead to nausea
and vomiting and on the receptors involved:

-   Prokinetic drugs (metoclopramide or domperidone, possibly
    erythromycin) for gastritis or gastric fluid stasis

-   Metoclopramide or haloperidol for nausea and vomiting caused by
    pharmacological stimulation of the chemoreceptor trigger zone
    (particularly opioids), hypercalcaemia, or renal insufficiency

-   Serotonin (5HT3) antagonists (possibly in combination with
    dexamethasone) for nausea and vomiting following surgery,
    radiotherapy, or chemotherapy (only during the first 24 hours)

-   Aprepitant for nausea and vomiting following chemotherapy

-   Corticosteroids for nausea induced by chemotherapy (in combination
    with serotonin antagonists) or increased intracranial pressure, or
    nausea resistant to other antiemetics

-   Cyclizine or scopolamine patch for vestibular causes of nausea and
    vomiting

-   Octreotide/lanreotide and/or butylscopolamine for conservative
    treatment of bowel obstruction

-   Levomepromazine, serotonin antagonists, or olanzapine for nausea and
    vomiting that is refractory to other treatments

Approximately 30% of cases will require a combination of different
antiemetics.

Parenteral administration of the following agents may be considered for
persistent vomiting when rectal administration is not available or
feasible:

-   Metoclopramide 40-100 mg/24 hours s.c. or i.v. as continuous
    infusion

-   Haloperidol 2-5 mg/24 hours s.c. or i.v. as continuous infusion

-   Dexamethasone 2-4 mg once daily s.c. (preferably not as continuous
    infusion)

-   Ondansetron 16 mg/24 hours s.c. or i.v.

-   Levomepromazine 3.25-25 mg s.c. a.n. or as continuous infusion

With the exception of dexamethasone, the aforementioned agents may be
easily combined with other agents (e.g., morphine) in one solution. The
disadvantages to this approach, however, are that the dose of each agent
can no longer be adjusted individually and bolus injection is not
possible. Given that metoclopramide and haloperidol are both dopamine
antagonists, combining these agents for the treatment of nausea is not
rational. If given for the treatment of delirium, haloperidol may be
added to metoclopramide. However, this is associated with an increased
risk of developing extrapyramidal symptoms.

NB: Cannabis (in cigarettes or tea or as tetrahydrocannabinol \[THC\])
has a limited role in treating nausea and vomiting, particularly for
chemotherapy-induced nausea and vomiting. It is not generally
recommended due to its side effects, such as dysphoria, particularly in
elderly patients.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not identified or graded for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate management and treatment of nausea and vomiting in cancer
patients, to improved quality of life and prevent morbidity.

#### POTENTIAL HARMS

Side effects of antiemetics

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The duration of the palliative phase can vary from weeks to years;
therefore, the guideline is in no way limited to the terminal phase. The
applicability and relevance of the diagnostic and treatment options
discussed in these guidelines are highly dependent on the phase of the
disease process and life expectancy. Care providers who make use of this
guideline must therefore determine which of the diagnostic and treatment
options mentioned in the guideline are applicable to his or her working
environment, specialty, and the individual situation of the patient in
question.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Foreign Language Translations\
Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

End of Life Care\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Editorial Board Palliative Care: Practice Guidelines. Nausea and
vomiting. Utrecht, The Netherlands: Association of Comprehensive Cancer
Centres (ACCC); 2006 Jan 12. 28 p. \[73 references\]

#### ADAPTATION

The first version of the guideline on nausea and vomiting was written in
1996 as part of the guideline on palliative care developed by the
Comprehensive Cancer Centre Middle Netherlands (Integraal Kankercentrum
Midden-Nederland, IKMN). The current version was revised in cooperation
with the Palliative Care Working Group of the Comprehensive Cancer
Centre Middle Netherlands and the Quapal Working Group of the
Comprehensive Cancer Centre East (Integraal Kankercentrum Oost, IKO) in
2005.

#### DATE RELEASED

2006 Jan

#### GUIDELINE DEVELOPER(S)

Association of Comprehensive Cancer Centres - Disease Specific Society

#### SOURCE(S) OF FUNDING

Association of Comprehensive Cancer Centres

#### GUIDELINE COMMITTEE

Editorial Board Palliative Care: Practice Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*The Editorial Board Palliative Care: Practice Guidelines Members*: A.
de Graeff, medical oncologist, University Medical CentreUtrecht; M.B.
Kuyper, general practitioner, Integraal Kankercentrum Oost; Nijmegen;
G.M. Hesselmann, palliative care nurse specialist, University Medical
Centre Utrecht

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Available in English and Dutch from the
[Association of Comprehensive Cancer Centres Web
site](http://www.oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&richtlijn_id=549).

Print copies: Available from the Association of Comprehensive Cancer
Centres PO Box 19001, 3501 DA Utrecht, The Netherlands

#### AVAILABILITY OF COMPANION DOCUMENTS

A version of the guideline for Personal Digital Assistants (PDAs) is
also available at the [Association of Comprehensive Cancer Centres Web
site](http://www.oncoline.nl/index.php?pagina=/richtlijn/item/pagina.php&richtlijn_id=549).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI Institute on May 8, 2008. The
information was verified by the guideline developer on July 15, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/10/2008