The Management of Opioid-Induced Constipation in Cancer and Advanced Illness: A Meta-Analysis

CONTEXT

Constipation is a common problem among patients with cancer. By some accounts, about 60% of cancer patients experience constipation. There is limited empirical evidence of the clinical effectiveness of pharmacologic agents in opioid-induced constipation in advanced diseases.

OBJECTIVES

We sought to quantitatively summarize the therapeutic effectiveness of the pharmacologic means of managing opioid-induced constipation.

METHODS

Randomized control trials (RCTs) identified from medical literature databases that reported quantitative measures of the effect of pharmacotherapeutic agents to treat opioid induced constipation in patients with cancers and other advanced illnesses were included in this study. A conventional random effects meta-analysis was conducted including >3 trials with the same exposure and outcome assessed, and a network-meta-analysis was conducted for all placebo-controlled trials.

RESULTS

Eighteen studies that examined the effect of various pharmacotherapeutic agents were included. The medications were Methylnatrexone (N = 5), Naldemedine (N = 5), other conventional agents (N = 4) and herbal medicines (N = 4). In conventional meta-analysis, methylnaltrexone increased the proportion achieving rescue-free laxation by 2.68 fold (95% CI: 1.34, 5.37; P = 0.0054) within 4 hours of the administration compared to placebo. In network meta-analysis, the pooled RR of the pharmacotherapeutic agents on rescue-free bowel movements as 2.26 (95% CI: 1.52, 3.36) for methylnaltrexone, 1.58 (95% CI: 0.94, 2.66) for naldemedine, and 0.74 (95% CI: 0.45, 1.23) for polyethylene glycol, compared to placebo.

CONCLUSION

Methylnatrexone and Naldemedine have currently shown promise in randomized trials concerning opioid-induced constipation in cancer and advanced illness. It is imperative that future research ascertain not just the relative therapeutic efficacy but also the cost-benefit analyses of these newer regimens with more commonly used and accessible laxatives.

Factors associated with post traumatic hydrocephalus following decompressive craniectomy: A single-center experience

Background

A decompressive craniectomy (DC) is a surgical procedure sometimes utilized to manage refractory intracranial hypertension following severe traumatic brain injury (sTBI). The previous studies have established a relationship between DC and post traumatic hydrocephalus (PTH). This study aimed to identify the factors responsible for developing shunt-amenable PTH in patients who underwent DC following sTBI.

Methods

A review of a prospectively collected database of all patients admitted with severe TBI in a tertiary neurosurgical center in North-west England between January 2012 and May 2022 was performed. PTH was defined as evidence of progressive ventricular dilatation, clinical deterioration, and/or the eventual need for cerebrospinal fluid diversion (i.e., a ventriculoperitoneal shunt). Statistical analysis was carried out using IBM SPSS versus 28.0.1.

Results

Sixty-five patients met the eligibility criteria and were included in the study. The mean age of the PTH group was 31.38 ± 14.67, while the mean age of the non-PTH group was slightly higher at 39.96 ± 14.85. No statistically significant difference was observed between the two groups' mechanisms of traumatic injury (P = 0.945). Of the predictors investigated, cerebellar hematoma (and contusions) was significantly associated with PTH (P = 0.006).

Conclusion

This study concludes that cerebellar hematoma (and contusions) are associated with developing PTH in patients undergoing DC.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt insertion for the management of pediatric hydrocephalus in African centers – A systematic review and meta-analysis

Background:

Ventriculoperitoneal shunt (VPS) insertion and endoscopic third ventriculostomy (ETV) are common surgical procedures used to treat pediatric hydrocephalus. There have been numerous studies comparing ETV and VPS, but none from an African perspective. In this study, we sought to compare outcomes from African neurosurgical centers and review the associated complications.

Methods:

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in conducting this study. PubMed, Google Scholar, and African Journal Online were searched. Data on treatment successes and failures for ETV and VPS were pooled together and analyzed with a binary meta-analysis. A clinically successful outcome was defined as no significant event or complication occurring after surgery and during follow-up (e.g., infection, failure, CSF leak, malfunction, and mortality). Seven studies fully satisfied the eligibility criteria and were used in this review.

Results:

There was no statistically significant difference between the outcomes of ETV and VPS (OR- 0.27; 95% CI −0.39–0.94, P = 0.42). After reviewing the rates of complications of ETV and VPS from the identified studies, four were recurrent. The infection rates of ETV versus VPS were 0.02% versus 0.1%. The mortality rates were 0.01% versus 0.05%. The reoperation rates were 0.05% versus 0.3%, while the rates of ETV failure and shunt malfunction were 0.2% versus 0.2%.

Conclusion:

This study concludes that there is no significant difference between the outcomes of ETV and VPS insertion.

Becoming a neurosurgeon in the United Kingdom: A road map for medical students and early career doctors

Neurosurgery is one of the most sought-after specialties worldwide. It is one of the most competitive specialties in the United Kingdom. The entire process takes 8 years and the recruitment process aims to select the best of candidates. Not much has been said about the entire selection process from the online application to the interview process, especially with the unprecedented changes brought about by the coronavirus pandemic. There needed to be a roadmap of the entire process, from start to finish, to enable the medical students and early career doctors to make an informed decision, as well as prepare beforehand to meet the criteria that have been set out. A balanced perspective is needed as well, to highlight the drawbacks of pursuing this arduous training specialty in the United Kingdom. This article builds on existing information and throws more light on the application, interview, and the challenges faced by doctors in training. It also shows the challenges the international medical graduate might face during the application process in terms of the shortlisting matrix as well as during training. This article offers advice to all doctors willing to specialize in neurosurgery and highlights what they can do to improve their chances. It sheds more light on the interview process so that shortlisted doctors can know where to focus on during the interviews. Most importantly, by describing the challenges that may be encountered as doctors in training under the NHS, it aims to give a balanced view. This will enable the would-be candidate to make a well-informed choice.

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Neurosurgical training is highly competitive in the UK.

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The process involves an online application (building of portfolio) and writing the multi-specialist recruitment exam.

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International medical graduates have some challenges with some of the portfolio domains.

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Important domains highlighted as well as things that can be done to improve each domain.

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An overview of what takes place in the interview.