Laxatives or methylnaltrexone for the management of constipation in palliative care patients

Background: Constipation is common in palliative care; it can generate considerable suffering due to the unpleasant physical symptoms. In the first Cochrane Review on effectiveness of laxatives for the management of constipation in palliative care patients, published in 2006, no conclusions could be drawn because of the limited number of evaluations. This article describes the first update of this review. / Objectives: To determine the effectiveness of laxatives or methylnaltrexone for the management of constipation in palliative care patients. / Search methods: We searched databases including MEDLINE and CENTRAL (The Cochrane Library) in 2005 and in the update to August 2010. / Selection criteria: Randomised controlled trials (RCTs) evaluating laxatives for constipation in palliative care patients. In the update we also included RCTs on subcutaneous methylnaltrexone; an opioid-receptor antagonist that is now licensed for the treatment of opioid-induced constipation in palliative care when response to usual laxative therapy is insufficient. / Data collection and analysis: Two authors assessed trial quality and extracted data. The appropriateness of combining data from the studies depended upon clinical and outcome measure homogeneity. / Main results: We included seven studies involving 616 participants; all under-reported methodological features. In four studies the laxatives lactulose, senna, co-danthramer, misrakasneham, and magnesium hydroxide with liquid paraffin were evaluated. In three methylnaltrexone. In studies comparing the different laxatives evidence was inconclusive. Evidence on subcutaneous methylnaltrexone was clearer; in combined analysis (287 participants) methylnaltrexone, in comparison with a placebo, significantly induced laxation at 4 hours (odds ratio 6.95; 95% confidence interval 3.83 to 12.61). In combined analyses there was no difference in the proportion experiencing side effects, although participants on methylnaltrexone suffered more flatulence and dizziness. No evidence of opioid withdrawal was found. In one study severe adverse events, commonly abdominal pain, were reported that were possibly related to methylnaltrexone. A serious adverse event considered to be related to the methylnaltrexone also occurred; this involved a participant having severe diarrhoea, subsequent dehydration and cardiovascular collapse. / Authors' conclusions: The 2010 update found evidence on laxatives for management of constipation remains limited due to insufficient RCTs. However, the conclusions of this update have changed since the original review publication in that it now includes evidence on methylnaltrexone. Here it found that subcutaneous methylnaltrexone is effective in inducing laxation in palliative care patients with opioid-induced constipation and where conventional laxatives have failed. However, the safety of this product is not fully evaluated. Large, rigorous, independent trials are needed

Analysis of Artisanal Small-scale Gold Mining Sector in West Sumbawa Regency, Indonesia

Background. The high value of gold reserves in West Sumbawa Regency (WSR) and West Nusa Tenggara Province, Indonesia has resulted in an increase in small-scale gold mining activity in this area. Artisanal and small-scale gold mining (ASGM) is an attractive alternative livelihood for rural workers because it has good potential to improve the wealth of a community. Miners need very little training to mine gold and the transition from traditional farming or fishing is easy to make. However, the key environmental consequence of ASGM in West Sumbawa is the extensive use of mercury and its impact on human health. Objectives. The ASGM activity in WSR is quite recent when compared to other ASGM activity in Indonesia. The current study was conducted to better understand the lifestyle, extent of mercury exposure, and the health of people living in WSR, West Nusa Tenggara Province, Indonesia. Methods. The present study was designed as a purposive field sampling study conducted in WSR, West Nusa Tenggara Province, Indonesia. The subjects were miners and families from three different sites within the WSR: individuals directly exposed to mercury, indirectly exposed individuals and non-exposed individuals. Hair mercury analysis was done with all subjects. Health questionnaires, physical examinations and socio-economic surveys were conducted with exposed subjects. Results. The ASGM sector in the WSR consists of a high number of migrant workers who have a great economic impact on the local area, high mercury use, a great deal of illegal mercury trading, and a high mercury concentration (>13 mg/kg) in their hair. The results suggest that ASGM activities affect the health of exposed and indirectly exposed individuals. Conclusions. The current scale of ASGM activity in the WSR is predicted to rise. ASGM activities in the WSR is an important challenge that needs to be addressed. Competing Interests. The authors declare no competing financial interests. Informed Consent. Obtained Ethical Approval. The protocols and informed consent documents were approved by the Ethics Committee (Medical Faculty) of the University of Mataram, West Nusa Tenggara Province, Indonesia

Interdisciplinarity in Transdisciplinary Projects: Circulating Knowledges, Practices and Effects

This article argues that the emphasis on solving substantive “real-world” problems through interdisciplinary research collaboration can neglect the wider value created by such collaborations. Championing the role of a knowledge integration and reflection facilitator, the article contends that more recognition be given to the value of “spillover” effects associated with interdisciplinary modes of working, rather than focusing solely on knowledge outputs and impacts. Drawing on embedded research conducted in relation to a project on local energy futures involving physicists, architects and geographers, the paper illustrates such “spillover” in relation to academic practice in teaching, project management and research methods. Such “spillovers” signal that what travels in interdisciplinary working is much more than formal knowledge and point to potential long-term legacy effects from interdisciplinary working occurring back in the disciplines