Signal of harm in morphine use in adults with acute pulmonary oedema: A rapid systematic review

BACKGROUND

Heart failure affects nearly 65 million people globally, resulting in recurrent hospital admissions and substantial healthcare expenditure. The use of morphine in the management of acute pulmonary oedema remains controversial, with conflicting guidance and significant variation in practice. Synthesised evidence is needed to inform standard treatment guidelines and clinical practice.

OBJECTIVE

To determine whether morphine should be used in the treatment of acute pulmonary oedema (APE) in adults.

METHODS

A rapid review of systematic reviews of randomised controlled trials or observational studies, and then randomised controlled trials, was conducted searching three electronic databases (PubMed, Embase, Cochrane Library) and one clinical trial registry on 12 February 2022. We used a prespecified protocol following Cochrane rapid review methods and aligned to the National Standard Treatment Guidelines and Essential Medicines List methodology. We first considered relevant high-quality systematic reviews of randomised controlled trials or observational studies, then (if required) randomised controlled trials to inform time-sensitive or urgent evidence requests, clinical practice, policy, or standard treatment guidelines.

RESULTS

We identified four systematic reviews of observational studies. The two most relevant, up-to-date, and highest-quality reviews were used to inform evidence for critical outcomes. Morphine may increase in-hospital mortality (odds ratio (OR) 1.78; 95% confidence interval (CI) 1.01 - 3.13; low certainty of evidence; six observational studies, n=151 735 participants), resulting in 15 more per 1 000 hospital deaths, ranging from 0 to 40 more hospital deaths. Morphine may result in a large increase in invasive mechanical ventilation (OR 2.72; 95% CI 1.09 - 6.80; low certainty of evidence; four observational studies, n=167 847 participants), resulting in 45 more per 1 000 ventilations, ranging from 2 more to 136 more. Adverse events and hospital length of stay were not measured across reviews or trials.

CONCLUSION

Based on the most recent, relevant and best-available quality evidence, morphine use in adults with APE may increase in-hospital and all-cause mortality and may result in a large increase in the need for invasive mechanical ventilation compared to not using morphine. Recommending against the use of morphine in pulmonary oedema may improve patient outcomes. Disinvesting in morphine for this indication may result in cost savings, noting the possible accrued benefits of fewer patients requiring invasive ventilation and management of morphine-related side-effects.

Predictors of type 2 diabetes remission in the Diabetes Remission Clinical Trial (DiRECT)

AIM

To identify predictors of type 2 diabetes remission in the intervention arm of DiRECT (Diabetes Remission Clinical Trial).

METHODS

Participants were aged 20-65 years, with type 2 diabetes duration of <6 years and BMI 27-45 kg/m² , and were not receiving insulin. Weight loss was initiated by total diet replacement (825-853 kcal/day, 3-5 months, shakes/soups), and weight loss maintenance support was provided for 2 years. Remissions (HbA_1c <48 mmol/mol [<6.5%], without antidiabetes medications) in the intervention group (n = 149, mean age 53 years, BMI 35 kg/m² ) were achieved by 68/149 participants (46%) at 12 months and by 53/149 participants (36%) at 24 months. Potential predictors were examined by logistic regression analyses, with adjustments for weight loss and effects independent of weight loss.

RESULTS

Baseline predictors of remission at 12 and 24 months included being prescribed fewer antidiabetes medications, having lower triglyceride and gamma-glutamyl transferase levels, and reporting better quality of life with less anxiety/depression. Lower baseline HbA_1c was a predictor at 12 months, and older age and male sex were predictors at 24 months. Being prescribed antidepressants predicted non-remission. Some, but not all effects were explained by weight loss. Weight loss was the strongest predictor of remission at 12 months (adjusted odds ratio per kg weight loss 1.24, 95% CI 1.14, 1.34; P < 0.0001) and 24 months (adjusted odds ratio 1.23, 95% CI 1.13, 1.35; P <0.0001). Weight loss in kilograms and percentage weight loss were equally good predictors. Early weight loss and higher programme attendance predicted more remissions. Baseline BMI, fasting insulin, fasting C-peptide and diabetes duration did not predict remission.

CONCLUSIONS

Other than weight loss, most predictors were modest, and not sufficient to identify subgroups for which remission was not a worthwhile target.

'I have been all in, I have been all out and I have been everything in-between': A 2-year longitudinal qualitative study of weight loss maintenance

BACKGROUND

Qualitative studies investigating weight management experiences are usually cross-sectional or of short duration, which limits understanding of the long-term challenges.

METHODS

Eleven women [mean (SD) age 44.9 (9.8) years; body mass index 40.3 (4.0) kg m^-2 ] participated in this longitudinal qualitative study, which included up to 20 weeks of total diet replacement (825-853 kcal day^-1 ) and ongoing support for weight loss maintenance (WLM), to 2 years. Semi-structured interviews were conducted at baseline and programme end, as well as at key intervals during the intervention. Questions examined five theoretical themes: motivation, self-regulation, habits, psychological resources and social/environmental influences. Data were coded and analysed in nvivo (https://qsrinternational.com/nvivo) using the framework method.

RESULTS

In total, 64 interviews were completed (median, n = 6 per participant). Mean (SD) weight loss was 15.7 (9.6) kg (14.6% body weight) at 6 months and 9.6 (9.9) kg (8.8% body weight) at 2 years. The prespecified theoretical model offered a useful framework to capture the variability of experiences. Negative aspects of obesity were strong motivations for weight loss and maintenance. Perceiving new routines as sustainable and developing a 'maintenance mindset' was characteristic of 'Maintainers', whereas meeting emotional needs at the expense of WLM goals during periods of stress and negative mood states was reported more often by 'Regainers'. Optimistic beliefs about maintaining weight losses appeared to interfere with barrier identification and coping planning for most participants.

CONCLUSIONS

People tended to be very optimistic about WLM without acknowledging barriers and this may undermine longer-term outcomes. The potential for regain remained over time, mainly as a result of emotion-triggered eating to alleviate stress and negative feelings. More active self-regulation during these circumstances may improve WLM, and these situations represent important targets for intervention.

A tale of two sit-bones: The cyclist's ischial hygroma (Perineal nodular induration)

The ischial hygroma, also known as a perineal nodular induration, is a relatively rare and mostly cycling-specific injury that is often incorrectly diagnosed and managed. Here two cases with divergent managements are described to highlight the spectrum of treatment available to manage this condition. The presentation, assessment and management of two cases of perineal nodular induration are discussed. The management options, namely surgical excision vs conservative management, with saddle pressure mapping highlight that there is no single optimal method and that a multidisciplinary approach should be applied to treat these injuries successfully. Perineal nodular induration should be investigated appropriately to exclude less benign causes of perineal masses. Conservative management and surgical excision can both be successful. Clinicians should be familiar with the assessment and management of this relatively rare but debilitating condition in competitive cyclists.

A conserved role of a DEAD box helicase in mRNA masking

Clam p82 is a member of the cytoplasmic polyadenylation element-binding protein (CPEB) family of RNA-binding proteins and serves dual functions in regulating gene expression in early development. In the oocyte, p82/CPEB is a translational repressor, whereas in the activated egg, it acts as a polyadenylation factor. Coimmunoprecipitations were performed with p82 antibodies in clam oocyte and egg lysates to identify stage-regulated accessory factors. p47 coprecipitates with p82 from oocyte lysates in an RNA-dependent manner and is absent from egg lysate p92-bound material. Clam p47 is a member of the RCK/p54 family of DEAD box RNA helicases. Xp54, the Xenopus homolog, with bona fide helicase activity, is an abundant and integral component of stored mRNP in oocytes (Ladomery et al., 1997). In oocytes, clam p47 and p82/CPEB are found in large cytoplasmic mRNP complexes. Whereas the helicase level is constant during embryogenesis, in contrast to CPEB, clam p47 translocates to nuclei at the two-cell stage. To address the role of this class of helicase in masking, Xp54 was tethered via 3' UTR MS2-binding sites to firefly luciferase, following microinjection of fusion protein and nonadenylated reporter mRNAs into Xenopus oocytes. Tethered helicase repressed luciferase translation three- to fivefold and, strikingly, mutations in two helicase motifs (DEAD--> DQAD and HRIGR-->HRIGQ), activated translation three- to fourfold, relative to MS2. These data suggest that this helicase family represses translation of maternal mRNA in early development, and that its activity may be attenuated during meiotic maturation, prior to cytoplasmic polyadenylation.

[Recombinant tissue plasminogen activator in treatment of fulminant meningococcal infection]

This article reports about a young boy with fulminant meningococcal septicemia. Conventional treatment with antibiotics, intensive care and hemostatic drugs hold up vital functions. Because of extensive purpura fulminans with skin necrosis recombinant tissue plasminogen activator (rt-PA) was used. Under this therapy clinical improvement was observed.

The selection in vivo and characterization of an RNA recognition motif for spectinomycin

Ribonucleoprotein (RNP) complexes participate in almost all macromolecular processes, including RNA processing, protein synthesis, and the signal recognition of proteins targeted for export. An understanding of these processes requires detailed knowledge of interactions at the molecular level, which has evidently been difficult due to the size and complexity of the particles. Fragmentation of large RNP complexes into functional subdomains is proven to be a successful in vitro strategy to probe ligand interactions at the molecular level. We reasoned that RNA molecules expressed in vivo may fold in such a manner as to mimic a drug binding site present on the intact ribosome. If expressed at sufficient levels, the RNA would sequester the antibiotic thereby permitting the continued function of the ribosome and consequently allow the cell to survive in the presence of the drug. Evidence is presented here in support of this RNA fragment-rescue concept following the selection and characterization of RNA fragments that confer resistance to the antibiotic spectinomycin.

Antibody reactivity profiles following immunization with diverse peptides of the PERB11 (MIC) family

PERB11 (MIC) is a gene family possessing multiple copies located within the MHC. Structurally, PERB11 is related to the MHC class I, neonatal IgG Fc receptor (FcRn) and Zn-alpha 2-glycoprotein molecules. The MHC class I family is complex in terms of its genomic arrangement, expression and function, and available evidence suggests that the PERB11 family may be similarly complex. We have adopted an approach to study the expression of such complex gene families by immunizing with multiple peptides and by screening the resulting antibodies against a large range of tissues. The amino acid sequences of PERB11.1 and PERB11.2 as well as those of other related molecules were analysed and compared. Peptides were chosen for immunization based upon (i) loop formation within the equivalent known structure of the MHC class I molecules; (ii) immunogenicity by computer analysis; and (iii) evolutionary relationships. Antibodies in serum from immunized rabbits bound to three out of six peptides used for immunization. ELISA and immunoprecipitation demonstrated binding both to the peptides and to the PERB11.2 recombinant protein. By immunofluorescent staining of various tissues of several species, the three antisera generated overlapping profiles of activity. These included reactions with kidney, small and large intestine, oesophagus, testis, ovary and human neutrophils. This is the first description of antibodies induced by the PERB11 peptides. The extreme complexity of these profiles requires further investigation, but may be explained in terms of antibodies against diverse products of the PERB11 gene family and/or related molecules.

Fragmentation of the ribosome to investigate RNA-ligand interactions

RNA molecules perform a variety of important and diverse functions and, therefore, an understanding of their structure and interaction with proteins and ligands is essential. Large RNA molecules (for example, the ribosomal RNAs) are complex and hence reports describing their fragmentation into functional subdomains has provided a means for their detailed analysis. We present here an in vivo approach to study RNA-ligand interactions. This is based on the concept that an RNA fragment could mimic a drug-binding site present on the intact molecule. Overexpression of the fragment would sequester the drug thereby permitting the continued functioning of the ribosome and, thus, ensuring cell viability. Accordingly, a fragment of 16S rRNA encompassing the spectinomycin-binding domain in helix 34 (nucleotides 1046-1065 and 1191-1211) was cloned and in vivo expression resulted in drug resistance. Furthermore, an RNA fragment lacking flanking sequences to helix 34 was also selected from among a pool of random rRNA fragments and shown to confer spectinomycin resistance. A similar in vitro approach is also described for the analysis of rRNA molecules that interact with the yeast elongation factor 3 (EF-3).

[Elucidation and control of parafunctions by means of a modified self-observation test by Schulte and their effective treatment by occlusal adjustment and reconstruction]

A modified selfobservation test by Schulte enable us to differ parafunction quantitative as qualitative. By means of it were stated, toothclenching is induced by a missing or insufficient free way space on a large scale. Clenching could be reduced by occlusal adjustment and reconstruction significant about 45 percent. The free way space ought to be greater than or equal to 1 mm. The test is suitable for controlled treatment of temporomandibular joint and myofascial disorders. It could substitute electromyograms in outpatients, Toothclenching dominate with 85 percent before grinding with 27 percent in patients with wedge shaped defects.

[Influence of functional therapy on the gingival recession in patients with wedge shaped defects. A 2.5-year longitudinal study of the etiology of periodontal atrophy]

In 20 patients a free way space of greater than or equal to 1.0 mm and a cuspid protected guidance was formed. A previous study has shown, that prematurity and defective contacts reduce the free way space step by step and induce an artificial clenching. The front teeth was relieved in intercuspal position. The increase sof gingival recessions at the upper jaw was over five times significant slighter in treated patients than one in the 22 men of the control group. There was no significant, differences in the lower jaw. The recessions are represented as a sequence of a chronic biomechanical overloading.

[Treatment of hypersensibility of the neck of tooth by occlusion correction and removal of parafunction]

Tooth sensitivity, parafunctions and stress were proved in 44 patients with wedge shaped defects significantly more frequent than in 17 patients without ones. A cuspid protected guidance and a sufficient free way space could be found in patients with cervical notch defects evidently fewer. After reestablishment of a cuspid protected guidance and of a sufficient free way space and reduction of parafunctions the sensitivity estimated by means of a dental probe could be removed permanent on a number of teeth after two weeks already. The parafunctions have been detected before by using selfoservations test by Schulte.

[How can the progress of wedge shaped defects be reduced? A longitudinal study of 2.5 years to aetiology]

Malocclusion was removed according to direction by Motsch and Schulte. In addition a sufficient free way space was made. The patient was enlightened on connection between stress and problems, which he can't overcome, and parafunctions. The volumeestimation of wedge shaped defects elicited a significant reduction of 45 percent in regard of the progress. In order to malocclusion and parafunctions play an important part in making cervical notch defects.

[Volume estimation of non-caries related enamel defects]

The volume of wedge shaped defects can be estimated by means of massa suppositoriorum on a plaster cast. The substance are pressed in a graduated pipette. The average relative error is six percent. The absolute error of defects of 2.0, 10.0 respectively 20.0 mm3 ranges from 0.12, 0.6 to 1.2 mm3.

[Placement of the sensitivity tester in "Probaset" and "Probamat D"]

For ergonomical reasons the authors suggest, if a Probamat D unit and a fixed turbine are used, to place the turbine handpiece on the mount destined for the sensibility tester and to manufacture a new holder for the latter. The Probaset unit provides no place for the sensibility tester. Therefore, it is recommended to fit the bracket table with a suitable mount.

[Diagnosis of frequent periodontal diseases by the specialist for general dentistry]

It is reasonable to refer a patient to a specialist or a special clinic if the own diagnostic possibilities are not sufficient to elucidate the case. But the own diagnostic possibilities should be fully used to spare the patient unnecessary travelling and loss of time. The most reliable and important symptoms and the local causes of frequent periodontal diseases are described and tabulated. All the symptoms indicated may be verified in any institution by inspection, palpation, measuring of socket depth and radiological examination. In this way the specialist is general stomatology will be aided in establishing a periodontal differential diagnosis.