SUGAR-DIP trial: oral medication strategy versus insulin for diabetes in pregnancy, study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial.

INTRODUCTION: In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM. METHODS: The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle. ETHICS AND DISSEMINATION: The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NTR6134; Pre-results.

Carboplatin instead of cisplatin in combination with dexamethasone, high-dose cytarabine with or without rituximab (DHAC+/-R) is an effective treatment with low toxicity in Hodgkin's and non-Hodgkin's lymphomas.

The DHAP regimen (high-dose cytarabine in combination with dexamethasone and cisplatin) with or without rituximab (DHAP+/-R) is one of the most common regimens in daily practice. It is considered the standard treatment for relapse or refractory Hodgkin's and non-Hodgkin's lymphoma (NHL). Cisplatin nephrotoxicity is a major concern, and other platinum compounds are being tried. We performed a monocentric retrospective analysis to evaluate the use of carboplatin, so-called DHAC+/-R regimen. The purpose was to assess the toxicity of the DHAC+/-R regimen in real-life. The Dexamethasone, Cytarabine, Carboplatin (DHAC) regimen consisted of carboplatin AUC = 5 mg/ml/min (targeted area under the curve with Calvert's formula) on day 1, cytarabine 2 g/m2 twice a day on day 2 and IV dexamethasone 40 mg from days 1 to 4. Rituximab was administrated at 375 mg/m2 on day 1 for CD20+ NHL. The interval between courses was 21 days. During the period considered, 199 patients received DHAC+/-R. For the entire cohort, median follow-up is 24 months (range, 2-82), median OS is not reached (NR), estimated 2-year OS is 75% (95% CI, 69-83) and median progression-free survival (PFS) is 46 months (95% CI, 22-NA). Of 144 patients scheduled for autologous stem cell transplantation (ASCT), 102 (71%, NA = 2) were in response after DHAC+/-R and all except 4 underwent ASCT. Grade ≥ 3 haematological toxicities were mainly thrombocytopenia (n = 101) and anaemia (n = 95). Grade ≥ 3 neutropenia occurred in 10 patients. No grade ≥ 3 renal and one grade 3 neurological toxicity were reported. DHAC+/-R is feasible in daily practice, provides good response rates and jeopardises neither stem cell collection nor ASCT.

Rituximab maintenance after autologous stem cell transplantation prolongs response duration in non-naive rituximab follicular lymphoma patients: a single institution experience.

We retrospectively evaluated the role of rituximab (R) in maintenance treatment after autologous stem cell transplantation performed in patients with relapsed follicular lymphoma. We compared the outcome of 67 follicular lymphoma (FL) patients according to the use of rituximab maintenance (RM) or not. All patients received rituximab plus chemotherapy before autologous stem-cell transplantation (ASCT). Patients received median of two lines of prior therapy. The RM schedule was one injection of rituximab every 3 months for 2 years. Median follow-up is 4.6 years. The 3-year progression-free survival (PFS) after ASCT was 86 % with RM vs. 46 % without (p = 0.0045). Median is not reached in the RM arm vs. 31 months in non-RM arm. The 3-year OS was 96 % with RM vs. 78 % without (p = 0.059). The present monocentric study shows that 2 years of RM after ASCT significantly increases response duration for non-naive rituximab relapsed FL patients compared with observation.

Thyroid dysfunction during pregnancy and in the first postpartum year in women with diabetes mellitus type 1.

BACKGROUND: The prevalence of thyroid dysfunction in pregnancy and in the first postpartum year (postpartum thyroid dysfunction (PPTD)) in women with diabetes mellitus type 1 (DM1) is known to be higher than in the general population. To assess prevalence, incidence and risk factors in The Netherlands we performed a prospective cohort study. DESIGN: From 1994 to 1998, 126 women with DM1 from eight Dutch clinics were included. TSH, free thyroxine, free tri-iodothyronine and anti-thyroid peroxidase antibodies (TPO-ab) were measured pre-pregnancy, in the first and last trimester of pregnancy and at 1.5, 3, 6, 9 and 12 months after delivery. RESULTS: Eighty-two women completed the study. Thyroid dysfunction during pregnancy was observed in 22.5% (first trimester) and 18.4% (third trimester), and mostly consisted of subclinical hypothyroidism. Baseline characteristics of women with thyroid dysfunction in pregnancy did not differ from those without thyroid dysfunction. Overt PPTD was seen in 15.9%. Incidence of PPTD was 10%. Patients with PPTD were slightly older than those without PPTD and the prevalence of TPO-ab was higher in these women. CONCLUSION: In women with DM1 the prevalence of thyroid dysfunction during pregnancy and overt PPTD is 3-fold higher than in the general Dutch population. Risk factors are age and TPO-ab. Given the possible impact on psychomotor development of the offspring and on well-being of the mother these data suggest there is a case for screening (pre-)pregnant women with DM1 for TSH and TPO-ab.

Risk-based evaluation of postmortem inspection procedures for pigs in Australia.

The results of traditional (incision) and risk-based (visual) postmortem inspection procedures were compared on groups of approximately 30,000 pigs. The performance characteristics used as a basis for comparison included the non-detection rates of grossly detectable abnormalities, the microbiological contamination rates of carcases and boned product, the association of reactive lymph nodes with carcase condemnation and the achievement of 'finished product standards' for 'wholesomeness'. It was estimated that 6 per cent of all cases of abscessation and 28 per cent of all cases of arthritis were undetected by the traditional method, and the comparable figures for the risk-based procedure were 19 per cent and 39 per cent. However, when the rates of contamination of undetected abnormalities with foodborne hazards and other carcase contamination parameters were taken into account, it was concluded that both inspection systems were likely to result in a very similar level of consumer protection. Any increase in potential exposure to foodborne hazards in the abnormalities undetected by risk-based inspection would be insignificant in comparison with the potential exposure to foodborne hazards resulting from contaminated 'normal' lymph nodes and carcase surfaces. There were no statistically significant differences between the two procedures in the contamination rates of pre-chill carcases or boned retail products with Salmonella and Yersinia species.

Cushing's syndrome complicated by multiple opportunistic infections.

The case history of a 56-year-old man is described who suffered from severe adrenocorticotrophic hormone (ACTH)-dependent Cushing's syndrome. The clinical course was complicated by simultaneous infections with Pneumocystis carinii, Staphylococcus aureus, Candida albicans, Aspergillus fumigatus and Herpes simplex, which proved to be fatal. A study of the literature shows that opportunistic infections in endogenous Cushing's syndrome are associated with severe cortisol excess and carry a high mortality. Opportunistic infections are most prevalent in the ectopic ACTH syndrome explained by the very high plasma cortisol concentrations in this condition. Infections with Aspergillus species, Cryptoccus neoformans, Pneumocystis carinii and Nocardia asteroides predominated. Cushing's syndrome with a very high plasma cortisol concentration causes a severe immunocompromized state. Prompt evaluation of the cause of the hypercortisolism, initiation of cortisol lowering therapy, primary prophylaxis for Pneumocystis carinii infection when plasma cortisol exceeds 2500 nmol L-1 and a search for concomitant infectious disease is recommended.

[Collagenous colitis; an invisible disease?]. / Collagene colitis; een onzichtbare aandoening?

A middle-aged female with chronic diarrhoea was diagnosed after extensive evaluation as having collagenous colitis. Remarkable in this case was the definitely abnormal-looking mucosa in a period of clinical exacerbation whereas the subepithelial collagenous band completely disappeared in a clinically more quiet stage of the disease. The diagnostic importance of performing stepwise colonic biopsies even in normal-appearing colon in a patient with chronic undiagnosed diarrhoea is discussed.

The external shunt in the treatment of idiopathic priapism.

A new surgical procedure for idiopathic priapism has been used successfully in patients. In 2 of these patients the procedure was done after 5 days of persistent or recurrent erections. The method consists of a combination of external polyethylene shunts between the corpora cavernosa and the venous systems of the underarms drip infusion of a heparin-saline solution into the corpora and prompt systematic anticoagulant therapy. All 3 patients were cured of the priapism and recovered normal sexual powers.