Comparison of insulin degludec with insulin glargine in insulin-naive subjects with Type 2 diabetes: a 2-year randomized, treat-to-target trial

AIMS

The aim of this study was to compare long-term safety and efficacy of the basal insulin analogue degludec with glargine in insulin-naive subjects with Type 2 diabetes.

METHODS

This open-label trial included a 52-week core period followed by a 52-week extension. Participants were randomized 3:1 to once-daily degludec or glargine, administered with metformin ± dipeptidyl peptidase-4 inhibitors. Basal insulin was titrated to target pre-breakfast plasma glucose 3.9-4.9 mmol/l.

RESULTS

At end of treatment (104 weeks), mean HbA1c reductions were similar for degludec and glargine; estimated treatment difference between degludec and glargine was 1 mmol/mol (95% CI -1 to 3) [0.07% (95% CI -0.07 to 0.22)], P = 0.339 in the extension trial set (degludec 551, glargine 174), comprising subjects who completed core trial and continued into the extension trial. Overall confirmed hypoglycaemia rates (1.72 vs. 2.05 episodes/patient-year), rates of adverse events possibly or probably related to trial product (0.19 events/patient-year), weight gain (2.7 vs. 2.4 kg) and mean daily insulin doses (0.63 U/kg) were similar between treatments in the safety analysis set (degludec 766, glargine 257) comprising all treated subjects. Rates of nocturnal confirmed hypoglycaemia (0.27 vs. 0.46 episodes/patient-year; P = 0.002) and severe hypoglycaemia (0.006 vs. 0.021 episodes/patient-year, P = 0.023) were significantly lower with degludec for the safety analysis set (analysis based on intention-to-treat full analysis set comprising all randomized subjects).

CONCLUSIONS

In Type 2 diabetes, insulin degludec in combination with oral anti-diabetic drugs, safely and effectively improves long-term glycaemic control, with a significantly lower risk of nocturnal hypoglycaemia as compared with glargine.

Insulin degludec improves glycaemic control with lower nocturnal hypoglycaemia risk than insulin glargine in basal-bolus treatment with mealtime insulin aspart in Type 1 diabetes (BEGIN(®) Basal-Bolus Type 1): 2-year results of a randomized clinical trial

AIMS

The goal of this study was to compare the long-term safety and efficacy of the basal insulin analogue, insulin degludec with insulin glargine (both with insulin aspart) in Type 1 diabetes, over a 2-year time period.

METHODS

This open-label trial comprised a 1-year main trial and a 1-year extension. Patients were randomized to once-daily insulin degludec or insulin glargine and titrated to pre-breakfast plasma glucose values of 3.9-4.9 mmol/l.

RESULTS

The rate of nocturnal confirmed hypoglycaemia was 25% lower with insulin degludec than with insulin glargine (P = 0.02). Rates of confirmed hypoglycaemia, severe hypoglycaemia and adverse events, and reductions in glycated haemoglobin and fasting plasma glucose were similar between groups. Despite achieving similar glycaemic control, insulin degludec-treated patients used 12% less basal and 9% less total daily insulin than did insulin glargine-treated patients (P < 0.01).

CONCLUSIONS

Long-term basal therapy using insulin degludec in Type 1 diabetes required lower doses and was associated with a 25% lower risk for nocturnal hypoglycaemia than insulin glargine.

Is Local Anesthetic Infiltration Prior to Intravenous Cannulation Beneficial to Patients?

Aims: Intravenous cannulation causes pain, anxiety and frustration in patients along with changes in hemodynamic parameters. Infiltration of local anesthetic lessens the pain of intravenous cannulation. This study was performed to compare cardiovascular responses and verbal rating pain scores in two groups with and without local anesthetic infiltration prior to venous cannulation. Methods: This was a randomized study conducted in 100 elective surgical patients, divided into two study groups with 50 patients in each: group A (Control) and group B (local anesthetic infiltration). Prior to venous cannulation in group B, 0.5 ml of 1% lidocaine was infiltrated at the procedure site at dorsum of the wrist. Patients in group A were cannulated directly without local anesthetic infiltration. The hemodynamic changes pre and post cannulation and verbal pain rating scores were recorded by blind observers in all patients. Results: Demographic values in two groups were similar. Increase in heart rate from baseline value was significant in control group (p < 0.05). Post cannulation heart rate, systolic and diastolic blood pressure were significantly higher in group A compared to group B for the first three minutes (p < 0.05). Amongst higher number of patients in group A, verbal rating pain score was significantly higher. Ninety-four percent of the patients in group B were pain free, comfortable and satisfied with the procedure. Conclusions: Intravenous cannulation can be made pain free with patient satisfaction and hemodynamic stability if carried out with prior local anesthetic infiltration. Nepal Journal of Obstetrics and Gynaecology / Vol 8 / No. 1 / Issue 15 / Jan- June, 2013 / 10-13 DOI: http://dx.doi.org/10.3126/njog.v8i1.8853

Fetal biophysical profile score and perinatal outcome

BACKGROUND

Sudden fetal demise, perinatal morbidity and mortality are still some of the major obstetrical challenges. Reduced fetal movements may have some bearing to fetal asphyxia and death, so timely detection of such condition and measures taken can prevent such mishaps.

METHODS

A descriptive prospective study was conducted at Tribhuvan University Teaching Hospital, Department of Obstetrics and Gynecology from January to December 2002 in 55 cases to find out the relationship of Biophysical Profile Score with perinatal outcome in pregnant mothers with decreased fetal movement counts at or above 34 weeks of gestational age. The mode of delivery, Apgar score, neonatal admission and perinatal mortality were analyzed.

RESULTS

The study demonstrated that most of the fetuses were in good condition with 87% of the cases scoring 8-10 BPS (normal), 6% scoring six (equivocal) and only 7% got four score (abnormal). Having the abnormal BPS of four significantly increased the risk of perinatal mortality by 50% (p=0.000). This study could not detect any significant association between Apgar score and neonatal morbidities, but showed significant correlation between BPS and caesarean section. The patients having lower BPS tended to undergo more caesarean section delivery than patients having normal BPS (p=0.009).

CONCLUSIONS

An abnormal BPS of four in cases of reduced fetal movement counts significantly influenced the risk of perinatal death. However reduced fetal movements only did not raise the risk of fetal morbidity and mortality. So BPS should be beneficial to detect the fetuses at risk in the patients having less fetal movements for the proper management at right time.

Post Caesarean Caecal Perforation with Fecal Peritonitis

NJOG 2011 Nov-Dec; 6 (2): 58-59 DOI: http://dx.doi.org/10.3126/njog.v6i2.6762

mTOR as a target of everolimus in refractory/relapsed Hodgkin lymphoma

Despite impressive treatment advances, few options for refractory or relapsed Hodgkin Lymphoma (HL) are available and there is a need for new compounds development. A number of promising agents with multiple mechanisms of action are under investigation. Microenvironment and neoangiogenesis are acquiring a rising relevance in the pathophysiology and progression of HL. Everolimus (RAD001) is an oral antineoplastic agent derived from rapamycin, a macrocyclic lactone antibiotic, targeting the mammalian target of rapamycin (mTOR). Although the importance of mTOR signaling in the deregulated cell growth of human neoplastic cells has been recognized, this pathway is also emerging as a key regulator of the tumor response to hypoxia, as well as endothelial and stromal cells function, thereby regulating neoangiogenesis. Furthermore, mTOR plays an important role in anticancer drug resistance. The actions of everolimus within the mTOR pathway in HL result in decreased protein synthesis and cell cycle arrest, as well as in decreased angiogenesis. Everolimus has shown preliminary evidence of efficacy as a single-agent in heavily pretreated relapsed/refractory HL, with an overall fair safety profile. The purpose of this review is to discuss the employment of everolimus as an antiproliferative and antiangiogenic agent in HL and to report the critical role of the mTOR pathway and angiogenesis in this malignancy.

Gene expression of cytokines (TNF-α, IFN-γ), serum profiles of IL-17 and IL-23 in paediatric systemic lupus erythematosus

OBJECTIVE

Paediatric systemic lupus erythematosus (pSLE) exhibits an aggressive clinical phenotype and severe complications commonly renal involvement. This could be reflective of the ongoing chronic pro-inflammatory cytokine milieu. We examined relative gene expression of tumour necrosis factor-alpha (TNF-α), interferon-γ (IFN-γ) and serum levels of interleukin-17 (IL-17) and IL-23 and their association with SLEDAI (SLE disease activity index) score and organ manifestations in pSLE.

METHODS

We enrolled 40 pSLE patients (age 5-16 years, on treatment) and 20 age-matched healthy controls. Relative gene expression levels of IFN-γ and TNF-α in the peripheral blood were determined by quantitative real-time reverse transcriptase polymerase chain reaction (RT-PCR). β actin gene was used for normalization of gene expression. Serum levels of IL-17 and IL-23 were determined by solid phase sandwich ELISA. Statistical analysis were carried out for comparing (Mann-Whitney U test) and correlating data (Univariate, multivariate analysis and Pearson correlation test) with SLEDAI scores and clinical manifestations.

RESULTS

Over-expression of TNF-α and IFN-γ was found in 90% (36/40) and 80% (32/40) of pSLE patients, respectively. The relative gene expression of TNF-α and IFN-γ were significantly correlated with renal manifestations (p < 0.05). Further, relative expression of IFN-γ gene correlated significantly with skin manifestations and SLEDAI (p < 0.05). Serum levels of IL-17 (766.95 ± 357.83 pg/ml) and IL-23 (135.4 ± 54.23 pg/ml) in pSLE were significantly higher than in controls (IL-17, 172.7 ± 39.19 pg/ml and IL-23, 21.15 ± 10.99 pg/ml) (p < 0.05). Patients with cutaneous (p = 0.002) and haematological involvement (p = 0.003) had high serum IL-17 levels. Serum IL-17 levels correlated with SLEDAI (r = 0.447; p < 0.05).

CONCLUSIONS

In this preliminary study, we observed a persistent, strong pro-inflammatory cytokine milieu in pSLE patients which reflects ongoing inflammatory damage in different organs. The gene expression profile of these cytokines may be used for assessing organ involvement in pSLE. IL-17 may also serve as a prognostic marker in pSLE. However, longitudinal studies on treatment of naïve patients are required to corroborate these findings.

Risk factors of hyperparathyroidism in advanced stages of chronic kidney disease

The pathogenesis of renal osteodystrophy is not clearly defined. We evaluate in this study the potential effect of demographic and biochemical markers on parathormone (PTH) level in patients with chronic kidney disease (CKD) stages 4 and 5. We retrospectively studied 138 patients with CKD stages 4 and 5 selected from the database of the Sheffield Kidney Institute in the interval from 1996 to 2005. All patients had baseline as well as follow-up levels of PTH, adjusted serum calcium, phosphate, calcium phosphorus product, albumin, bicarbonate and estimated glomerular filtration rate (eGFR). At baseline, serum albumin, eGFR and adjusted serum calcium levels significantly negatively correlated with PTH serum levels. Adjusted serum calcium levels at last follow-up remained a significant negative predictor of PTH levels; however, baseline PTH levels demonstrated a significant positive correlation with final serum PTH levels. This study high lights the significance of serum PTH levels at presentation on the long-term effect of parathyroid gland function. This reinforces the need for early intervention to achieve optimal control of hyperparathyroidism in CKD patients.

Live birth following treatment of post molar choriocarcinoma

A G3P(1+1) who underwent dilatation and curettage (D and C) for persistent vaginal bleeding after a month of molar evacuation, underwent successful treatment of choriocarcinoma with methotrexate and was able to have normal baby weighing 2800 gms with good Apgar score and normal placenta. This shows that a normal menstruation and uncomplicated term delivery can be expected after complete chemotherapy for gestational trophoblastic neoplasia (GTN).

Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation

It is critical to balance waitlist mortality against posttransplant mortality. Our objective was to devise a scoring system that predicts recipient survival at 3 months following liver transplantation to complement MELD-predicted waitlist mortality. Univariate and multivariate analysis on 21,673 liver transplant recipients identified independent recipient and donor risk factors for posttransplant mortality. A retrospective analysis conducted on 30,321 waitlisted candidates reevaluated the predictive ability of the Model for End-Stage Liver Disease (MELD) score. We identified 13 recipient factors, 4 donor factors and 2 operative factors (warm and cold ischemia) as significant predictors of recipient mortality following liver transplantation at 3 months. The Survival Outcomes Following Liver Transplant (SOFT) Score utilized 18 risk factors (excluding warm ischemia) to successfully predict 3-month recipient survival following liver transplantation. This analysis represents a study of waitlisted candidates and transplant recipients of liver allografts after the MELD score was implemented. Unlike MELD, the SOFT score can accurately predict 3-month survival following liver transplantation. The most significant risk factors were previous transplantation and life support pretransplant. The SOFT score can help clinicians determine in real time which candidates should be transplanted with which allografts. Combined with MELD, SOFT can better quantify survival benefit for individual transplant procedures.

Simultaneous occurrence of hematometrocolpos and consecutive pregnancies in uterine didelphys : a case report

Hematometrocolpos drained abdominally at laparotomy done, with suspicion of an ovarian torsion in an adolescent with ipsilateral renal agenesis, was eventually rediscovered to have in coexistent uterine didelphys in a 25 year P3+0 at the time repeat caesrean for breech in the event of third parturition, complicated by partum hemorrhage as in all her previous delivery (first vaginal delivery and retained placenta, second caesarean for obstructed labor by non pregnant half of didelphic uterus). This illustrates how simultaneous occurrence of hematometrocolpos can go unnoticed although there was every reason for this condition not to go unrecognized for the simple fact ofhemivaginal obstruction and hematometra with ipsilateral renal agenesis (on the left side) unaffecting the consecutive pregnancy in the other uterus.

Heterotopic pregnancy with spontaneous intrauterine conception: a rare clinical entity with diagnostic dilemma

Twenty-one years old primigravida presented to emergency with amenorrhoea for 2 months and complaints of severe abdominal pain for few hours. The pain was associated with 2 episodes of fainting attacks in emergency during the period of observation. Viable intrauterine pregnancy of 8-9 weeks along with collection of fluid in the Pouch of Douglas was detected by ultrasound examination and on laparotomy ectopic pregnancy was confirmed with haemoperitoneum of 2 litres with 500gms of clots. Histopathology report confirmed the tubal ectopic pregnancy and postlaparotomy, transvaginal sonography confirmed the salvage of the intrauterine pregnancy. Despite massive haemoperitoneum, the pregnancy continued till 40+6 weeks with uneventful antenatal period. She underwent emergency caesarean section for meconium stained liquor with foetal distress and delivered of an alive healthy female of 2.5 kg with good Apgar score.

A simple new technique of performing myomectomy for a predominantly subserosal myoma quickly within few minutes

Removing a degenerated myoma located around the uterine cornu by an innovative technique shelling the myoma a little away from the base by choice of a low placed incision, advantageous in terms of no requirement of blood transfusion because of the reduction in the surgical time is described in a 24 years old lady demanding a fertility conserving surgery.

Acute hepatitis E in pregnancy--study of 16 cases

This retrospective study was done at Tribhuvan University Teaching Hospital between April 1999 to April 2003, to asses the maternal and perinatal outcome of acute hepatitis E in pregnancy. During this period a total of 19 patients presented with jaundice. Out of 19 cases, 16 suffered from acute hepatitis due to hepatitis E. Acute hepatitis was diagnosed by presence of prodromal symptoms and anti HEV IgM in the body. Hepatitis B and C were ruled out in all these cases. Out of 16, 15 delivered in the hospital. Average age of the patients was 24 years. 81.2% (13/16) presented during the third trimester of pregnancy. There were 3 maternal deaths (20%). Other complications were; Preterm delivery 53.3% (8/15), post partum haemorrhage 26.7% (4/15), low birth weight in 33.3% (5/15). This analysis showed increased maternal and perinatal complications of hepatitis E contracted during pregnancy, especially so in those with fulminant hepatitis.

PLACENTA PREVIA ACCRETA

Placenta accreta is defined as any placental implantation in which the placenta isabnormally and firmly adherent to the underlying uterine wall in part or in total. Theprobable cause is defective decidual formation as shown by its occurence in area wherethe endometrium is deficient or damaged.The commonest condition associated with it are placenta previa and previous caesareansection. A case of placenta previa accreta is described herewith in a 2nd gravida whoeventually needed emergency caesarean hysterectomy (total) due to profuse bleeding.Key Words: Placenta accreta, placenta, caesarean hysterectomy.