2 days versus 5 days of postoperative antibiotics for complex appendicitis:a pragmatic, open-label, multicentre, non-inferiority randomised trial

Background: The appropriate duration of postoperative antibiotics for complex appendicitis is unclear. The increasing global threat of antimicrobial resistance warrants restrictive antibiotic use, which could also reduce side-effects, length of hospital stay, and costs. Methods: In this pragmatic, open-label, non-inferiority trial in 15 hospitals in the Netherlands, patients with complex appendicitis (aged ≥8 years) were randomly assigned (1:1) to receive 2 days or 5 days of intravenous antibiotics after appendicectomy. Randomisation was stratified by centre, and treating physicians and patients were not masked to treatment allocation. The primary endpoint was a composite endpoint of infectious complications and mortality within 90 days. The main outcome was the absolute risk difference (95% CI) in the primary endpoint, adjusted for age and severity of appendicitis, with a non-inferiority margin of 7·5%. Outcome assessment was based on electronic patient records and a telephone consultation 90 days after appendicectomy. Efficacy was analysed in the intention-to-treat and per-protocol populations. Safety outcomes were analysed in the intention-to-treat population. This trial was registered with the Netherlands Trial Register, NL5946. Findings: Between April 12, 2017, and June 3, 2021, 13 267 patients were screened and 1066 were randomly assigned, 533 to each group. 31 were excluded from intention-to-treat analysis of the 2-day group and 30 from the 5-day group owing to errors in recruitment or consent. Appendicectomy was done laparoscopically in 955 (95%) of 1005 patients. The telephone follow-up was completed in 664 (66%) of 1005 patients. The primary endpoint occurred in 51 (10%) of 502 patients analysed in the 2-day group and 41 (8%) of 503 patients analysed in the 5-day group (adjusted absolute risk difference 2·0%, 95% CI −1·6 to 5·6). Rates of complications and re-interventions were similar between trial groups. Fewer patients had adverse effects of antibiotics in the 2-day group (45 [9%] of 502 patients) than in the 5-day group (112 [22%] of 503 patients; odds ratio [OR] 0·344, 95% CI 0·237 to 0·498). Re-admission to hospital was more frequent in the 2-day group (58 [12%] of 502 patients) than in the 5-day group (29 [6%] of 503 patients; OR 2·135, 1·342 to 3·396). There were no treatment-related deaths. Interpretation: 2 days of postoperative intravenous antibiotics for complex appendicitis is non-inferior to 5 days in terms of infectious complications and mortality within 90 days, based on a non-inferiority margin of 7·5%. These findings apply to laparoscopic appendicectomy conducted in a well resourced health-care setting. Adopting this strategy will reduce adverse effects of antibiotics and length of hospital stay. Funding: The Netherlands Organization for Health Research and Development.</p

How land use/land cover changes can affect water, flooding and sedimentation in a tropical watershed: a case study using distributed modeling in the Upper Citarum watershed, Indonesia

[EN] Human activity has produced severe LULC changes within the Upper Citarum watershed and these changes are predicted to continue in the future. With an increase in population parallel to a 141% increment in urban areas, a reduction of rice fields and the replacement of forests with cultivations have been found in the past. Accordingly, LCM model was used to forecast the LULC in 2029. A distributed model called TETIS was implemented in the Upper Citarum watershed to assess the impact of the different historical and future LULC scenarios on its water and sediment cycles. This model was calibrated and validated with different LULCs. For the implementation of the sediment sub-model, it was crucial to use the bathymetric information of the reservoir located at the catchment's outlet. Deforestation and urbanization have been shown to be the most influential factors affecting the alteration of the hydrological and sedimentological processes in the Upper Citarum watershed. The change of LULC decreases evapotranspiration and as a direct consequence, the water yield increased by 15% and 40% during the periods 1994-2014 and 2014-2029, respectively. These increments are caused by the rise of three components in the runoff: overland flow, interflow and base flow. Apart from that, these changes in LULC increased the area of non-tolerable erosion from 412 km(2) in 1994 to 499 km(2) in 2029. The mean sediment yield increased from 3.1 Mton -yr(-1) in the 1994 LULC scenario to 6.7 Mton-yr(-1) in the 2029 LULC scenario. An increment of this magnitude will be catastrophic for the operation of the Saguling Dam.This study was partially funded by the Spanish Ministry of Economy and Competitiveness through the research projects TETISMED (CGL2014-58,127-C3-3-R) and TETISCHANGE (RTI2018-093717-B-I00). The authors are also thankful to the Directorate General of Higher Education of Indonesia (DIKTI) for the Ph.D. funding of the first author.Siswanto, SY.; Francés, F. (2019). How land use/land cover changes can affect water, flooding and sedimentation in a tropical watershed: a case study using distributed modeling in the Upper Citarum watershed, Indonesia. Environmental Earth Sciences. 78(17):1-15. https://doi.org/10.1007/s12665-019-8561-0S115781

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