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

Cross-border trade and conservation in the Sangha river region (Cameroon, Central African Republic and Republic of Congo)

In Africa conservation areas are increasingly established along national borders where human activity seems low. In reality border areas are often vibrant places of economic interaction. This article looks at conservation opportunities and challenges posed by cross border natural resource trade in the Sangha River Region, which straddles the borders of Cameroon, the Central African Republic and the Republic of Congo. It argues that conservation projects and forestry administrations can and should contribute to trade liberalisation, thereby unlocking the economic potential in poor and remote forest areas. If accompanied with strict law enforcement in cases of major disruptive and illegal practices, policies in this direction can help to integrate development and conservation objectives

Commerce transfrontalier et conservation dans la région du fleuve Sangha (Cameroun, République Centrafricaine et République du Congo)

En Afrique, les zones de conservation sont implantées de plus en plus le long des frontières nationales où les activités humaines semblent moins dynamiques. En réalité, les zones frontalières sont souvent le lieu d'échanges économiques très actifs. Le présent article examine les possibilités offertes, du point de vue de la conservation, par le commerce transfrontalier ainsi que les défis qu'il pose dans la région du fleuve Sangha, qui chevauche les frontières du Cameroun, de la République centrafricaine et de la République du Congo. Il défend l'idée que les projets de conservation et les administrations forestières peuvent et doivent contribuer à la libéralisation du commerce en vue de débloquer le potentiel économique des zones forestières éloignées et pauvres. Si elles sont accompagnées d'une stricte application de la loi dans les cas de pratiques illégales et nuisibles, les politiques de libéralisation peuvent contribuer à intégrer des objectifs de conservation et de développement

Forest-related conflict: impacts, links and measures to mitigate

Forest-based conflict is one of the major global challenges for the international forestry agenda together with poverty, climate change, conservation, and biofuels. In this paper, we will estimate the scope of the problem for people and forests, identify the role of forest rights and tenure as part of the cause of and solution to conflict, and project future challenges. We will recommend a set of actions that donors, govern¬ments, and civil society organizations should embark on to fight corruption, to tackle power imbalances, to clarify rights, to improve corporate responsibility, and to engage communities in resource management. Forest tenure and governance reform will not resolve the most violent conflicts that play out in forests around the world. However, forestry sectors can contribute to the creation of enabling environments for peace by preventing conflict escalation and by contributing to postconflict reconstruction. Engagements in structural forest-sector reform and forest-based investment are particularly needed in forest-rich and conflict-prone countries in the tropics. The ideas and projections included in this paper are preliminary and meant to stimulate reflection rather than to insist on particular conclusions