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Background Non-medical data, such as the amount of time that patients and caregivers spend managing their condition, may be relevant when assessing therapeutic strategies. For chronic pediatric conditions, the time that patients and caregivers spend in seeking and providing care (which are the indirect costs in an economic evaluation) can be significantly different depending on the treatment arm. To explore methods for collecting information on the care burden for caregivers and patients, we investigated whether a patient diary provided additional information compared to retrospective investigator-led interviews and whether a diary that was completed intermittently produced more or less information than a diary completed continually. The main objective of this study was to identify which type of data collection was most effective for measuring the time spent by caregivers and for estimating indirect treatment costs over 9 months. Methods Start-In! is a randomized controlled trial comparing the efficacy of three strategies of real-time continuous glucose monitoring for 12 months in children and adolescents with type 1 diabetes. We designed an ancillary study to assess methods of collecting information on the time spent by patients and caregivers in managing their condition (indirect costs). Data were entered retrospectively in case report forms (CRFs) by investigators during quarterly follow-up visits, which were supplemented with diaries completed prospectively by children or caregivers either continuously or intermittently. Data about absences from school and work as well as the time that caregivers spent on diabetes care were collected and the three collection methods were compared. Results At the end of the 9-month study, 42% of the study participants failed to return their diary. For the diaries that were received, less than 10% of expected data were collected versus 82% during investigators'interviews. Based on all the information collected, we calculated that over 9 months, caregivers lost on average 3.9 days of working time (€786) and 4 days of personal time, i.e. the equivalent of €526, and spent around 15 min of time on care per day, i.e. the equivalent of €1700. Conclusions The CRFs completed by investigators during quarterly visits cannot be replaced by a diary. Completing the diaries appeared to represent an important additional burden to children and their caregivers, and the diaries provided little additional information compared to investigators’ entries in the CRF. Trial registration ClinicalTrials.gov, NCT00949221. Registered on 30 July 2009. Registry name: Study of Insulin Therapy Augmented by Real Time Sensor in Type 1 Children and Adolescents (START-IN!).

AIM To assess the safety and efficacy of hybrid closed-loop (HCL) insulin delivery 24/7 versus only evening and night (E/N), and on extended 24/7 use, in free-living children with type 1 diabetes. MATERIALS AND METHODS Prepubertal children (n = 122; 49 females/73 males; age, 8.6 ± 1.6 years; diabetes duration, 5.2 ± 2.3 years; insulin pump use, 4.6 ± 2.5 years; HbA1c 7.7% ± 0.7%/61 ± 5 mmol/mol) from four centres were randomized for 24/7 versus E/N activation of the Tandem Control-IQ system for 18 weeks. Afterwards, all children used the activated system 24/7 for 18 more weeks. The primary outcome was the percentage of time spent in the 70-180 mg/dL glucose range (TIR). RESULTS HCL was active 94.1% and 51.1% of the time in the 24/7 and E/N modes, respectively. TIR from baseline increased more in the 24/7 versus the E/N mode (52.9% ± 9.5% to 67.3% ± 5.6% [+14.4%, 95% CI 12.4%-16.7%] vs. 55.1% ± 10.8% to 64.7% ± 7.0% [+9.6%, 95% CI 7.4%-11.6%]; P = .001). Mean percentage time below range was similarly reduced, from 4.2% and 4.6% to 2.7%, and the mean percentage time above range decreased more in the 24/7 mode (41.9% to 30.0% [-11.9%, 95% CI 9.7%-14.6%] vs. 39.8% to 32.6% [-7.2%, 95% CI 5.0%-9.9%]; P = .007). TIR increased through the whole range of baseline levels and always more with 24/7 use. The results were maintained during the extension phase in those initially on 24/7 use and improved in those with initial E/N use up to those with 24/7 use. Neither ketoacidosis nor severe hypoglycaemia occurred. CONCLUSIONS The current study shows the safety and efficacy of the Tandem Control-IQ system in free-living children with type 1 diabetes for both E/N and 24/7 use; 24/7 use shows better outcomes, sustained for up to 36 weeks with no safety issues.

Resume La transition des soins designe le passage des adolescents et jeunes adultes porteurs d’un diabete, du systeme de soin centres sur la pediatrie a celui des adultes. Cette transition imposee par nos systemes de soin, remet en question notre organisation des soins. C’est un processus qui comprend trois etapes : le suivi en pediatrie, puis le passage lui-meme de la pediatrie a la medecine pour adultes, et le suivi en medecine pour adultes. Ces etapes prennent plusieurs annees si on prend en compte la necessaire preparation a la transition dans la periode pediatrique et l’accrochage, puis l’engagement du suivi en medecine pour adultes. Nous ferons appel a notre experience clinique, aux travaux du programme de recherche Pass’âge en Ile-de-France, et aux publications recentes sur ce sujet pour faire le point sur les criteres d’impact, la methodologie et les outils d’evaluation des interventions/ programmes de transition. Nous synthetiserons les guides de bonne pratique de la transition des soins, le parcours de transition specifique, les ressources - en particulier, les plateformes de transition et actions associatives et le role des coordinateurs de la transition/transiteur.e.s, un nouveau metier de sante a promouvoir.

International audience; Automated closed-loop (CL) insulin therapy has come of age. This major technological advance is expected to significantly improve the quality of care for adults, adolescents and children with type 1 diabetes. To improve access to this innovation for both patients and healthcare professionals (HCPs), and to promote adherence to its requirements in terms of safety, regulations, ethics and practice, the French Diabetes Society (SFD) brought together a French Working Group of experts to discuss the current practical consensus. The result is the present statement describing the indications for CL therapy with emphasis on the idea that treatment expectations must be clearly defined in advance. Specifications for expert care centres in charge of initiating the treatment were also proposed. Great importance was also attached to the crucial place of high-quality training for patients and healthcare professionals. Long-term follow-up should collect not only metabolic and clinical results, but also indicators related to psychosocial and human factors. Overall, this national consensus statement aims to promote the introduction of marketed CL devices into standard clinical practice.

International audience; BACKGROUND: Metastatic colorectal cancer (mCRC) is increasingly treated using targeted therapies. Their real-life evaluation is insufficient, especially in elderly and frail patients. The aim was to describe use, safety, and effectiveness of targeted therapies in first-line mCRC treatment according to age. PATIENTS AND METHODS: Two field cohorts of patients initiating bevacizumab or cetuximab for first-line mCRC were pooled. Patients characteristics, use, and safety were compared between younger and elderly patients (/=75 years). Two-year overall survival (OS) and progression-free survival (PFS) were estimated in both age groups using the Kaplan-Meier method adjusted on factors associated with death or progression identified with Cox multivariate modeling. RESULTS: Eight hundred patients (n = 411, 51.4% bevacizumab) were included: 498 (62.3%) male, median age 64 years, 118 (14.8%) Eastern Cooperative Oncology Group performance status (ECOG-PS) >/=2. Elderly patients (n = 126, 15.8%) were more often treated with 5-fluorouracil alone than younger. Severe adverse events were equivalent across age groups. ECOG-PS >/=1, abnormal hemoglobin, and abnormal alkaline phosphatases were associated with a higher risk of death; OS adjusted on these factors was similar between elderly and younger patients. ECOG-PS >/=1, lung metastases, abnormal hemoglobin, and abnormal creatinine clearance were associated with a higher risk of progression or death; PFS adjusted on these factors was similar across groups. CONCLUSION: Despite treatment adaptations, elderly patients could benefit from targeted therapies as younger without safety warning.

Resume • Les nouvelles technologies ont elles une place dans le traitement de l’enfant atteint de diabete de type 1 (DT1) ? Ne sont-elles pas source de nouvelles contraintes qui vont s’ajouter au poids du traitement deja tres lourd a porter pour les enfants et leurs parents, les adolescents pour qui le diabete « prend la tete » ? N’est-ce pas « trop » pour les nourrices, les grands-parents ? Est-ce gerable a l’ecole ? • « Ce qui est nouveau n’est pas necessairement mieux », entend-on a propos de l’accroissement des technologies dans les soins aux personnes diabetiques [1], et c’est vrai. Mais qu’est ce qui est mieux ? Et pour qui ? Etait-ce mieux de se piquer les doigts avec des auto-piqueurs traumatisants, d’avoir un enfant qui a des hypoglycemies severes la nuit ou a l’ecole, de devoir respecter des horaires stricts de reveil et de repas ? Ces questions pertinentes en pediatrie se posent depuis 30 ans avec les pompes a insuline, les injections multiples. C’est avec une grande serenite que nous avons aborde ces questions avec les capteurs, il y a 10 ans, fort d’une longue experience des pompes a insuline et des autres technologies en pediatrie, du nouveau-ne a l’adolescent. Nous verrons que si les benefices reels des technologies, comme ce fut le cas avec la pompe a insuline, et comme c’est le cas avec la mesure continue du glucose (MCG), en font des solutions a des problemes specifiques a ces âges, il faut soutenir ce qui est, pour certains, un paradoxe. Alors, les moyens doivent etre mis pour former, eduquer, accompagner, faciliter l’utilisation, et donner l’acces aux nouvelles technologies. Avec la MCG en pediatrie, la satisfaction exprimee, la reassurance observee, l’efficacite – en particulier sur les hypoglycemies et la peur de l’hypoglycemie –, montrent qu’il faut poursuivre et avancer. C’est plus difficile et un peu plus lent en pediatrie. Avancer, signifie : alleger les contraintes des technologies, les faire evoluer vers de plus en plus de facilite d’utilisation et de convivialite, en donner l’acces a tous les enfants par un remboursement. • La solution pour les enfants, plus d’efficacite et moins de contraintes, viendra du pancreas artificiel, dont la pompe a insuline et les capteurs sont des composants incontournables, avec les algorithmes qui permettent une delivrance automatisee de l’insuline ; c’est dans cet esprit aussi que nous devons tout faire pour nous preparer (soignants), et preparer nos jeunes patients a cet avenir proche. • Gageons (en agissant) que la promesse faite aux enfants atteints de DT1 et a leurs parents sera tenue !

Aim To compare the efficacy of three strategies for real-time continuous glucose monitoring (RT-CGM) over 12 months in children and adolescents with type 1 diabetes. Methods A French multicenter trial (NCT00949221) with a randomized, controlled, prospective, open, and parallel-group design was conducted. After 3 months of RT-CGM, patients were allocated to one of three groups: return to self-monitoring of blood glucose, continuous CGM (80% of the time), or discontinuous CGM (40% of the time). The primary outcome was hemoglobin A1c (HbA1c) levels from 3 to 12 months. The secondary outcomes were acute metabolic events, hypoglycemia, satisfaction with CGM and cost. Results We included 151 subjects, aged 2 to 17 years, with a mean HbA1c level of 8.5% (SD0.7; 69 mmol/mol). The longitudinal change in HbA1c levels was similar in all three groups, at 3, 6, 9 and 12 months. The medical secondary endpoints did not differ between groups. The rate of severe hypoglycemia was significantly lower than that for the pretreatment year for the entire study population. Subjects reported consistent use and good tolerance of the device, regardless of age or insulin treatment. The use of full-time RT-CGM for 3 months costs the national medical insurance system €2629 per patient. Conclusion None of the three long-term RT-CGM strategies evaluated in pediatric type 1 diabetes was superior to the others in terms of HbA1c levels. CGM-use for 3 months decreased rates of severe hypoglycemia. Our results confirm the feasibility of long-term RT-CGM-use and the need to improve educational support for patients and caregivers.

This randomized control trial investigated glucose control with closed-loop (CL) versus threshold-low-glucose-suspend (TLGS) insulin pump delivery in pre-pubertal children with type 1 diabetes in supervised hotel conditions. The patients [n = 24, age range: 7-12, HbA1c: 7.5 ± 0.5% (58 ± 5 mmol/mol)] and their parents were admitted twice at a 3-week interval. CL control to range or TLGS set at 3.9 mmoL/L were assessed for 48 hour in randomized order. Admissions included three meals and one snack, and physical exercise. Meal boluses followed individual insulin/carb ratios. While overnight (22:00-08:00) per cent continuous glucose monitoring (CGM) time below 3.9 mmol/L (primary outcome) was similar, time in ranges 3.9 to 10.0 and 3.9 to 7.8 mmoL/L and mean CGM were all significantly improved with CL (P < 0.001). These results were confirmed over the whole 48 hour. Disconnections between devices and limited accuracy of glucose sensors in the hypoglycaemic range appeared as limiting factors for optimal control. CL mode was well accepted while fear of hypoglycaemia was unchanged. CL did not minimize nocturnal hypoglycaemia exposure but improved time in target range compared to TLGS. Although safe and well-accepted, CL systems would benefit from more integrated devices.

Resume • L’incidence du diabete de type 1 (DT1) chez les enfants est en augmentation. Cet accroissement est 2 fois plus eleve chez les enfants de moins de 5 ans. • Aujourd’hui, en France, un enfant DT1 sur deux est traite par pompe a insuline, selon des indications etablies au niveau national et international. Ce traitement qui utilise des dispositifs precis et adaptes aux enfants, est pris en charge par l’Assurance maladie. • L’actualite porte sur : - la meilleure connaissance des facteurs associes a l’efficacite therapeutique, et de l’utilisation a long terme de ce traitement dans des grandes populations pediatriques ; - la mesure continue du glucose par le couplage de la pompe aux capteurs sous-cutanes ; - la suspension temporaire du debit de base en cas d’atteinte d’un seuil hypoglycemique preetabli, un premier pas vers la boucle fermee. • L’avenir c’est maintenant ! Le pancreas artificiel par voie sous-cutanee associant pompe, capteurs, et la delivrance automatisee d’insuline selon des modeles d’algorithmes predictifs, est au stade d’etudes cliniques chez des enfants.

Resume L’objectif de cette etude etait d’evaluer, au cours de la premiere annee suivant une campagne nationale d’information, l’effet sur la frequence et la severite de l’acidocetose au moment du diagnostic de diabete de type 1 (DT1) chez l’enfant et l’adolescent. Les donnees suivantes ont ete colligees pendant deux annees consecutives chez les jeunes de moins de 15 ans ayant un DT1 debutant dans 146 services de pediatrie : âge, sexe, duree des symptomes, parcours du patient, signes cliniques et biologiques, antecedents familiaux de DT1. L’acidocetose etait definie par un pH p = 0,08), exclusivement du fait d’une diminution des acidocetoses severes, de 14,8 a 11,4 % ( p = 0,01). Dans les groupes d’âge 0–5 ans et 5–10 ans, la baisse relative de la frequence de l’acidocetose a ete respectivement de 13 % et 15 %, et celle des formes severes de 23 % et 41 %. Chez les enfants adresses a l’hopital par un pediatre ou venus a l’initiative de la famille, elle a ete respectivement de 34 et 7 %, et celle des formes severes de 39 et 32 %. Aucun changement n’a ete observe pour les jeunes de 10–15 ans et pour ceux qui ont ete adresses par un medecin generaliste. En analyse multivariee, une frequence plus elevee de l’acidocetose etait associee avec le jeune âge de l’enfant (

Aim of no residual macroscopic disease has to be the objective of the gynecologist oncologist surgeon. It can require extensive surgical procedures in all the abdomen area. We report 2 rare cases of cytoreductive surgery with iliac vessels resection and use of vascular prosthesis. We discuss the opportunity of this surgery with high morbidity.

The most recent innovations serving pediatric type 1 diabetes patients are the insulin pump and its new functions and continuous glucose measurement, which, associated with the pump, foreshadows the artificial pancreas. Strictly controlling glycemia in type 1 diabetes is necessary to prevent complications, but the main side effect is the risk of frequent episodes of hypoglycemia, most particularly severe hypoglycemia.

Resume L’incidence du diabete de type 1 chez les tres jeunes enfants est en augmentation et ces enfants sont de plus en plus souvent traites par pompe a insuline. L’experience des parents sur l’integration de leur enfant en collectivite et a l’ecole, en Ile-de-France, a ete evaluee retrospectivement. Les resultats portent sur 42 enfants, âges en moyenne de 4,8 ± 1 ans et ayant un diabete de type 1 depuis l’âge de 2,3 ± 0,5 ans. Les parents estiment que la prise en charge de leurs enfants, au cours de la periode analysee, s’est globalement « plutot bien passee, voire tres bien passee » dans 84 % des cas (70,5 % pour les enfants en maternelle). Toutefois, 93 % des parents ont du surmonter des difficultes dont les plus importantes ont ete le refus d’accueil de leur enfant, la participation aux sorties scolaires et la realisation des glycemies et des bolus avant les repas. Le temps periscolaire (cantine, garderie) est le plus difficile a gerer. L’integration a ete plus satisfaisante quand les personnels ayant en charge ces tres jeunes enfants ont accepte d’etre informes et formes. En conclusion, le parcours des parents est difficile mais ces jeunes enfants sous pompe a insuline arrivent a suivre leur scolarite normalement, en bonne securite. Toutefois, beaucoup d’enfants ne beneficient pas encore d’une integration normale dans toutes les collectivites periscolaires. L’augmentation du nombre des tres jeunes enfants diabetiques sous pompe a insuline rend necessaire le renforcement coordonne de l’information des collectivites en charge de ces jeunes enfants.

Aim Insulin allergy is a rare but serious and challenging condition in patients with type 1 diabetes (T1D). This is a case report of an 8-year-old boy with T1D and an allergy to insulin. Case report Three months after being diagnosed with T1D, the patient developed progressive skin reactions to insulin, characterized by small 1.5-cm pruritic wheals at injection sites that persisted for several days. Seven months after diagnosis, he experienced two episodes of generalized urticaria with systemic symptoms that were seen within a few seconds of insulin injection. Examination revealed lipoatrophy of the thighs. Intradermal skin tests were positive for protamine, glargine and lispro. The patient was started on a continuous subcutaneous insulin infusion (CSII) tolerance induction protocol, consisting of a very low basal rate that was progressively increased, with the first bolus given under medical supervision, and was well tolerated for 4 months. After this period of time, the skin wheals reappeared, localized to the infusion sites, but without urticaria or any other generalized reactions. Intradermal skin tests were repeated and were again positive. Serum insulin-specific IgE measured 30 months after the first allergic reactions were positive. After 3 years, pump therapy is ongoing and blood glucose control has remained relatively good (HbA 1c 7.6%). Conclusion In T1D children with insulin allergy, CSII can successfully be used to both induce insulin tolerance and allow diabetes insulin therapy, although insulin desensitization cannot always be fully achieved. The induction protocol was easily manageable partly due to the "honeymoon" period that the patient was still in, but it should nonetheless be used even when the patient has higher insulin requirements.

P.-Y. Benhamou, B. Catargi, B. Delenne, B. Guerci, H. Hanaire, N. Jeandidier, R. Leroy, L. Meyer, A. Penfornis, R.-P. Radermecker, E. Renard, S. Baillot-Rudoni, J.-P. Riveline, P. Schaepelynck, A. Sola-Gazagnes, V. Sulmont, N. Tubiana-Rufi, D. Durain, I. Mantovani Coordination: A. Sola-Gazagnes, J.-P. Riveline Societe Francophone du Diabete (SFD), Societe Francaise d’Endocrinologie (SFE) and EVADIAC group (EVAluation dans le Diabete des Implants ACtifs)

Insulin pump therapy is an emerging option in the management of type 1 diabetes (T1D), but it often remains unused. For this reason, in 2007, a French national survey was carried out to update the frequency of insulin pump use in the paediatric population compared with a previous survey done in 2001.The present survey was performed in hospital departments involved in paediatric diabetes management (n = 67) and in adult departments involved in adolescent diabetes management (n = 113). The number of T1D children (age18 years) treated in each department, with or without the use of an insulin pump, and the number of insulin pump therapies initiated during the previous year were collected.A total of 60 paediatric and 28 adult centres responded, involving 9073 T1D children and adolescents (93% in paediatric departments). Of these patients, 1461 (16%) were treated by insulin pump, 89% of which were managed in paediatric centres. However, pump use was more frequent in adult than in paediatric centres (32% versus 18%, respectively). Also, 38% of insulin pumps were initiated during the year prior to the survey. In addition, in 2001, 140 children were treated with insulin pump in 13 paediatric centres (versus 56 centres in 2007).The number of centres using insulin pump therapy for diabetic children and the number of children treated by insulin pump were increased fourfold and 10-fold, respectively, from 2001 to 2007, indicating greater access to pump therapy in the French paediatric population. The present survey is still ongoing to evaluate the decision-making criteria that influence the initiation of insulin pump therapy in T1D paediatric patients.

Introduction et but de l’etude Le cancer pulmonaire est une pathologie frequente et grave, les possibilites therapeutiques dependent de l’etat general du patient et en particulier de son etat nutritionnel. L’objectif de cette etude etait de mettre en evidence un benefice de la nutrition enterale (NE) sur la survie versus complements nutritionnels oraux (CNO) seuls. Materiel et methodes Nous avons mene une etude retrospective au centre hospitalier universitaire de Limoges sur des patients atteints de cancer bronchique non a petites cellules de stade III ou IV, denutris hospitalises en oncologie thoracique. Etaient exclus les patients en soins de support exclusifs. Les patients etaient repartis en 2 groupes : l’un recevant une nutrition enterale (NE) et l’autre recevant des CNO seuls. Le critere de jugement principal etait la survie globale, les criteres de jugement secondaires etaient la survie sans progression, la toxicite des traitements et la meilleure reponse tumorale selon les criteres RECIST. Resultats et analyse statistique Soixante trois patients ont ete inclus entre mars 2014 et mars 2016, 37 dans le groupe NE et 26 dans le groupe CNO seuls. Les patients etaient comparables sur l’âge, le sexe, l’etat general, le type histologique et le stade tumoral. La mediane de survie globale etait meilleure dans le groupe NE (353 jours versus 282 jours dans le groupe CNO, p = 0,0474). Il n’y avait pas de difference statistiquement significative entre les 2 groupes concernant la survie sans progression (208 jours dans le groupe NE versus 181 jours dans le groupe CNO, p = 0,0809), la toxicite des traitements (24 % de toxicite ≥ grade 2 dans le groupe NE versus 48 % dans le groupe CNO) et la meilleure reponse selon les criteres RECIST. Conclusion La nutrition enterale semble ameliorer la survie globale chez les patients atteints de cancer bronchique non a petites cellules, ceci devra etre confirme par des donnees prospectives et randomisees.

Resume L’autosurveillance glycemique (ASG), conduisant a l’autocontrole est un pilier indispensable a la prise en charge du diabete de type 1. Les interets de l’ASG chez l’enfant et l’adolescent sont semblables a ceux de l’adulte : evaluer l’equilibre glycemique, permettre l’adaptation du traitement par insuline au quotidien, permettre l’autocontrole pour depister et prevenir les complications aigues et limiter les complications a long terme. Cependant, de nombreuses specificites liees a l’âge sont fondamentales a integrer pour personnaliser les objectifs et les modalites de realisation de la surveillance. Au cours de la petite enfance, le diabete est souvent instable, les hypoglycemies asymptomatiques et l’ASG doit etre frequente et parfois nocturne. L’enfance est marquee par la dependance a l’adulte et la multiplicite des intervenants pour les soins des patients (famille, ecole, creche, clubs.). L’adolescence est une phase de transition au cours de laquelle les besoins d’integration sociale et de construction de l’autonomie interagissent avec les contraintes du traitement. Ainsi, l’education therapeutique du patient en pediatrie doit d’une part s’adapter aux stades du developpement physiologique et psychoaffectif de l’enfant ou de l’adolescent et, d’autre part, integrer les adultes impliques dans les soins. L’objectif principal etant l’autonomisation du jeune et de ses parents pour la realisation, l’observation, l’analyse, l’utilisation active des resultats pour l’adaptation des doses d’insuline et l’efficacite optimale du traitement. De nombreux progres ont ete realises ces dernieres decennies pour obtenir une surveillance capillaire plus fiable, plus precise, plus simple au quotidien (sites alternatifs, cetonemie, logiciels de recueil et d’analyse des donnees…). Plus recemment, le developpement de la mesure continue du glucose en temps reel est un moyen efficace, chez l’adulte comme chez l’enfant et l’adolescent, pour l’amelioration de l’equilibre glycemique a moyen terme. Ces innovations permettent d’ameliorer la tolerance et l’acceptabilite de l’ASG et de pallier aux limites, y compris en pediatrie, de l’autosurveillance conventionnelle.

The first Injection Technique workshop brought together endocrinologists and injection experts from around the world in Strasbourg in 1997. From its work came groundbreaking recommendations which advanced best practices in areas such as the use of a skin fold when injecting. The second Injection Technique workshop, with an expanded format including nurses and diabetes educators, took place in Barcelona in 2000. The initial stimulus to use shorter injecting needles can be said to date from this meeting. The third Injection Technique workshop was held in Athens in September 2009 and involved 127 experts from across the globe. After a comprehensive review of all publications since 2000 as well as several unpublished studies, the attendees divided into smaller groups to debate and draft new injecting recommendations based on the new data and their collective experience. This paper summarizes all the formal presentations given at this practical consensus workshop. (C) 2010 Elsevier Masson SAS. All rights reserved.

Introduction/Background Engaging in sufficient physical activity post diagnosis has been consistently associated with reduced treatment-related side effects, recurrence, all cause and cancer specific mortality, and enhanced HRQOL in breast cancer survivors. Research indicates that adults spend the vast proportion of their sitting and light-intensity physical activity. Objective evaluation such as accelerometer provide detailed data of physical activities performed across the day and the week and can give a clearer understanding of the behavior of cancer survivors (Lynch, 2011). The aim of this study was to evaluate and compare accelerometer-based and self-reported measures of physical activity level (PA) in patients having a breast cancer just after the end of adjuvant treatment without incitation or education program. Material and method For this prospective study 31 Women (mean age = 66.1 years) with no metastatic breast cancer were included after the treatment. Measures were released with an Actigraph GT3X accelerometer for seven consecutive days then complete the IPAQ-SF every 3 months after the last session of radiotherapy. Results The evolution of level MET is not significantly different between P1-P2, P2-P3 and P1-P3 (P > 0.05), the score IPAQ-SF between P1-P2 is statistically different (P = 0.0461) and is not significantly different between P2-P3 and P1-P3. The analyses of the concordance both methods (Kappa coefficient) reveal poor to fair agreement between data for P1 (k = 0.0142), P2 (k = 0.0119) and P3 (k = 0.0057) period. Conclusion The objective measure demonstrates the low physical activity level and no evolution during 3 months after treatment. This study shows poor agreement between accelerometer and self-reported physical activity data, these results are consistent with previous studies in cancer survivors (Pinto 2013, Johnson-Kozlow 2006). The finding of this study highlight the need to estimate physical activity level with objective method before intervention or incitation in breast cancer population.

35 patients with refractory or relapsed acute leukemia received salvage chemotherapy using high-dose cytosine arabinoside 2 g/m2 intravenously for 3 hours every 12 h, in 8 doses, followed by continuous infusion of mitoxantrone 12 mg/m2/day for 2 d. 9 patients had acute myeloblastic leukemia (AML), (4 relapsed, 5 refractory), 20 had acute lymphoblastic leukemia (ALL) (11 relapsed, 9 refractory) and 6 had chronic myelogenous leukemia (CML) in the blastic phase (BP). 4 out of 9 AML and 16 out of 20 ALL achieved complete remission. Median survival was 6 months for all patients and 10 months for responders. A short (1.5 months) chronic phase was achieved in 3 patients with CML. The main toxic effect was hematologic. A pharmacokinetic study was performed on mitoxantrone. No correlation was found with clinical response. The combination of mitoxantrone and ara-C is an effective antileukemic regimen, especially in ALL.

Introduction Le cancer est un probleme majeur de sante publique, notamment avec le vieillissement de la population. La decision therapeutique en geriatrie est complexe, surtout au tres grand âge, du fait de la polypathologie ou les troubles cognitifs sont souvent presents. Cette etude vise a evaluer la prevalence de la demence chez des sujets âges atteints de cancer, au sein de l’Unite Pilote d’Oncogeriatrie du CHU de Limoges.

Aims/hypothesis To assess the use of paediatric continuous subcutaneous infusion (CSII) under real-life conditions by analysing data recorded for up to 90 days and relating them to outcome.Methods Pump programming data from patients aged 0-18 years treated with CSII in 30 centres from 16 European countries and Israel were recorded during routine clinical visits. HbA(1c) was measured centrally.Results A total of 1,041 patients (age: 11.8 +/- 4.2 years; diabetes duration: 6.0 +/- 3.6 years; average CSII duration: 2.0 +/- 1.3 years; HbA(1c): 8.0 +/- 1.3% [means +/- SD]) participated. Glycaemic control was better in preschool (n=142; 7.5 +/- 0.9%) and pre-adolescent (6-11 years, n=321; 7.7 +/- 1.0%) children than in adolescent patients (12-18 years, n=578; 8.3 +/- 1.4%). There was a significant negative correlation between HbA(1c) and daily bolus number, but not between HbA(1c) and total daily insulin dose. The use of 7.5%. The incidence of severe hypoglycaemia and ketoacidosis was 6.63 and 6.26 events per 100 patient-years, respectively.Conclusions/interpretation This large paediatric survey of CSII shows that glycaemic targets can be frequently achieved, particularly in young children, and the incidence of acute complications is low. Adequate substitution of basal and prandial insulin is associated with a better HbA(1c).

Intravenous (i.v.) vinorelbine (VRL) generally given on days 1 and 8 of an every three-week cycle in combination with paclitaxel (PTX) is an effective option for the treatment of metastatic breast cancer (MBC). In an effort to improve both patient and chemotherapy unit convenience, oral VRL was used at equivalent doses of i.v. VRL.The maximal tolerated dose (MTD) was determined during the first cycle of oral VRL given on days 1 and 8 or 15 and PTX infused over 3 h on day 1 every 3 weeks, maximum of 6 cycles. The dose of oral VRL was escalated from 60 to 80 mg/m2 in 10 mg/m2 increments. Paclitaxel was administered at 110 and then 135 mg/m2. The combination regimen was given as first-line chemotherapy of MBC. Three to six patients per cohort were treated.Twenty-two patients were treated in the first four cohorts (oral VRL/PTX): 60/110, 70/110, 80/110 and 80/135. In cohort 4, seven patients were treated, one patient being non-evaluable for MTD, three of them presented a dose-limiting toxicity (DLT) consisting of febrile neutropenia and neutropenic infection. Therefore 80/135 was the MTD. Because 36% of oral VRL administrations on day 8 were delayed to day 15 at 80/110, two additional cohorts were tested: in cohort 5, oral VRL 60 mg/m2 on days 1 and 15 and PTX 135 mg/m2 on day 1 and in cohort 6, oral VRL 80 mg/m2 on days 1 and 15 and PTX 110 mg/m2 on day 1, every 3 weeks. In cohort 5, six out of eight patients had DLTs: omission of oral VRL on day 15 for five patients, grade 4 neutropenia7 days for another one. Therefore the recommended dose (RD) for further clinical testing was oral VRL 80 mg/m2 on days 1 and 15 and PTX 110 mg/m2 on day 1 of an every 3-week cycle. Two of the three evaluable patients treated at the RD had a partial response. The pharmacokinetics of VRL and PTX is being analysed and will be further presented in a separate publication.This phase I study has determined the doses of oral VRL and PTX to be used in combination for the benefit of the patient and of the chemotherapy unit in term of nurse's workload. The recommended regimen of oral VRL 80 mg/m2 on days 1 and 15 and PTX 110 mg/m2 on day 1 given every 3 weeks will be further tested in phase II.

Aim To analyse the change in adherence to diabetes treatment and its association with metabolic control from childhood to adolescence. The Tanner pubertal staging model was selected as a marker of developmental maturity. Methods In a multicentre, longitudinal cohort study, 142 children with Type 1 diabetes completed a scale that assessed adherence to treatment and a test of diabetes knowledge at the beginning of the study (T0) and four years later (T4). HbA1c and clinical data were collected at T0 and at T4. Results From T0 to T4, the mean HbA1c increased from 8.2 ± 1.6 to 9.1 ± 1.4% (P

Introduction En France, 15 % des enfants et adolescents, soit trois millions, sont atteints de maladie chronique. A l’adolescence, ils sont confrontes a une etape de transition des structures pediatriques aux structures de soins adulte, dont le succes ou l’echec peut avoir des consequences durables sur la sante (risque accru de decompensation ou de complications de la maladie). De nombreuses recommandations ont ete emises pour preparer la transition, insistant notamment sur l’apport des questionnaires d’aptitude a la transition. Notre objectif est de mesurer les proprietes psychometriques du questionnaire Good 2 Go en langue francaise. Materiel et methodes La traduction et l’adaptation transculturelle du Good 2 Go en langue francaise (25 items) ont ete realisees a partir de sa version anglaise validee, et par une equipe interdisciplinaire et bilingue du Reseau mere–enfant de la francophonie. La validation s’appuie sur deux etudes prospectives multicentriques d’evaluation du processus de transition, menees aupres de jeunes porteurs respectivement de maladies chroniques diverses (projet international, Reseau mere–enfant de la francophonie ; n = 250) ou de diabete de type 1 (projet regional Ile-de-France Pass’Age ; n = 91). Resultats La validite de contenu sera evaluee sur les criteres suivants : taux de non-reponse et de donnees manquantes, effets plafond et plancher. La validite de structure sera analysee par l’analyse en composantes principales et le diagramme de valeurs propres. Le coefficient α de Cronbach mesurera la consistance interne. La fiabilite interjuges sera evaluee par le coefficient de correlation intraclasse calcule a partir des reponses des adolescents d’une part et de leurs parents d’autre part. La sensibilite au changement sera evaluee par l’aire sous la courbe de ROC. Conclusions La validation est encore en cours. La methodologie de construction, l’exhaustivite des dimensions explorees et la large diffusion de la version anglaise du Good 2 Go font prevoir sa forte utilisation en langue francaise.

Resume Introduction. – Les raisons pour lesquelles le diagnostic de diabete de type 1 de l’enfant est souvent porte au stade de l’acidocetose (ACD) en France sont mal connues. Patients et methode. – Dans une etude prospective portant sur 72 nouveaux cas (âge moyen = 9,4 ans), nous avons analyse les facteurs lies au mode de revelation par ACD et a sa severite (pH Resultats. – L’âge inferieur a 5 ans etait associe a l’ACD (p = 0,03), mais ne l’etait pas a sa severite. Les enfants apparentes a un diabetique insulinotraite avaient moins d’ACD (p = 0,04). Les erreurs diagnostiques etaient plus frequentes en cas d’acidocetose qu’en son absence (p = 0,02) et encore plus pour les ACD severes (76 vs 23 % ; p = 0,002). Les enfants de familles dont les revenus etaient faibles avaient plus de risque d’ACD severe (77 vs 23 % ; p = 0,002) et plus souvent des erreurs au diagnostic (48 vs 10 % ; p Conclusion. – Ces resultats soulignent la necessite d’informer et de sensibiliser les medecins sur les signes et moyens simples et immediats de poser le diagnostic de diabete de l’enfant. Cette mesure associee a un meilleur acces aux soins des plus demunis, devrait permettre de reduire l’incidence d’un mode de revelation grave du diabete de l’enfant dans notre pays.

The aim of the study was to evaluate, after the first year of a national information campaign, the effect on the frequency and severity of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in children and adolescents in France. The following data were collected during a 2-year period in people younger than 15 years of age at diagnosis of T1D, in 146 pediatric centers: age, sex, duration of symptoms, patient's previous care, clinical and biological signs, and family history of T1D. DKA was defined as pH7.30 or bicarbonate15mmol/L, severe DKA as pH7.10 or bicarbonate5mmol/L. During the 2nd year, an information campaign targeting health professionals and families was launched with the objective of reducing the time to diagnosis. Data were compared between the year before the campaign (year 0) and the first year of the campaign (year 1). The number of new cases of T1D was 1299 for year 0 and 1247 for year 1. Between year 0 and year 1, the rate of DKA decreased from 43.9% to 40.5% (P=0.08), exclusively due to the decrease of severe DKA from 14.8 to 11.4% (P=0.01). In the 0- to 5-year-old and 5- to 10-year-old age groups, the relative decrease in the rate of DKA was 13% and 15%, and 23% and 41% for severe DKA, respectively. In patients referred to the hospital by a pediatrician or who came at the family's initiative, the decrease was 34% and 7%, and 39% and 32% for severe DKA, respectively. No change was observed in the 10- to 15-year-old group or in those children who were referred by a general practitioner. In multivariate analyses, a higher DKA rate was associated with the young age of the child (5 years), being hospitalized at the parents' initiative rather than being referred by a doctor, and the absence of a family history of T1D. A higher rate of severe DKA was associated with these last two factors but not with the child's age. The frequency of DKA at diagnosis of type 1 diabetes remains high in children and adolescents, but the first year of an information campaign decreased it. The results have also helped better define the strategy and targets of the continuing prevention campaign, to more efficiently reduce the morbidity and mortality of T1D at diagnosis in children and adolescents in France.

UNLABELLED: In patients with cystic fibrosis (CF), glucose intolerance preceding diabetes (prediabetes) may have adverse effects on nutritional status and respiratory function, which are reversible after the start of insulin therapy. Respiratory function (forced vital capacity and forced expiratory volume in one second) and body mass index (BMI) were compared retrospectively in a French cohort of 14 patients during the 5 y preceding insulin therapy for diabetes and in 14 age- and sex-matched controls with normal oral glucose tolerance tests. In the diabetic group, all three parameters deviated increasingly from the values in the controls; the differences became statistically different during the 6 mo before insulin therapy. The effect was more important in patients for whom diabetes mellitus was diagnosed on the basis of symptoms of hyperglycaemia than in patients for whom it was diagnosed by systematic screening, but still present in the latter. After insulin was started, respiratory function improved and the BMI returned to normal within 1 y. The annual insulin requirement increased from 0.62 during the first year to 1.25 during the fifth year. Glycosylated haemoglobin (HbAIc) values ranged from 6.6 to 7.8%. Only 2 episodes of severe hypoglycaemia were recorded over 42 patient-years of follow-up. The insulin regimen most often used was two daily injections of a mixture of short- and intermediate-acting insulin (n = 10) given with an insulin pen. CONCLUSION: The clinical status of CF patients who will need insulin therapy deteriorates before the start of insulin. In patients with CF-related diabetes, with or without fasting hyperglycaemia, insulin therapy improves anabolism and provides good glycaemic control with few severe hypoglycaemic episodes.

A liquid chromatography-electrospray mass spectrometry method was developed for the quantitation of vinorelbine (VNB) and two metabolites, vinorelbine N-oxide (VNO) and deacetyl vinorelbine (DAV) in human serum. The limits of quantitation (LOQ) reached 0.5 ng/ml for both VNB and VNO and 1 ng/ml for DAV. The method was proved linear in the range of LOQs up to 1000 ng/ml, and extraction recovery was 80% on average for the three compounds. It was applied to the pharmacokinetic monitoring of vinorelbine and, for the first time, to the detection of VNO in the serum of patients suffering from non-small-cell lung cancer.

Resume L'objectif de cette etude est d'evaluer les conditions du transfert des adolescents diabetiques de la pediatrie vers les structures de soins pour adultes et de recueillir l'opinion sur celles-ci des medecins concernes. Methode Une enquete par questionnaire a ete menee aupres de tous les pediatres hospitaliers et des diabetologues de la region Paris-Ile-de-France. Les reponses de 50 pediatres et de 51 diabetologues ont ete analysees (taux de reponse: 68 %). Resultats.-1) La transmission des informations est insuffisante: un quart des diabetologues font leur premiere consultation sans renseignements, et la moitie des pediatres sont informes par les diabetologues apres cette premiere consultation. Tous considerent pourtant qu'il est important de se tenir informes apres ta premiere consultation et ulterieurement 2) Les relations medicales sont pauvres: plus des trois quarts des pediatres et des diabetologues n'ont que rarement ou jamais de retalions de travail entre eux et deux tiers des pediatres et des diabetologues ne connaissent pas ou imparfaitement leurs methodes de travail respectives. 3) Quatrevingts pour cent des pediatres et diabetologues estiment que le transfert des adolescents doit beneficier d'une organisation particuliere, du fait de l'importance de ses enjeux: preserver la coherence du suivi medical, attenuer les effets psychologiques du transfert a la periode critique de l'adolescence, et eviter une rupture du suivi medical. 4) Les attentes principales de ce passage sont, pour les pediatres, une validation de leur travail avec retour des informations et continuite dans la prise en charge medicale; pour les diabetologues, gagner la confiance du patient pour eviter la rupture et maitriser ses antecedents pour un meilleur suivi. S) De l'avis des pediatres et des diabetologues, les erreurs principales a eviter par les pediatres sont de rater le moment du passage et sa preparation; par les diabetologues, de denigrer la prise en charge pediatrique et de modifier immediatement le traitement. Conclusion — Cette enquete met en evidence le manque de communication entre les pediatres et les diabetologues; neanmoins, elle revele l'importance pour les medecins des enjeux du passage, leurs motivations communes et leurs souhaits de tes concretiser.

Summary Background Anemia is a common side effect of anticancer chemotherapy. Blood transfusion, previously the only available treatment for chemotherapy-induced anemia, may result in some clinical or subclinical adverse effects in the recipients. Recombinant human erythropoietin (rhEPO) provides a new treatment modality for chemotherapy-induced anemia. Patients and methods To evaluate the effect of rhEPO on the need for blood transfusions and on hemoglobin (Hb) concentrations, 227 patients with solid tumors and chemotherapy-induced anemia were enrolled in a randomized, controlled, clinical trial. Of 189 patients evaluable for efficacy, 101 received 5000 IU rhEPO daily s.c, while 88 patients received no treatment during the 12-week controlled phase of the study. Results The results demonstrate a statistically significant reduction in the need for blood transfusions (28% vs. 42%, P = 0.028) and in the mean volume of packed red blood cells transfused (152 ml vs. 190 ml, P = 0.044) in patients treated with rhEPO compared to untreated controls. This effect was even more pronounced in patients receiving platinum-based chemotherapy (26% vs. 45%, P = 0.038). During the controlled treatment phase, the median Hb values increased in the rhEPO patients while remaining unchanged in the control group. The response was seen in all tumor types. Conclusions RhEPO administration at a dose of 5000 IU daily s.c. increases hemoglobin levels and reduces transfusion requirements in chemotherapy-induced anemia, especially during platinum-based chemotherapy.

Resume En France, le diabete de l'enfant est diagnostique dans 48 % des cas au stade de l'acidocetose. Observations. - Les observations rapportees montrent que la gravite de l'etat clinique des quatre enfants de 6 a 11 ans a leur admission est liee a un diagnostic tardif de diabete. Ils presentaient tous un coma, des troubles de l'hemodynamique, une deshydration et une acidose severes (pH = 6,86 a 7,06). Les signes du diabete, presents depuis 2 semaines a 4 mois, n'ont pas toujours inquiele les parents.Un ou plusieurs medecines consultes, 2 a 21 jours avant l'admission n'ont pas evoque d'emblee le diagnostic de diabete. Une acidocetose manifeste etait presente dans tous les cas 48 heures avant l'hospitalisation. Conclusions. - Le diagnostic de diabete de l'enfant a un stade plus precoce est facile, immediat au cabinet medical et peu couteux. Il response sur un geste simple, l'utilisation d'une bandelette reactive urinaire. Les medecins generalistes, les pediatres, les medecins d'urgence doivent etre sensibilises pour penser a ce diagnostic chez l'enfant. Le defi a relever est de diminuer la frequence des acidocetoses revelatrices du diabete chez l'enfant, potentiellement graves, en portant le diagnostic a un stade anterieur de la malaidie.

The most recent innovations serving pediatric type 1 diabetes patients are the insulin pump and its new functions and continuous glucose measurement, which, associated with the pump, foreshadows the artificial pancreas. Strictly controlling glycemia in type 1 diabetes is necessary to prevent complications, but the main side effect is the risk of frequent episodes of hypoglycemia, most particularly severe hypoglycemia.

There is an increase in the incidence of type 1 diabetes (T1D) in children younger than 5 years of age and continuous subcutaneous insulin infusion (CSII) appears to be an increasingly popular therapeutic option in France. A retrospective self-evaluation questionnaire was distributed to parents of young children with T1D treated by CSII (42 children, age 4.8±1.0 years, 2.3±0.5 years at the onset of TD1, mean± SD). It focused on the quality of diabetes management in daycare centers or with nannies and at school. Parental satisfaction related to the management of their children was overall good (84% for all the parents, 70.5% for the parents of children at nursery-school, from 3 to 6 years. However 93% of the parents experienced and overcame serious difficulties: exclusion of the children on account of DT1 (school trips, daycare centers after school), use of the pump for lunch and snacks, realization of glycemic controls, participation in school trips, survey during school meals. In spite of these difficulties these young children had a normal and safe time at school. The management of the young children with DT1, treated by CSII, in alternate care centers and at school need to be improved; the experience was positive when daycare workers and teachers agreed to be instructed.

International audience; OBJECTIVES: This study aimed to evaluate the frequency of diabetic ketoacidosis (DKA) and its associated factors at the diagnosis of type 1 diabetes (T1D) in French children and adolescents prior to launching a public-health campaign of information to prevent DKA. PATIENTS AND METHODS: Over a 1-year period, 1299 youngsters (aged

Aim of no residual macroscopic disease has to be the objective of the gynecologist oncologist surgeon. It can require extensive surgical procedures in all the abdomen area. We report 2 rare cases of cytoreductive surgery with iliac vessels resection and use of vascular prosthesis. We discuss the opportunity of this surgery with high morbidity.

Les therapies orales sont en plein developpement dans la prise en charge des tumeurs solides. Elles ne sont pas denuees de toxicites et leur suivi a domicile demande une gestion extremement rigoureuse [1, 2].

ML18147 evaluated continued bevacizumab with second-line chemotherapy for patients with metastatic colorectal cancer (mCRC) progressing after the standard first-line bevacizumab-containing therapy.Evaluating outcomes according to tumor Kirsten rat sarcoma virus oncogene (KRAS) status was an exploratory analysis. KRAS data were collected from local laboratories (using their established methods) and/or from a central laboratory (mutation-specific Scorpion amplification-refractory mutation system). No adjustment was made for multiplicity; analyses were not powered to detect statistically significant differences.Of 820 patients, 616 (75%) had unambiguous KRAS data; 316 (51%) had KRAS wild-type tumors and 300 (49%) had mutant KRAS tumors. The median progression-free survival (PFS) was 6.4 months for bevacizumab plus chemotherapy and 4.5 months for chemotherapy [P0.0001; HR = 0.61; 95% confidence interval (CI): 0.49-0.77] for wild-type KRAS and 5.5 and 4.1 months, respectively (P = 0.0027; HR = 0.70; 95% CI: 0.56-0.89) for mutant KRAS. The median overall survival (OS) was 15.4 and 11.1 months, respectively (P = 0.0052; HR = 0.69; 95% CI: 0.53-0.90) for wild-type KRAS and 10.4 versus 10.0 months, respectively (P = 0.4969; HR = 0.92; 95% CI: 0.71-1.18) for mutant KRAS. In both analyses, no treatment interaction by KRAS status was observed (PFS, P = 0.4436; OS, P = 0.1266).Bevacizumab beyond first progression represents an option for patients with mCRC treated with bevacizumab plus standard first-line chemotherapy, independent of KRAS status.

Resume Le risque d'hypoglycemie severe est particulierement eleve chez les jeunes enfants diabetiques traites. Patients. - Une etude retrospective comparant tous les enfants ages de moins de 6 ans traites dans notre service par pompe a perfusion continue d'insuline (P, n = 10, âge moyen: 3,7 ans) a 17 enfants traites de facon conventionnelle (C, âge moyen: 5,1 ans) a ete menee dans la meme peroide de temps. Le recul moyen a ete de 2 ans dans les deux groupes. Resultats. - Les doses d'insuline, les taux d'HbAle et les glycemies moyennes preprandiales et de la journee, evalues a 0, 3, 6, 12, 18 et 24 mois ne differaient pas dans les deux groupes. Les taux moyens d'hemoglobine glyquee etaient inferieurs ou egaux a 8% dans les deux groupes. Le benefice du traitement par pompe demontre dans cette etude a ete l'absence d'hypoglycemie severe: groupe P. zero episode vs groupe C, dix episodes; p

Glutamate synthase (NADH-GOGAT) is one of several proteins whose expression is either enhanced in, or specific to developing legume root nodules induced by (Brady)Rhizobium infection. This enzyme catalyzes the second committed step in the assimilation of symbiotically fixed nitrogen; the transamidation of 2-oxoglutarate by glutamine to yield two moles of glutamate. We have previously purifed alfalfa root nodule NADH-GOGAT and raised antibodies against this protein. To investigate the regulation of the gene encoding this enzyme, we have isolated a full length cDNA clone for NADH-GOGAT from an alfalfa nodule cDNA library. This 7.5 kb cDNA includes the sequence encoding the mature 210 kd protein (the amino terminus of which has been sequenced), as well as an apparent transit peptide. Northern blots indicate that mRNA levels are developmentally regulated in the nodule, showing a similar pattern to that of previously characterized genes encoding aspartate aminotransferase and phosphoenoylpyruvate carboxylase.

We describe a case of right mammary homolateral recurrence with controlateral axillary invasion. The absence of occult involvement of the left breast was confirmed by MRI. A subsequent thoraco-abdomino-pelvic scan and bone scintigraphy did not reveal any metastases. Lymphoscintigraphy of the right breast, after periareolar injection, revealed lymphatic drainage from the right breast into the left contralateral axillary lymph node. Because of the changes in axillary drainage after mammary and axillary surgery observed by lymphoscintigraphy, contralateral axillary involvement could be considered as locoregional disease in the same way as homolateral lymph node involvement.

Aim: Injections administered by patients are one of the mainstays of diabetes management. Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy. Yet few formal guidelines have been published summarizing all that is known about best practice. We propose new injection guidelines which are thoroughly evidence-based, written and vetted by a large group of international injection experts. Methods: A systematic literature study was conducted for all peer-reviewed studies and publications which bear on injections in diabetes. An international group of experts met regularly over a two-year period to review this literature and draft the recommendations. These were then presented for review and revision to 127 experts from 27 countries at the TITAN workshop in September, 2009. Results: Of 292 articles reviewed, 157 were found to meet the criteria of relevance to the recommendations. Each recommendation was graded by the weight it should have in daily practice and by its degree of support in the medical literature. The topics covered include The Role of the Professional, Psychological Challenges, Education, Site Care, Storage, Suspension and Priming, Injecting Process, Proper Use of Pens and Syringes, Insulin analogues, Human and Pre-mixed Insulins, GLP-1 analogs, Needle Length, Skin Folds, Lipohypertrophy, Rotation, Bleeding and Bruising, Pregnancy, Safety and Disposal. Conclusion: These injecting recommendations provide practical guidance and fill an important gap in diabetes management. If followed, they should help ensure comfortable, effective and largely complication-free injections. (C) 2010 Elsevier Masson SAS. All rights reserved.