Work outcomes of breast cancer survivors who returned to work after treatment: CANTO cohort

Background

As survival rates among breast cancer patients improve there is an increasing need to address breast cancer survivors’ (BCS) issues, professional life being a key aspect. Return to work (RTW) of BCS has been largely studied, but studies on job maintenance and its determinants are scarce. We aim to study job maintenance after RTW and the associated factors among BCS.

Methods

We used data from the CANTO cohort, a French prospective cohort of BCS. We included 1643 BCS aged <57 at diagnosis (dx) who returned to work two years after dx. We excluded self-employed BCS. Using multinomial logistic models, we assessed the association between activity status one year after they return to work. (i.e. active, sick leave, or unemployed, retired or invalidity) and sociodemographic, clinical, health status and work-related factors.

Results

Overall, 87% of BCS were active, 10% were on sick leave and 3% were on unemployment, retirement or invalidity one year after they return to work. In the fully adjusted model being on sick leave was associated with stage III at dx (OR: 1.89, 95% CI: 1.11-3.22), being severely fatigued at the moment of returning to work (OR: 1.53, 1.04-2.27), and having workplace accommodations (OR: 1.79, 1.14-2.81). The unemployed, retired, invalidity status was negatively associated with professional life being more than or as important as one’s personal life (OR: 0.51, 0.26-0.98) and being <50 years old (OR: 0.51, 0.27-0.96), and positively associated with having a fixed-term contract (OR: 2.69, 1.39-5.18) and working for a small company (OR: 2.73, 1.24-6.02).

Conclusions

A non-negligible proportion of BCS are non-active one year after they return to work. While clinical factors are associated with sick leave, work related factors are associated with the unemployed, retired, and invalidity status. RTW should not be regarded as the ultimate goal and future policies should focus on ensuring people are ready to return to work and maintain their jobs.

Key messages

• A non-negligible proportion of breast cancer survivors are non-active one year after they return to work.

• Future policies should ensure job maintenance along with return to work.

Functional Analysis and Successful Treatment of a Captive Rhesus Macaque's Disruptive Behavior

Functional analysis (FA) is a method developed and used by behavior analysts in human clinical settings to identify possible environmental variables that reinforce undesired behavior. FA is increasingly being applied to better understand the behavior of nonhuman animals. When training monkeys in a room with others, disruptive behavior displayed by neighboring monkeys can impede training progress. In the present study, a FA identified possible reinforcers of disruptive behavior (loud shaking of a toy) exhibited frequently (24% duration pre-treatment) by a rhesus macaque (Macaca mulatta) during in-room training sessions. The functional analysis identified that contingent delivery of foods was maintaining the disruptive behavior, with a mean percent duration of 57% in this condition. The implementation of a function-based treatment consisting of continuous access to a preferred food during in-room training sessions successfully decreased disruptive behavior by over 90% as measured during 15 subsequent sessions. This study advances the current literature applying functional analysis to nonhuman primates as a means of determining the reinforcers maintaining aberrant or undesirable behavior and applying effective treatments based on understanding this function.

Effects of aldosterone and related steroids on LPS-induced increased expression of inducible NOS in rat aortic smooth muscle cells

BACKGROUND AND PURPOSE

Expression of inducible NOS (iNOS) is important in certain inflammatory diseases. We determined if the hormone aldosterone, a mineralocorticoid receptor (MR) agonist, affects LPS activation of iNOS expression in rat aortic smooth muscle cells (RASMC).

EXPERIMENTAL APPROACH

Cultured RASMC were treated with LPS, with or without agonists/antagonists of steroid receptors. iNOS expression was determined by nitrite assays on culture medium removed from treated cells and by immunoblotting of cell protein extracts.

KEY RESULTS

LPS (1 µg·mL(-1) ) increased nitrite and iNOS protein above that in control (untreated) cells. These effects of LPS were reduced by aldosterone (0.1-10 µM). The MR antagonists, eplerenone (10 µM) and spironolactone (10 or 50 µM), did not inhibit these actions of 1 µM aldosterone, but the latter were prevented by 10 µM mifepristone, a glucocorticoid (GR) and progestogen receptor (PR) antagonist. Mifepristone also prevented the reduction of LPS-induced nitrite increase produced by 1 µM dexamethasone (GR agonist) and 10 µM progesterone (PR agonist). Spironolactone (10-50 µM) by itself decreased LPS-induced increases in nitrite and iNOS protein. Mifepristone (10 µM) partially reversed these effects of 10 µM spironolactone, but not those of 50 µM; the effects of 50 µM spironolactone were also unchanged when mifepristone was increased to 50 µM.

CONCLUSIONS AND IMPLICATIONS

This pharmacological profile suggests that aldosterone, and possibly 10 µM spironolactone, use mechanisms that are dependent on PR and/or GR, but not MR, to inhibit iNOS induction in RASMC. With 50 µM spironolactone, other inhibitory mechanisms requiring further investigation may become predominant.

OT2-04-03: Uptake of a Randomized Breast Cancer Prevention Trial Comparing Letrozole to Placebo in BRCA1/2 Mutations Carriers: The FNCLCC ONCO-03/LIBER Trial

Background: Women with germline BRCA1or BRCA2 (BRCA1/2) mutations are an extreme risk population for developing breast cancer, with a life-time risk of 56–80%. Prophylactic mastectomy provides a valid option to reduce such risk, but it considerably affects the quality of life. Medical prevention by aromatase inhibitor that has been recently shown to have preventive effect may thus be an alternative. LIBER is an ongoing, double-blind, randomized phase III trial to evaluate the efficacy of five-years letrozole versus placebo to decrease breast cancer incidence in post-menopausal BRCA1/2 mutation carriers (NCT00673335). We present data on the uptake of this trial. Methods: To evaluate theoretical feasibility, we compared inclusion criteria of women in the LIBER trial (n=113) to characteristics of women entered in the prospective ongoing national GENEPSO cohort (n=1505). Uptake was evaluated through a survey sent to all active centres, with responses obtained from 17 of the 20 (85%) centres. Results: According to characteristics of the women included in GENEPSO cohort (n=1505) and the survey, approximately one third of BRCA1/2 mutation carriers are eligible for this study. From november 2009 to may 2010, 534 women eligible from chart review have been informed by mail of the trial and were invited to an oral information by participating centres. Of them, 44% of women came to the dedicated medical visit. Uptake of drug prevention trial was 32 % of orally informed women and 15 % of overall eligible women. Main reasons of refusal were: potential side effects, probability to receive the placebo and lack of support from the women's physicians. Prior prophylactic oophorectomy and history ***of previous unilateral breast cancer were more frequent in women enrolled in the ONCO-03/LIBER trial than in the French cohort (93% versus 60% and 50 % versus 39 %, respectively), suggesting a higher motivation for medical prevention in these subgroups of patients.

Conclusion: One third of women with a BRCA1/2 mutation are eligible to the ONCO-03/LIBER prevention trial. 32 % of orally informed women and, only 15% of overall eligible women entered the trial. To reach accrual objective (n=308), a greater information of the trial should be offered to women with BRCA1/2 mutation and the trial has been proposed to other countries.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT2-04-03.

P5-18-04: Safety Profile of Ixabepilone as Adjuvant Treatment for Poor Prognosis Early Breast Cancer: First Results of the Unicancer-PACS 08 Trial

Purpose: PACS 01 trial demonstrated that the sequential adjuvant chemotherapy with FEC100 followed by docetaxel (D) significantly improves disease-free and overall survival in node-positive(N+) early breast cancer (BC). However, Triple negative (TN) and ER+/ PR-/HER2− subgroups are significantly associated to a worse prognosis even after adjunction of D. As Ixabepilone (Ixa) has notable preclinical and clinical activity in these subgroups, the PACS 08 trial aims to compare standard FEC100-D regimen to 3 cycles of FEC100 followed by 3 cycles of Ixa. We report the preliminary results of the toxicity profile.

Patients and methods: Patients (pts) had localized resectable unilateral ER-/PR-/HER2− or ER+/PR-/HER2− BC. Main inclusion criteria were: age&lt;70 years, normal cardiac, hepatic, haematological and renal functions. Arm A: pts received 3 cycles of FEC100 (F and C, each at 500 mg/m2, E 100 mg/m2, every 3 weeks) followed by 3 cycles of D (100 mg/m2 every 3 weeks); Arm B, Ixa 40 mg/m2 replaced D. Radiotherapy was mandatory after conservative surgery and endocrine therapy was given to ER+ pts. A 5% absolute difference in disease-free survival at 5 years is the main statistical end-point. Results: Between October 2007 and September 2010, 762 pts with TNBC or ER+/PR-/HER2− BC were enrolled. Recruitment was interrupted due to BMS decision to stop Ixa development in adjuvant setting. Main pts characteristics were well balanced between the 2 arms: median age 53 years, postmenopausal 57.8%, conservative surgery 68.4%, node positive 59.5%. A total of 755 pts were evaluable for safety. Treatment was completed for 93.4% and 86.1% of pts in arms A and B, respectively. During FEC100 sequence, toxicities were well balanced between the two arms. From cycle 4, whereas Gr3/4 sensory neurotoxicity (12pts; 3.5%) and thrombopenia (7pts; 2%) were reported in Ixa arm, none of these toxicities was reported in the D arm (p0.001). There were significantly more Gr3/4 neutropenia on day 21 in Ixa arm (13pts, 6.6% vs 4pts, 1.9%; p&lt;10.005). No significant difference was observed for febrile neutropenia. Fewer cutaneous toxicities were observed in Ixa arm (2pts, 0.6% vs 10pts, 2.6%; p&lt;0.05). No significant difference was observed neither for motor neurotoxicity or hepatic function between two arms. More pts discontinued treatment in Ixa arm compared to D arm (49pts (13%) vs 26pts (7%), p&lt;0.05). Main reasons were Gr3/4 haematological adverse events (AE) and Gr3/4 neurotoxicities for Ixa arm and due to GR3/4 haematological AE for D arm. One non expected Gr4 bullous dermatitis was reported during the first Ixa cycle. 2 deaths due to septic shock occured in Ixa arm (both at cycle 4 for a 56- and a 66-year-old woman). However, according to the IDMC no obvious precipitating factor questioning the Ixa arm was identified.

Conclusion: Our results indicate that D arm is more often associated to significant haematological toxicities, whereas both neurotoxicities and haematological toxicities are reported in the Ixa arm. Although significantly more pts discontinued treatment due to adverse events in Ixa arm compared to D arm, Ixa may still represent a promising therapeutic option for pts in the adjuvant setting especially for poor prognosis BC.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-18-04.

A refined molecular taxonomy of breast cancer

The current histoclinical breast cancer classification is simple but imprecise. Several molecular classifications of breast cancers based on expression profiling have been proposed as alternatives. However, their reliability and clinical utility have been repeatedly questioned, notably because most of them were derived from relatively small initial patient populations. We analyzed the transcriptomes of 537 breast tumors using three unsupervised classification methods. A core subset of 355 tumors was assigned to six clusters by all three methods. These six subgroups overlapped with previously defined molecular classes of breast cancer, but also showed important differences, notably the absence of an ERBB2 subgroup and the division of the large luminal ER+ group into four subgroups, two of them being highly proliferative. Of the six subgroups, four were ER+/PR+/AR+, one was ER−/PR−/AR+ and one was triple negative (AR−/ER−/PR−). ERBB2-amplified tumors were split between the ER−/PR−/AR+ subgroup and the highly proliferative ER+ LumC subgroup. Importantly, each of these six molecular subgroups showed specific copy-number alterations. Gene expression changes were correlated to specific signaling pathways. Each of these six subgroups showed very significant differences in tumor grade, metastatic sites, relapse-free survival or response to chemotherapy. All these findings were validated on large external datasets including more than 3000 tumors. Our data thus indicate that these six molecular subgroups represent well-defined clinico-biological entities of breast cancer. Their identification should facilitate the detection of novel prognostic factors or therapeutical targets in breast cancer.

Prognostic value of the genomic grade index (GGi) as compared to centrally measured Ki-67 IHC and mitotic index in early breast cancer patients

11094

Background: Genomic grading has been proposed to improve tumor grading. The genomic grade index (GGi) is a 97-gene continuous measure which resolves 80% of histological grade 2 (HG 2) tumors into HG 1 and HG 3 risk categories. GGi has higher prognostic value than HG in patients treated with and without systemic adjuvant endocrine and chemotherapy. A key issue is whether the GGi adds prognostic information to centrally-determined mitotic index and Ki-67 IHC. Methods: The control arm of the PACS 01 trial included 996 women with node-positive (N+) early breast cancer treated with six cycles of fluorouracil, epirubicin, and cyclophosphamide (FEC) and tamoxifen as required. 128 genomic profiles could be obtained from available frozen tumor samples using Affymetrix U133 Plus 2.0 gene chips through the “Carte d'Identite des Tumeurs” program of the French Ligue Nationale contre le Cancer. The Genomic Grade index (GGi) was computed using Ipsogen MapQuant Dx(R). Central Elston-Ellis grade, mitotic index (mitosis / mm2), and Ki-67 IHC (% positive cells) were available for 125 patients. The GGi and histological parameters were correlated to the 5-year metastasis status (MFS-5) by ROC analysis and to the metastasis hazard (follow-up of 6.2 ± years) by Cox regression. Results: In ER+ patients (n=93), the GGi was the only significant correlate to metastasis hazard in multivariate Cox regression with histological parameters (HR = 3.5 [1.7–7.5], p<0.001). It was the best predictor of MFS-5 (ROC AUC = 0.83, p=1E-6) when compared to histological parameters (ROC AUC = 0.71, 0.72 and 0.66 resp. p=0.003 to 0.03). In HG 2 subgroup (n=43), the GGi was the only significant predictor of MFS-5 (ROC AUC = 0.81, p=0.016). Conclusions: In our sample of N+ ER+ breast cancer patients, the GGi improved prognostication compared to centrally-measured mitotic index and Ki-67 IHC used alone and in combination. Moreover, the GGi was the only prognostic factor in histological grade 2 patients.

[Table: see text]

Enlargement of the proximal pituitary stalk associated with spontaneous recovery from multiple pituitary hormone deficiencies

We report the case of a child with multiple pituitary hormone deficiencies and a truncated pituitary stalk on MR imaging who had recovery of normal secretion of pituitary hormones in early adulthood. Follow-up MR imaging examination after recovery revealed marked enlargement of the proximal pituitary stalk. The case of our patient helps to explain the mechanism whereby some patients experience recovery of hormonal function.

Observation of DNA-polymer condensate formation in real time at a molecular level

Dynamic real time assembly of toroidal and rod-like DNA condensates has been visualised using atomic force microscopy. Imaging has been conducted in an aqueous environment allowing the visualisation of hydrated, pegylated-polymer DNA condensates undergoing dynamic structural movement and conformational change. A major hurdle in the field of gene delivery is cellular transfection and the subsequent transfer of condensed genetic material to the cell nucleus. An increased understanding of the process of DNA condensation will aid the development and optimisation of gene delivery vectors.

Testicular seminoma in a patient with a constitutively activating mutation of the luteinizing hormone/chorionic gonadotropin receptor

A white man who had been diagnosed, 35 years previously at the age of 27 months, to have precocious puberty, was later determined to have familial male-limited precocious puberty (FMPP), on the basis of his family history, increased serum testosterone, prepubertal concentrations of follicle stimulating hormone and luteinizing hormone, and Leydig cell hyperplasia. Recently, this diagnosis was confirmed by molecular genetic analysis that demonstrated the presence of a heterozygous constitutive activating mutation of the luteinizing hormone/chorionic gonadotropin receptor. This dominant gain-of-function Asp578Gly mutation has been shown constitutively to activate the receptor in the absence of the agonist, leading to enhanced synthesis of cAMP and, in turn, to increased, sustained production of testosterone. In 1994, this patient was found to have a testicular seminoma. He represents the first case of a testicular germ cell tumor described in an FMPP patient, raising the possibility of a potentially harmful effect of prolonged increased concentrations of sex hormones, with onset early in life, upon the cellular components of the testes.

Clinical utility of plasma membrane vesicles expressing recombinant glycophorin A-encoded blood group antigens

BACKGROUND

Although the genes encoding most of the major blood group determinants are now cloned, recombinant blood group antigens are not commonly used in the clinical laboratory. This study assessed the feasibility of using plasma membrane vesicles expressing recombinant glycophorin A blood group antigens as soluble immunoadsorbants.

STUDY DESIGN AND METHODS

Chinese hamster ovary cells were transfected with plasmids containing the cDNA encoding the M- or N-allele of glycophorin A. Plasma membrane vesicles were chemically induced from stable, high-expressing cell lines. Antibodies were assessed for reactivity in hemagglutination-inhibition assays.

RESULTS

Eight anti-M antibodies were evaluated. Vesicles expressing the M-allele of glycophorin A neutralized four antibodies (two murine monoclonals; two human sera), while the activity of four human sera was unaffected. Three anti-N reagents were also evaluated (murine monoclonal antibody; rabbit polyclonal antibody; Vicia graminea lectin). All were neutralized by vesicles expressing the N-allele of glycophorin A. There was no detectable neutralization of other clinically significant blood group antibodies.

CONCLUSIONS

Plasma membrane vesicles expressing recombinant glycophorin blood group determinants may prove to be useful reagents in the clinical laboratory. However, the partial failure of M antibody recognition requires further study. This general approach could be utilized for any similarly expressed recombinant blood group antigen.

Fluctuations of antibody to ribosomal P proteins correlate with appearance and remission of nephritis in SLE

Antibodies to ribosomal P proteins are found in widely variable proportions (up to 42%) of patients with SLE depending on the ethnic background of the patient population. Neuropsychiatric disease was first recognized to have increased prevalence with anti-P and more recently liver and renal disease. We describe four patients with SLE and circumscribed episodes of nephritis of relatively short duration. In two patients, antibodies to ribosomal P protein were the only specificity detected at the time of appearance of active nephritis; and in the other two patients, the appearance and disappearance of anti-ribosomal P was simultaneously found with similar fluctuations in anti-dsDNA titers. Anti-ribosomal P antibodies were measured by Western blot and a P peptide-specific ELISA. These data raise the possibility for a pathogenic role for anti-ribosomal P antibodies in lupus nephritis.

[Comparison of the effects of Rocgel and anti-H2 on the symptomatology of gastroesophageal reflux without esophagitis]

The efficacy of boehmite (Rocgel) and of ranitidine was compared in a randomized, double-blind 4-week trial in patients with symptomatic, endoscopically free macroscopic reflux oesophagitis. Of the 64 patients who completed the study 33 received boehmite and 31 ranitidine. Significant symptomatic improvement occurred in both treatment groups (global clinical score and self evaluation by patients) (p < 0.001). Disappearance of heartburn was 52 per cent (15/29) with boehmite and 53 per cent (16/30) with ranitidine. Disappearance of regurgitation was 48 per cent (10/21) with both treatments. 33% of the patients became totally symptom-free. Our results indicate that boehmite seems to be at least as effective as ranitidine in relieving symptoms. Cost of treatment with boehmite, on the other hand is cheaper than ranitidine. As a safe, locally active mucosal protecting agent and antacid, boehmite is an effective drug for the treatment of reflux oesophagitis without macroscopic lesions.

The nutrition support team: surviving and thriving in an era of reform

Nutrition support teams today are being buffeted by the winds of change in the health care system. With the emphasis shifting from whether to deliver care to how to do so and to how much that care will cost, nutrition support professionals must stay attuned to their institution's needs--and be prepared to adapt to those needs. This article reviews the types of data collection necessary for teams to remain solid as well as offering tips from experts about ways to harness, and even capitalize on, the changes.

Enzyme immunoassay for identification of Vibrio vulnificus in seawater, sediment, and oysters

Historically, methods used to identify Vibrio vulnificus in environmental samples have been inadequate because isolation and identification procedures are time-consuming and fail to separate V. vulnificus from other bacterial species. We describe an enzyme immunoassay (EIA) and culture techniques which identified V. vulnificus in seawater, sediment, and oysters. The EIA used monoclonal antibody FRBT37 to a species-specific epitope of V. vulnificus. No cross-reactions were observed among 72 non-V. vulnificus strains comprising 34 species and 15 genera. In field trials, the EIA identified correctly 99.7% of 348 biochemically confirmed V. vulnificus isolates. The epitope corresponding to FRBT37 was found in cells lysed by Triton X-100, deionized H2O, and ultrasonication but was not found in culture supernatants, indicating that its location was intracellular. In addition, electron micrographs of V. vulnificus labeled with FRBT37-biotin-avidin-gold showed that epitope FRBT37 reacted with fragments of lysed cells but not whole cells. FRBT37 was expressed when V. vulnificus was cultured in different growth media. The minimum level of detection of the EIA was approximately 2,000 V. vulnificus cells per EIA well. Epitope FRBT37 was labile at 70 degrees C for 30 min. Immunoblot and EIA plate formats reduced assay time and facilitated handling large numbers of test samples.

Enzyme linked immunosorbent assay for detecting adenoviruses in stool specimens: comparison with electron microscopy and isolation

A commercial enzyme linked immunosorbent assay (ELISA) for detection of adenoviruses in stool samples was compared with the use of electron microscopy and isolation in Graham 293 cells. Although specific, the ELISA was less sensitive than both electron microscopy and isolation. The ELISA had an overall sensitivity of 78% and a specificity of 100%. The sensitivity was related to the amount of virus particles present in the stool sample, increasing to 90% with about 10(7) viral particles/ml of stool. The ELISA was easy to perform, requiring no instrumentation, and is a useful first line test for detection of adenoviruses in stool samples, especially in laboratories without access to an electron microscope. Wider use of ELISAs should help in evaluating the role of adenoviruses in viral gastroenteritis.

An assessment of the sensitivity of three methods for the detection of rotavirus

A comparison was made of the sensitivity of a current commercial ELISA for detecting rotavirus in faecal specimens with the more complex, technically demanding systems of electron microscopy and polyacrylamide gel electrophoresis. Even after modification, the ELISA failed to detect 22% of specimens with particles identifiable by electron microscopy. Polyacrylamide gel electrophoresis failed to identify 2 out of 50 specimens with particles present but did distinguish 2 group C rotaviruses.

Information systems and physician practice patterns: England and America compared

This paper discusses the opportunity for hospital management to make greater use of comparative data on physician productivity. We report findings from a study on utilization information provided to physicians in 19 US and British hospitals. Most doctors reported that they did not receive information comparing their own use of resources with that of their peers. However, our survey found that a significant majority of doctors want more information and find it useful; but, that hospital managers perceive doctors as being uninterested in such information. While there are wide variations between the two countries and between their hospitals in data collection and information systems, most hospitals surveyed could make better use of utilization information to influence physician practice patterns.

Testosterone treatment of constitutional delay in growth and development: effect of dose on predicted versus definitive height

The outcome of treatment in 3 groups of boys with constitutional delay in growth and development given monthly intramuscular injections of testosterone enanthate 200 mg (22 subjects) 100 mg (10 subjects) and 50 mg (12 subjects) was compared with the outcome in a control group (14 subjects) without treatment. The 4 groups were similar in chronological age, height, height age, bone age, height age/bone age ratio, pubertal development and had similar predicted adult heights. All treated subjects achieved an excellent growth response with growth velocities reflecting androgen dose. Bone age advanced commensurate with height age in all the treated groups and delta height age/delta bone age ratios at the end of therapy did not differ significantly. Nor was there a significant difference in the height prediction by the RWT method before and at the end of treatment. However, the year following treatment, growth velocities reversed so that those who received the largest steroid dose and had grown the fastest, decelerated the most and eventually ended up significantly shorter than their predicted adult height. In contrast the control group and those treated with smaller doses of testosterone achieved their predicted heights. The present study confirms that large doses of androgens compromise adult height and are contraindicated in the treatment of constitutional delay in growth and development. Testosterone enanthate 50 mg/mo did not affect predicted adult height adversely, but to the contrary, permitted it to be fully realised. The data caution against drawing conclusions based on changes observed during androgen therapy in the absence of extended follow-up.

Continuous infusion of insulin vs repeated S.C. injections in the treatment of diabetic ketoacidosis in children

Thirty-two episodes of diabetic ketoacidosis in 30 children treated with conventional repeated s.c. injections of insulin every 4 h are compared with 18 episodes in 14 children treated with continuous i.v. insulin infusion. Fluid therapy, bicarbonate and potassium supplementation were essentially the same for both groups. Recovery as reflected in serum glucose, bicarbonate and the rate of rehydration, was smoother and more rapid in the children receiving continuous i.v. insulin, though the difference just failed to attain statistical significance in this small series of cases. There was, however, a marked difference in insulin administered (0.58 U/kg +/- 0.05 SEM in the children treated with continuous i.v. insulin infusion vs 2.54 +/- 0.27 SEM in the children treated with repeated s.c. injections). Hypoglycemia was noted in 11 and hypokalemia in 10 children on conventional insulin therapy given every 4 h s.c. In contrast, there was no hypoglycemia and only one case of hypokalemia with the i.v. insulin infusion.