Fine tuning of the DNAM-1/TIGIT/ligand axis in mucosal T cells and its dysregulation in pediatric inflammatory bowel diseases (IBD).

De-regulated T-cell activation and functions are pivotal in the orchestration of immune-mediated tissue damage in IBD. We investigated the role of DNAM-1 (co-activating)/TIGIT (co-inhibitory)/ligand axis in the regulation of T-cell functions and its involvement in IBD pathogenesis. We show that DNAM-1 and TIGIT display a peculiar expression pattern on gut mucosa T-cell populations, in a microenvironment where their shared ligands (PVR and Nectin-2) are physiologically present. Moreover, DNAM-1 family receptor/ligand system is perturbed in IBD lesions, in a disease activity-dependent manner. The expression profile of CCR6 and CD103 mucosa addressins suggests that microenvironment-associated factors, rather than skewed recruitment of circulating T-cell populations, play a more relevant role in supporting the establishment of DNAM-1 and TIGIT expression pattern in mucosal T-cell populations, and may explain its alteration in IBD. Although both co-receptors mark functionally competent T cells, DNAM-1 and TIGIT segregate on T cells endowed with different proliferative potential. Moreover, their opposing role in regulating T-cell proliferation exquisitely depends on ligand availability. All together, our data propose a role for DNAM-1 and TIGIT in regulating mucosal T-cell activation and immune homeostasis, and highlight the involvement of an imbalance of this system in IBD.

Measurement of the parity-violating asymmetry in inclusive electroproduction of π- near the Δ0 resonance.

The parity-violating (PV) asymmetry of inclusive π- production in electron scattering from a liquid deuterium target was measured at backward angles. The measurement was conducted as a part of the G0 experiment, at a beam energy of 360 MeV. The physics process dominating pion production for these kinematics is quasifree photoproduction off the neutron via the Δ0 resonance. In the context of heavy-baryon chiral perturbation theory, this asymmetry is related to a low-energy constant d(Δ)- that characterizes the parity-violating γNΔ coupling. Zhu et al. calculated d(Δ)- in a model benchmarked by the large asymmetries seen in hyperon weak radiative decays, and predicted potentially large asymmetries for this process, ranging from A(γ)-=-5.2 to +5.2 ppm. The measurement performed in this work leads to A(γ)-=-0.36±1.06±0.37±0.03 ppm (where sources of statistical, systematic and theoretical uncertainties are included), which would disfavor enchancements considered by Zhu et al. proportional to V(ud)/V(us). The measurement is part of a program of inelastic scattering measurements that were conducted by the G0 experiment, seeking to determine the N-Δ axial transition form factors using PV electron scattering.

Surgical management of morbidity due to lymphatic filariasis: the usefulness of a standardized international clinical classification of hydroceles.

The objective of this work is to evaluate the usefulness of a standardized clinical classification of hydroceles in lymphatic filariasis endemic countries to guide their surgical management. 64 patients with hydroceles were operated in 2009-2010, in Level II hospitals (WHO classification), during two visits to Fiji, by the same mobile surgical team. The number of hydroceles treated was 83. We developed and evaluated a much needed clinical classification of hydroceles based on four criteria: Type (uni/bilateral); Side (left/right); Stage of enlargement of the scrotum rated from I to VI; Grade of burial of the penis rated from 0 to 4. It lead to the conclusion that 1) A Stage I or II hydrocele, associated with Grade 0 or 1 penis burial could be considered a "Simple Hydrocele". The surgical treatment is simple with no anticipated early complication. WHO Level II of health care structure seems adapted. 2) A Stage III or IV hydrocele associated with Grade 2, 3 or 4 penis burial could be considered a "Complicated Hydrocele". The operation is longer, more complicated and the possibility of occurrence of complications seems greater. A level III health care facility would be more adapted under the normal functioning of the health system. We conclude that a standardized clinical classification of hydroceles based on the Stage of enlargement of the scrotum and the Grade of burial of the penis appears to be a useful tool to guide the decision about the level of care and the surgical technique required. We use the same classification for penoscrotal lymphoedema. A decision tree is presented for the management of hydroceles in lymphatic filariasis endemic countries which could usefully complement the "Algorithm for management of scrotal swelling" proposed by WHO in 2002. An international classification system of hydroceles would also allow standardization and facilitate study design and comparisons of their results.

Surgical management of morbidity due to lymphatic filariasis: The usefulness of a standardized international clinical classification of hydroceles

Abstract. The objective of this work is to evaluate the usefulness of a standardized clinical classification of hydroceles in lymphatic filariasis endemic countries to guide their surgical management. 64 patients with hydroceles were operated in 2009-2010, in Level II hospitals (WHO classification), during two visits to Fiji, by the same mobile surgical team. The number of hydroceles treated was 83. We developed and evaluated a much needed clinical classification of hydroceles based on four criteria: Type (uni/bilateral); Side (left/right); Stage of enlargement of the scrotum rated from I to VI; Grade of burial of the penis rated from 0 to 4. It lead to the conclusion that 1) A Stage I or II hydrocele, associated with Grade 0 or 1 penis burial could be considered a “Simple Hydrocele”. The surgical treatment is simple with no anticipated early complication. WHO Level II of health care structure seems adapted. 2) A Stage III or IV hydrocele associated with Grade 2, 3 or 4 penis burial could be considered a “Complicated Hydrocele”. The operation is longer, more complicated and the possibility of occurrence of complications seems greater. A level III health care facility would be more adapted under the normal functioning of the health system. We conclude that a standardized clinical classification of hydroceles based on the Stage of enlargement of the scrotum and the Grade of burial of the penis appears to be a useful tool to guide the decision about the level of care and the surgical technique required. We use the same classification for penoscrotal lymphoedema. A decision tree is presented for the management of hydroceles in lymphatic filariasis endemic countries which could usefully complement the “Algorithm for management of scrotal swelling” proposed by WHO in 2002. An international classification system of hydroceles would also allow standardization and facilitate study design and comparisons of their results.

Parasellar myxoid chondrosarcoma: a rare variant of cranial chondrosarcoma.

Primary cranial chondrosarcoma in an uncommon cartilaginous tumours of which the myxoid variant is the least reported in the literature. This tumour accounts for 0.15% of all primary intracranial lesions and 6% of all skull base tumours. Chondrosarcomas are frequently misdiagnosed as chordomas, which have a different prognosis. Differential diagnosis is very important because, when treated with similar aggressive treatment strategies, chondrosarcoma has a much better prognosis than chordoma. We describe a 54-year-old female with a 9-month history of left ophtalmoplegia and increasing headache. MR imaging of the head showed a sellar and left parasellar mass. We performed a gross total removal of the mass via a left pterional approach. The histopathologic diagnosis was of a myxoid chondrosarcoma. A post-operative contrast-enhanced computed tomography (CT) scan of the head showed a total removal of the neoplasm. After surgery, the patient showed a transitory dysphasia with right hemiparesis, but they both considerably improved before discharge. Review of the literature was identified using the Medline database: only 10 cases in the worldwide literature were identified to report on this kind of tumour. We present a case report of myxoid chondrosarcoma, a rare variant of chondrosarcoma, with sellar and left parasellar localization. This histopathological type is a low-grade variant and its total removal is effective.

Transverse beam spin asymmetries at backward angles in elastic electron-proton and quasielastic electron-deuteron scattering.

We have measured the beam-normal single-spin asymmetries in elastic scattering of transversely polarized electrons from the proton, and performed the first measurement in quasielastic scattering on the deuteron, at backward angles (lab scattering angle of 108°) for Q² = 0.22 GeV²/c² and 0.63 GeV²/c² at beam energies of 362 and 687 MeV, respectively. The asymmetry arises due to the imaginary part of the interference of the two-photon exchange amplitude with that of single-photon exchange. Results for the proton are consistent with a model calculation which includes inelastic intermediate hadronic (πN) states. An estimate of the beam-normal single-spin asymmetry for the scattering from the neutron is made using a quasistatic deuterium approximation, and is also in agreement with theory.

Strange quark contributions to parity-violating asymmetries in the backward angle G0 electron scattering experiment.

We have measured parity-violating asymmetries in elastic electron-proton and quasielastic electron-deuteron scattering at Q2=0.22 and 0.63 GeV2. They are sensitive to strange quark contributions to currents in the nucleon and the nucleon axial-vector current. The results indicate strange quark contributions of approximately < 10% of the charge and magnetic nucleon form factors at these four-momentum transfers. We also present the first measurement of anapole moment effects in the axial-vector current at these four-momentum transfers.

Estudio comparativo de dos programas rurales / A comparative study of two rural programs

El objetivo del presente trabajo fue evaluar dos programas rurales realizados en niños que concurren a escuelas de Caraguatay, provincia de Misiones. Sobre una población de 40 niños de 7 años que se encuentran bajo programa de atención integral 1, con los primeros molares permanentes erupcionados, se realizó 1: 1- historia clínica, 2- cepillado mecánico y diagnóstico dentario. La muestra de 40 niños se dividió en dos grupos: Grupo 1 (n=20) al cual se le realizó 1 aplicación anual de bifloruro de amonio, y Grupo 2 (n=20) aplicación de selladores de fosas y fisuras. El examen basal registró: Grupo 1: CPOD, 0.15 +- 0.36; CPOS: 0,15 +- 0.36; Grupo 2: CPOD: 0.65 +- 0.30; CPOS: 0.65 +- 0.18. El examen al año registró: Grupo 1: CPOD: 0.45 +- 0.15; CPOS: 0.45 +- 0.15. Grupo 2: CPOD: 1.5 +- 0.30; CPOS: 1.5 +- 0.30. A los dos años la evaluación del programa registró para losmismos grupos una media para el componente C de 0.40 +- 0,18 en el grupo 1 y de 0.60 +- 0.13 para el Grupo 2, sin diferencias significativas entre ambos grupos. Luego de dos años de programa con aplicación de barniz de bifluoruro de amonio entre el 10 por ciento y el 40 por ciento de los molares reigstraron remineralización en los surcos mientras que el Grupo 2 al cabo de 2 años entre el 25 por ciento y el 60 por ciento mantuvo el sellador. Conclusión: en ambos programas rurales, la aplicación de barnices fluorados y de selladores de fosas y fisuras resultó efectiva para el control del componente C del CPOD

Estudio comparativo de dos programas rurales / A comparative study of two rural programs

El objetivo del presente trabajo fue evaluar dos programas rurales realizados en niños que concurren a escuelas de Caraguatay, provincia de Misiones. Sobre una población de 40 niños de 7 años que se encuentran bajo programa de atención integral 1, con los primeros molares permanentes erupcionados, se realizó 1: 1- historia clínica, 2- cepillado mecánico y diagnóstico dentario. La muestra de 40 niños se dividió en dos grupos: Grupo 1 (n=20) al cual se le realizó 1 aplicación anual de bifloruro de amonio, y Grupo 2 (n=20) aplicación de selladores de fosas y fisuras. El examen basal registró: Grupo 1: CPOD, 0.15 +- 0.36; CPOS: 0,15 +- 0.36; Grupo 2: CPOD: 0.65 +- 0.30; CPOS: 0.65 +- 0.18. El examen al año registró: Grupo 1: CPOD: 0.45 +- 0.15; CPOS: 0.45 +- 0.15. Grupo 2: CPOD: 1.5 +- 0.30; CPOS: 1.5 +- 0.30. A los dos años la evaluación del programa registró para losmismos grupos una media para el componente C de 0.40 +- 0,18 en el grupo 1 y de 0.60 +- 0.13 para el Grupo 2, sin diferencias significativas entre ambos grupos. Luego de dos años de programa con aplicación de barniz de bifluoruro de amonio entre el 10 por ciento y el 40 por ciento de los molares reigstraron remineralización en los surcos mientras que el Grupo 2 al cabo de 2 años entre el 25 por ciento y el 60 por ciento mantuvo el sellador. Conclusión: en ambos programas rurales, la aplicación de barnices fluorados y de selladores de fosas y fisuras resultó efectiva para el control del componente C del CPOD (AU)

Estudio epidemiológico en niños preescolares de 5 años de edad de una comunidad urbana de riesgo social / An epidemiological study of 5-year-old preschool children from an urban community at social risk

El objetivo de este trabajo fue caracterizar el perfil epidemiológico bucal de niños preescolares que concurren a un jardín de infantes de nivel inicial dependiente del gobierno de la ciudad de Buenos Aires. Sobre 150 niños de 5 años se realizó: (1) historia clínica, (2) índice de placa (IP) e índice gingival (IG) según Loe y Silness, (3) cepillado mecánico y a continuación examen clínico para establecer el estado dentario y registro documental (ceod). Se obtuvo la media y error estándar de las variables analizadas y se realizó x2 y coeficiente de correlación de Spearman. Los resultados revelaron un ceod de: 7.35 +- 0.31 y los c, eo fueron de: 6.58 +- 0.31, 0.35 +- 0.076 y 0.42 +- 0.098 respectivamente. El ceos de 13.20 +- 0.75 y los componentes cs, es. os. fueron de 10.72 +- 0.65, 1.73 +- 0.38 y 0.74 +- 0.17. El CPOD de 0.32 +- 0.18 y el componente C 0.32 +- 0.18. El CPOS fue de 0.36 +- 0.21 y el componente Cs, de 0.36 +- 0.21. El índice de placa fue de 1.09 +- 0.058 y el índice gingival de 0.58 +- 0.06. En el 5.3 por ciento de los niños no se registraron caries. Se registraron asociaciones y correlaciones significativas entre: ceod e IP: X2:35.11 rho:0.53 (p<0.001); ceod e IG (X2: 12.07 p <0.001 rho: 0.35 p < 0.0001); componente C e IP (X2:35.53 rho: 0.54 p <0.0001); componente C e IG (X2: 14.13 rho: 0.42 p < 0.001); ceos e IP (X2: 26.43 rho: 0.49 p<0.0001); ceos e IG (X2: 7.35 p<0.01 rho:0.54 p<0.0001); componente cs e IG (X2: 13.12 p<0.001 rho: 0.40 p<0.0001). Los niños preescolares presentaron elevada prevalencia de caries. El 5.3 por ciento de los niños no presentaron caries. El 84.7 por ciento de los niños presentaron ceod > a 4

Estudio epidemiológico en niños preescolares de 5 años de edad de una comunidad urbana de riesgo social / An epidemiological study of 5-year-old preschool children from an urban community at social risk

El objetivo de este trabajo fue caracterizar el perfil epidemiológico bucal de niños preescolares que concurren a un jardín de infantes de nivel inicial dependiente del gobierno de la ciudad de Buenos Aires. Sobre 150 niños de 5 años se realizó: (1) historia clínica, (2) índice de placa (IP) e índice gingival (IG) según Loe y Silness, (3) cepillado mecánico y a continuación examen clínico para establecer el estado dentario y registro documental (ceod). Se obtuvo la media y error estándar de las variables analizadas y se realizó x2 y coeficiente de correlación de Spearman. Los resultados revelaron un ceod de: 7.35 +- 0.31 y los c, eo fueron de: 6.58 +- 0.31, 0.35 +- 0.076 y 0.42 +- 0.098 respectivamente. El ceos de 13.20 +- 0.75 y los componentes cs, es. os. fueron de 10.72 +- 0.65, 1.73 +- 0.38 y 0.74 +- 0.17. El CPOD de 0.32 +- 0.18 y el componente C 0.32 +- 0.18. El CPOS fue de 0.36 +- 0.21 y el componente Cs, de 0.36 +- 0.21. El índice de placa fue de 1.09 +- 0.058 y el índice gingival de 0.58 +- 0.06. En el 5.3 por ciento de los niños no se registraron caries. Se registraron asociaciones y correlaciones significativas entre: ceod e IP: X2:35.11 rho:0.53 (p<0.001); ceod e IG (X2: 12.07 p <0.001 rho: 0.35 p < 0.0001); componente C e IP (X2:35.53 rho: 0.54 p <0.0001); componente C e IG (X2: 14.13 rho: 0.42 p < 0.001); ceos e IP (X2: 26.43 rho: 0.49 p<0.0001); ceos e IG (X2: 7.35 p<0.01 rho:0.54 p<0.0001); componente cs e IG (X2: 13.12 p<0.001 rho: 0.40 p<0.0001). Los niños preescolares presentaron elevada prevalencia de caries. El 5.3 por ciento de los niños no presentaron caries. El 84.7 por ciento de los niños presentaron ceod > a 4 (AU)

Left ventricular diastolic impairment during coronary arteriography with a non-ionic contrast medium.

AIM: The aim of this study was to assess the influence of coronary arteriography with the use of a non-ionic low molecular monomer (iopromide) on left ventricular function. METHODS: Fifty consecutive patients with coronary artery disease (CAD) and normal left ventricular ejection fraction were studied by coronary arteriography for a stable or unstable coronary syndrome by using iopromide. They were divided into 2 groups: group 1, patients with one vessel disease; group 2, patients with multiple vessel disease. A >50% reduction of the lumen diameter by on-line quantitative angiography was considered a significant coronary stenosis. Coronary arteriography was performed by hand injection of 5 ml of iopromide avoiding the use of nitrates during the procedure. Doppler echocardiography monitoring was performed immediately before the coronary arteriography and at the end of the last coronary injection. The following parameter were recorded: E peak velocity (E) (cm/s), A peak velocity (A) (cm/s), E/A ratio, E deceleration time (EDT) (ms), isovolumic relaxation time (IRT) (ms), and left ventricular ejection fraction (EF) (%). RESULTS: No complications were observed during the procedures. A mean amount of 40+/-8 ml of iopromide was used. No significant variation of heart rate and arterial pressure was shown during coronary arteriography. No changes were observed either for E, A, E/A ratio or for left ventricular EF in any group of patients. A significant increase of EDT and IRT in comparison with baseline values was documented only in group 2 (from 140+/-77 to 199+/-44 and from 98+/-33 to 144+/-44, p<0.01), returning to baseline values after 10+/-3 minutes. A positive correlation was observed between EDT and IRT shift from baseline values (r=0.77; p<0.01). CONCLUSION: In conclusion, iopromide temporarily impairs left ventricular diastolic dynamics during selective coronary angiography, but only in patients with multivessel CAD.

Occipital condyle fractures: a hidden nosologic entity. An experience with 10 cases.

INTRODUCTION: To report the incidence, treatment and outcome of occipital condyle fractures (OCFs) based on the experience of a single neurosurgical department over a period of two years. MATERIAL AND METHODS: From April 1999 to April 2001, ten cases of OCFs were identified in 110 cervical traumas observed over a period of two years. Patients were studied by cervical x-rays, high-resolution CT scan with a 1-2 mm slice of the cranio-cervical junction (CCJ) and MRI in selected cases to evaluate the integrity of supporting ligaments. According to the Anderson and Montesano classification, 5 cases of type III, 3 cases of type II and 2 cases of type I fractures were found. Dysfunction of lower cranial nerves was observed in 8 cases. Treatment was conservative in all cases. RESULTS: At follow-up, ranging from 18 months to 2 years, fusion was obtained in all cases; 8 patients were neurologically intact, one patient presented a mild persistent dysphonia and another mild trapezius weakness. CONCLUSION: OCFs are actually not rare, rather they are often overlooked. In cases of high-energy trauma of the cervical spine, the diagnostic suspicion should be kept in mind.High-resolution CT scan with slice at 1-2 mm of the CCJ is the key radiological examination in the diagnosis of this lesion. Conservative treatment using a hard collar is sufficient to obtain sound fusion.

[Campaign to eradicate yaws on Santo Island, Vanuatu in 2001]. / Campagne d'éradication du pian sur l'île de Santo, Vanuatu 2001.

At the beginning of the 1960s a campaign was carried out to eradicate endemic trepanematosis in the South Pacific. During the year 2000, twenty cases of yaws were diagnosed on Santo Island in Vanuatu. Recrudescence of this disease was confirmed by a seroprevalence testing showing 20.9% positive VDRL in 273 serum tests. In view of these findings, the Health Minister in collaboration with the WHO office in Vanuatu undertook mass benzathine-benzylpenicilline treatment in the population of the Santo and Malo (SANMA) province. The objective was to treat at least 85% of the population. Treatment was administered to 36,414 of the 39,397 inhabitants identified in 587 villages during the campaign, i.e., 92.4%. Coverage varied from 87.6 to 97.3% depending on the zone. Positive VDRL was obtained in 96 of the 230 serum samples collected for suspicion of yaws. All documented cases of yaws were found in the southeastern part of the island. Treatment had a dramatic effect on lesions within 24 hours. Cooperation of the population and involvement of mobile units and primary health-care providers were key factors in the success of this campaign. Further action will include training of health care workers and improvement of sanitary conditions in villages. Seroprevalence testing to assess the effectiveness of this campaign is to be carried out in 2003.

Percutaneous closure of patent foramen ovale: pathophysiology, indications, and technique.

The percutaneous closure of patent forame ovale (PFO) is currently performed in patients with cryptogenic stroke or paradoxical systemic embolism. The availability of new user friendly devices and the increase in knowledge of the pathophysiology, epidemiology, and follow-up of these patients has broadened the indications and drastically reduced the morbidity related to the intervention. This review considers the main pathophysiological and epidemiological features of PFO and discusses the indications and results of the intervention.

The direct measurement of 3-beta-hydroxy butyrate enhances the management of diabetic ketoacidosis in children and reduces time and costs of treatment.

In this study the effectiveness of a quantitative test of beta-hydroxybutyrate (beta-HBA) against a commercial test for urine ketone bodies (UKB) in monitoring diabetic ketoacidosis (DKA) was evaluated to verify whether this ketone-testing method was able to reduce the monitoring costs and professional burden of nurses and physicians. Thirty-three children with severe (arterial pH < or = 7.2) or moderate (7.2 < pH < or = 7.3) DKA were studied. Sixteen patients were randomly monitored with blood beta-HBA (group 1) and 17 by UKB (group 2). Contrary to UKB, beta-HBA levels appeared correlated with: HbA1c values on admission (r = 0.99; p = 0.0001); latent period before diagnosis of diabetes (r = 0.95; p = 0.0001); changes in arterial pH (r = -0.82; p = 0.0001) and blood bicarbonate values (r = -0.63; p = 0.001) during the treatment for DKA. Required time to achieve the resolution of ketosis in group 1 patients was related to the values of beta-HBA on admission (r = 0.84; p < 0.001). Determination of beta-HBA showed that ketosis in group 1 patients cleared 4 to 9.5 hours earlier than in group 2. Due to this early normalization, the patients of group 1 left the Intensive Care Unit 6.5 +/- 1.5 hr earlier than those of group 2. This led to 22 hr saved for clinical assessment and 375 laboratory investigations for a total saving of 2940 euros including costs for laboratory tests (29.8%) and clinical assessment (70.2%). Quantitative determination of beta-HBA levels seems to offer useful information for monitoring DKA in newly-diagnosed diabetic children and for reducing time and costs in an Intensive Care Unit.

Restenosis after NIR stent implantation.

The NIR stent is a "second-generation" slotted-tube stent that was developed after the Palmaz Schatz and the Gianturco-Roubin stents, and introduced into clinical practice in 1992. This review of the literature describes its clinical performance and the long-term outcomes after implantation in different anatomical and clinical subsets of patients. It also considers clinical experience with the gold-plated NIR stent.

[Diabetes and alternative medicine: diabetic patients experiences with Ayur-Ved, "clinical ecology" and "cellular nutrition" methods]. / Diabete e medicia alternativa. Tre esperienze di trattamento con metodi di "Ayur-Ved", "ecologia clinica" e "nutrizione cellulare."

In the last two years we discovered that three of our patients with type 1 diabetes mellitus (0.8%) suffered an unexpected worsening in their glycemic control due to a reduction of their insulin dosage in favour of some "alternative" diabetes treatments using herbs, vitamins, fantastic diets and trace elements prescribed by non-medical practitioners. The first patient, a 6.6 year old boy, was admitted to hospital because of a severe ketoacidosis with first degree coma as a result of his parents having reduced his insulin dosage by 77% and replacing the insulin with an ayurvedic herbal preparation (Bardana Actium Lapp). The second patient, a 10.4 year old boy, was admitted to hospital after his teachers noticed that he appeared tired, thinner and polyuric. During hospital admission for mild ketoacidosis the mother, reluctant at first, finally confessed that her son was under the care of a "clinical ecologist". Having identified several food allergies this "clinical ecologist" had placed the child on a spartan diet of bread, water and salt, and had reduced his insulin dosage by 68%. The third patient, a 21 year old male, upon transfer to the Adult Diabetic Center, reported that he had been under the care of a pranotherapist for several years. The pranotherapist had prescribed a cellular nutrition preparation (called "Madonna drops"), a meditation program and also a 50% reduction in his insulin dosage. During this period his HbAlc values had increased from 6.4% to 12%. Current orthodox diabetes treatments are considered unsatisfactory by many people and it is thus not surprising that they search for "miracle" cures. It is important, however, that hospital staff do not ridicule the patients or their parents for trying these alternative therapies. Nevertheless, it would be useful for staff to discuss in advance these "therapies" with patients, highlighting their ineffectiveness and strongly discouraging cures that call for a reduction or elimination of the insulin treatment.