OBJECTIVE -Large prospective studies have demonstrated that optimum glycemic control is not routinely achieved in clinical practice. Barriers to optimal insulin therapy include hypoglycemia, weight gain, and suboptimal initiation and dose titration. This study compared two treatment algorithms for insulin glargine initiation and titration: algorithm 1 (investigator led) versus algorithm 2 (performed by study subjects). RESEARCH DESIGN AND METHODS-A prospective, multicenter (n ϭ 611), multinational (n ϭ 59), open-label, 24-week randomized trial in 4,961 (algorithm 1, n ϭ 2,493; algorithm 2, n ϭ 2,468) suboptimally controlled type 2 diabetic subjects.RESULTS -At baseline, mean diabetes duration was 12.3 Ϯ 7.2 years, and 72% of subjects were pretreated with insulin. At end point, there was no significant difference in the incidence of severe hypoglycemia between algorithms 1 and 2 (0.9 vs. 1.1%). There was a significant reduction in HbA 1c from 8.9 Ϯ 1.3 to 7.8 Ϯ 1.2%, with a greater decrease (P Ͻ 0.001) with algorithm 2 (Ϫ1.22%) versus algorithm 1 (Ϫ1.08%). Fasting blood glucose decreased from 170 to 110 mg/dl, with a greater decrease (P Ͻ 0.001) with algorithm 2 (Ϫ62 mg/dl) versus algorithm 1 (Ϫ57 mg/dl). Mean basal insulin dose increased from 22.9 Ϯ 15.5 to 43.0 Ϯ 25.5 IU, with a significant difference (P Ͻ 0.003) between algorithm 2 (21.6 IU) and algorithm 1 (18.7 IU).CONCLUSIONS -Glargine is safe and effective in improving glycemic control in a large, diverse population with longstanding type 2 diabetes. A simple subject-administered titration algorithm conferred significantly improved glycemic control with a low incidence of severe hypoglycemia compared with physician-managed titration.

Initial clinical experience in the UK with maggot therapy for the treatment of necrotic or infected wounds has proved very encouraging. Sterile larvae have been reared in the Surgical Materials Testing Laboratory for this purpose. This paper reports the use of larvae in six patients and discusses some of the advantages and disadvantages of this form of therapy.

Compared with NPH insulin + unmodified human insulin, the combination of insulin glargine with a rapid-acting insulin analogue as multiple-injection therapy for Type 1 diabetes improves overall glycaemic control as assessed by HbA1c and 24-h plasma glucose monitoring to a clinically significant degree, together with a reduction in nocturnal hypoglycaemia.

The primary objective was to eliminate other causes before labelling it Martorell's ulcer. It was therefore arranged for her to have full blood count, liver, thyroid and renal function tests, C-reactive protein, erythrocyte sedimentation rate, antinuclear factor, rheumatoid factor, anti-mitochondrial antibodies, anti-thyroid antibodies, glucose and chest X-ray. The wound was dressed with an alginate and arrangements were made for weekly review.At her next appointment no significant wound changes were noted and a 6-mm punch biopsy was taken from the wound edge. Results of previous tests were unremarkable. Histology report from the punch biopsy supported a diagnosis of Martorell's ulcer. The report revealed no evidence of vasculitis or neoplastic disease and showed a medium-sized artery with intimal and medial hypertrophy (figure 1). On the basis ofthe report the patient's ulcer, during her third visit, was dressed with an alginate soaked in Brilliant Green (1% aqueous solution).By the patient's fourth visit wound dimensions were found to be half the original, the ulcer was reported to be less painful and the patient stated that she could sleep at night without being disturbed by pain. Further consultation was arranged on a fortnightly basis until complete wound closure had been achieved (week 14: figure 2). It was during this period that the literature was reviewed and the specificity debate re-addressed. Literature reviewThe ulcer has been thought to be caused by obliterating lesions of small arterioles.2 These lesions were held to be consistent with lesions found in other localities in essential hypertension (eg, narrowing of retina and renal arterioles). Whilst slight local trauma was felt to be significant to the development of arteriolar lesion and subsequent ulceration it has been acknowledged that the ulcers also develop in the absence of trauma.Histology' of these ulcers show an increase in the size of the arteriolar wall (hypertrophy of media musculature; enlargement of intima; figure 1) and a decrease in the diameter of the lumen tending to luminal stenosis. Occasionally hyalinosis of the media (figure 3), obliteration of the lumen by thrombi or on 7 May 2018 by guest. Protected by copyright.

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