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Editor’s comment : The commentary by Dr. Grajower has such important clinical relevance that responses were invited from the three pharmaceutical companies that supply insulin in the U.S. and the American Diabetes Association, and all of these combined in this commentary. The commenting letter and individual responses were authored separately and are completely independent of each other. Diabetic patients treated with insulin, whether for type 1 or type 2 diabetes, are prone to often unexplained swings in their blood glucose. These swings can vary from dangerously low to persistently high levels. Most diabetic patients, and most physicians, will adjust insulin regimens so as to avoid hypoglycemia at the expense of hyperglycemia. Among the “textbook” reasons for variable glucose responses to any given insulin regimen are 1 ) site of administration, 2 ) exercise, 3 ) bottles not adequately mixed before drawing the insulin (for NPH, Lente, or Ultralente), and 4 ) duration of treatment with insulin (1). A new insulin was marketed by Aventis Pharmaceuticals about 1 year ago, insulin glargine (Lantus). The manufacturer seemed to stress that patients not use a started bottle of this insulin for >28 days (2). Two patients of mine highlighted this point. L.K. is a 76-year-old woman with type 2 diabetes, diagnosed at 55 years of age, and treated with insulin since age 56. Her insulin regimen was changed to Lantus at night together with Novolog before meals. She monitors her blood glucose four times a day. She used a bottle of Lantus until it ran out; therefore, a bottle lasted for 2 months. Her recent HbA1c was 7.6%. I retrospectively analyzed her home glucose readings by averaging her fasting blood glucose levels for the first 15 days of a new bottle and the last 15 days of that same bottle. The results were 137 ± …

SUMMARYAlthough the embryonic development of the liver is complex and the early embryonic organ is multilobular, accessory lobes of the liver are very rare.Because these accessory lobes are quite small and usually on the undersurface of the liver, before necropsy, they have made their presence known

IN FASHIONING a colostomy one should consider the extent of serosa exposure; this should be kept at a minimum to prevent serositis. The complications of ileostomy are well known; its "maturation" was shown by Crile and Turnbull 1 to be completed when infection of the serosa subsides. Difficulties of the ileostomy stoma were lessened by covering the serosa with skin, as advocated by Dragstedt et al. , 2 and, better, by simply cutting the stoma off flush with the skin and sewing it, leaving no serosa exposed. As is attested by the relative paucity of complications from colostomy stomas, the serosa of the large bowel must be more resistant to infection than the serosa of the ileum; however, a similar "maturation" can take place, especially if a large amount of serosa is exposed for a prolonged time. Report of Cases The following cases illustrate serositis developing in colostomy stomas. Case

Recent clinical observations and animal experiments1have shown that prolonged administration of cortisone produces adrenal atrophy. According to the adaptation syndrome of Selye,2adrenal atrophy in turn may lessen the body's ability to withstand trauma and stress. One might suspect that patients receiving cortisone would not normally withstand major surgery; yet every day patients are successfully undergoing surgery while regularly taking cortisone in both the preoperative and postoperative periods. We wish to present the record of a patient who, while receiving a prolonged course of cortisone therapy, underwent a major operation, cup arthroplasty of the hip, and died of immediate postoperative shock, in spite of normally adequate, aggressive antishock therapy. Postmortem examination revealed marked bilateral adrenal atrophy and other conditions consistent with shock. REPORT OF A CASE A 34-year-old man had had rheumatoid arthritis for a period of seven years. Almost every joint of his body was involved