Shoe size was checked in 70 diabetics and 50 general medical patients. Thirty‐seven percent of the diabetics were wearing tight shoes compared with 24% of general medical patients (P=0.05). The wearing of tight shoes was associated with callosities in those with diabetic neuropathy. Callosities were present in three out of the six patients with neuropathy who wore tight shoes, but in none of the 16 who wore correct shoes (P<0.05).

Mental dullness after thrombolytic therapy 349 Final diagnosis Intracerebral haemorrhage complicating thrombolytic therapy for acute myocardial infarction.

A74-year-old woman with insulin-dependent diabetes was admitted to the medical high dependency unit with a 2-day history of increasing nausea and confusion. On examination she was afebrile, dehydrated and confused. Systemic examination was unremarkable. Capillary blood glucose by self-monitoring strip was 10.6 mmol/litre and urinalysis demonstrated 3+ ketones and 3+ glucose. Biochemical examination revealed plasma glucose 11.9 mmol/litre, sodium 127 mmol/litre, potassium 5.1 mmol/litre, urea 13.9 mmol/litre and creatinine 87 mmol/litre. Arterial blood gas analysis showed pH 7.30, partial pressure of carbon dioxide = 4.4 kPa, partial pressure of oxygen = 9.0 kPa, bicarbonate = 15.3 mmol/litre, base excess -9.2 mmol/litre and oxygen saturation 97%. She was treated with intravenous dextrose-saline and low dose insulin infusion. She made a good recovery and was well within 48 hours of presentation.

Long distance air travel which involves crossing time zones can cause problems with insulin dosage and timing. During the summer of 1993, 16 insulin-treated patients who sought advice about crossing time zones were advised to change to a pre-meal short-acting insulin regimen during their flight. Patients taking twice-daily insulin were individually advised and took between 15% and 20% of their total daily dose as short-acting insulin with each main meal. No intermediate-or long-acting insulin was given. They were encouraged to monitor blood glucose levels frequently, to make minor adjustments where necessary and to return to their usual regimen when their daily routine had returned to normal. Patients found this system easy to apply and were satisfied with it. No significant problems were encountered.

A patient developed a generalized reaction to purified bovine, purified porcine and human insulin. High levels of IgE antibody to bovine, porcine, human emp and human crb insulin were demonstrated. These fell dramatically following desensitization with human crb insulin. All four types of insulin gave superimposable RAST inhibition curves indicating a common allergen determinant.