The overall prevalence of CVD in these IDDM patients was approximately 10%, increasing with age and duration of diabetes and with a sixfold variation between different European centers. CVD prevalence was most strongly associated with elevated triglyceride and decreased HDL cholesterol concentrations. CVD was also associated with albuminuria, but when adjusted by age, this association vanished. Increasing waist-to-hip ratio was associated with a number of adverse characteristics, particularly in IDDM men, reflecting the metabolic syndrome previously described in other populations.

In seven insulin-dependent diabetic subjects the disappearance rate of 125I-labelled short-acting insulin from injection sites in the abdominal wall was 86% greater than from the leg (P less than 0.005) and 30% greater than from the arm (P less than 0.05). Absorption from the arm was 40% greater than from the leg (P less than 0.05). The postprandial rise in plasma glucose concentration varied inversely with the rate of insulin absorption and was 30 to 50 mg/dL less after abdominal than after leg injection; the glycemic response after arm injection was intermediate between that after leg and abdominal injection. These results indicate that changing the insulin injection site from the leg to the abdomen or arm accelerates the absorption of insulin and diminishes the postprandial rise in plasma glucose. Varying insulin injection sites within the same anatomic region rather than between different regions may diminish daily variations in insulin absorption and in metabolic control in insulin-dependent diabetic subjects.

No abstract

The Miller-Fisher variant of acute idiopathic polyneuropathy (Landry-Guillain-Barre syndrome) is characterised by external ophthalmoplegia, ataxia, and areflexia.1 Though the syndrome is usually benign, progressive motor and respiratory impairment necessitating ventilatory support has been reported.2 The anatomical basis of this condition and its relation to the Landry-Guillain-Barre syndrome is contentious.3 We report a case with clinical and radiological evidence of a cerebellar parenchymal lesion and progressive respiratory impairment that responded appreciably within six hours of plasmapheresis on day 8 of the illness. Case report A previously well 14-year-old boy presented two weeks after a mild respiratory illness with a two-day history of diplopia and ataxia. Examination showed minimal external ophthalmoplegia, bilateral mydriasis, prominent horizontal phasic nystagmus on abduction, vertical nystagmus on supraduction, and truncal ataxia. All deep tendon reflexes were absent despite

Spontaneous haemoperitoneum is an uncommon but dramatic surgical emergency. In areas with a high incidence of hepatoma it often results from rupture of the tumour.' Control of bleeding in such patients is often difficult, and the mortality is high.' 2 We report on three patients with ruptured hepatoma who were successfully treated by injection of alcohol. Case reportsCase I-A 60 year old woman had a laparotomy for severe abdominal pain and shock, at which 2 litres of blood was drained from the peritoneal cavity. The liver was cirrhotic with an extensive nodular tumour encasing the porta hepatis. The tumour had ruptured with brisk bleeding from a 3 cm crater. Absolute alcohol (20 ml) was injected directly into the crater. The area blanched immediately, and the bleeding stopped. The postoperative period was uneventful except that she had a swinging fever for five days. She was discharged on the eighth postoperative day. She remained well for 10 months but died 14 months after surgery of extensive hepatoma.Case 2-A 27 year old man presented with severe epigastric pain, shock, and peritonism. Laparotomy showed a 10 cm tumour at the dome of the right lobe of the liver. It had ruptured and was bleeding; 2 -5 litres of blood was drained from the peritoneal cavity. There was also a 5 cm tumour in the left lobe. Alcohol (50 ml) was injected into the ruptured tumour. Bleeding was controlled. He had low grade fever for five days postoperatively and was discharged on the eighth postoperative day. He died seven weeks later of disseminated carcinomatosis and liver failure.Case 3-A 53 year old man who was known to have a hepatoma suddenly developed severe abdominal pain and shock. At laparotomy an 8 cm ruptured hepatoma with profuse bleeding was found. The liver was severely cirrhotic. Ligation of the hepatic artery slowed but did not stop the bleeding. Absolute alcohol (40 ml) was injected into the lesion, and the haemorrhage stopped. He had swinging fever and a tachycardia for two days after the operation. He was discharged 21 days after operation. There was no evidence of rebleeding. He returned with disseminated carcinomatosis four weeks later and died seven weeks after the episode of bleeding. CommentResection of the affected lobe of the liver has been recommended as the treatment of choice for a ruptured hepatoma whenever possible.' Unfortunately, few patients are suitable candidates for resection because either the tumour is too extensive or the liver is too cirrhotic. Ligation of the hepatic artery stops the bleeding but is associated with a mortality from liver failure of 50%.2 In suitable patients angiographic embolisation can stop the bleeding without an operation.3 This, however, requires a highly skilled radiologist, who may not be readily available at all hours in all hospitals.Endoscopic injection of alcohol has been used to stop bleeding from oesophageal varices and peptic ulcers.4 Absolute alcohol stops bleeding by a process of dehydration and fixation of the tissues followed by thrombosis of the blood vessels...