Liver diseases in diabetes mellitus]

In a number of 3,554 clinically manifest diabetics who were admitted for the treatment of metabolism or other diseases from 1967 to 1974 12.1 per cent of hepatopathies were found. In men the incidence was 15.2 per cent, in women 10.7 per cent. Among these the fatty degeneration of the liver (28.8 per cent) and the cirrhosis (17.4 per cent) were most frequent. Referred to the entirety the result was an incidence of cirrhosis of 2.1 per cent. The confirmation of the diagnosis is performed by biopsy and endoscopy in 92 per cent. In 60 per cent of the examined persons the diagnosis was unknown before admission. There was no correlation to the duration of the diabetes. In the number of patients there appeared above all persons older than 50 to 60 years. The following concomitant diseases occurred: hypertension (33 per cent), coronary diseases (32 per cent), pyelonephritis (17 per cent) and adiposity (13 per cent).     

Multisystem involvement in chronic liver disease. Studies on the incidence and pathogenesis

Sjögren's syndrome occurred in 37 per cent, renal tubular acidosis in 32 per cent, pulmonary diffusion defects in 26 per cent and peripheral neuropathy in 10 per cent of patients with active chronic hepatitis, primary biliary cirrhosis or cryptogenic cirrhosis. The incidence of certain other conditions determined from clinical features alone was lower; these included arthropathy in 14 per cent, thyroid disorders in 10 per cent, skin lesions in 17 per cent and colitis in 5 per cent. In the complete series of 218 patients, 125 (57 per cent) had involvement of at least one organ other than the liver, such involvement being significantly more common in those with active chronic hepatitis (63 per cent of cases) and primary biliary cirrhosis (68 per cent) than in those with cryptogenic cirrhosis (38 per cent). In a number of patients, prednisone therapy was followed by both subjective and objective improvement in the features of the multisystem involvement.No correlation could be found between multisystem involvement and the presence of mitochondrial, smooth muscle or antinuclear antibodies in the serum or with the serum levels of immunoglobulins A (IgA), M (IgM) and G (IgG). Histologie examination of the various organs disclosed dense infiltration with small lymphocytes, suggesting that delayed hypersensitivity reactions were involved in the production of tissue damage. In support of this was the demonstration of cell-mediated reactivity in vitro to salivary or renal antigens in 42 per cent of the patients with Sjögren's syndrome and in 62 per cent of those with renal tubular acidosis, respectively.These findings, together with the frequency and similar pattern of multisystem involvement in the three conditions, suggest a common pathogenetic mechanism, and disordered cellular immune reactions directed primarily against the liver could affect other organs as a result of cross antigenicity.     

A note on the incidence of pectoral alopecia

Summary and conclusions Pectoral alopecia was found to be present in 26 per cent of an average sampling of the male hospital population exclusive of hepatic and endocrine disease. However, this was observed to be far more frequent in the Negro than the white groups—46 and 16 per cent, respectively. The total incidence of pectoral alopecia in a group of 34 white and 6 Negro patients with cirrhosis was only 20 per cent. In every instance alopecia had always been present and antedated the liver disease.It is concluded that pectoral alopecia is a common constitutional variant in hair distribution of the normal male population, that it is far more frequent in Negroes than in whites, and is unrelated to chronic liver disease, despite traditional views.     

Hepatic Histological Changes in Ulcerative Colitis

Operative liver biopsy was performed on 58 consecutive patients coming to radical excisional surgery for ulcerative colitis.

The histological changes seen in the liver were: increased cellularity of the portal tracts (83 per cent); fatty infiltration (83 per cent); areas of focal necrosis (47 per cent); and early cirrhosis (2 per cent).

Severe liver damage was shown to he associated with severe active colitis, and with a poor subsequent post-operative prognosis. The mechanisms responsible for liver damage in patients with colitis are discussed.     

Studies of the serum and urine constituents in patients with cirrhosis of the liver during water tolerance tests

Water tolerance tests were made in normal subjects and in patients with cirrhosis of the liver, without and with ascites. The capacity of the patients with cirrhosis to excrete ingested water was diminished. Normal subjects excreted 100 per cent of the ingested water in 180 minutes. In patients with cirrhosis of the liver without ascites, 100 per cent excretion of the ingested water did not occur during the test and at 180 minutes 80 per cent of the water had been excreted. In the patients with cirrhosis and ascites the average amount of the ingested water excreted by the end of the test was only 32 per cent.The minute volume of urine was depressed during the entire test in the patients with ascites. In the patients without ascites the minute volume decreased sharply once the peak of diuresis was reached. The decrease in the capacity of the patients with cirrhosis to excrete water was also observed following the intravenous administration of 5 per cent glucose.The concentration of sodium chloride in the serum fluctuated during the tests and the changes were greater in the patients with cirrhosis than in the normal subjects. In the patients with cirrhosis there was an increase of 3 per cent or more in the serum level of NaCl at the time the minute volume of urine was decreasing. It is suggested that this increase in sodium chloride may have served to stimulate the osmoreceptors, causing a discharge of the antidiuretic hormone. It is, therefore, possible that an increased secretion of the antidiuretic hormone is partly responsible for the decreased urine output in patients with cirrhosis of the liver and that the inability to excrete water, by contributing to the retention of fluid, is a factor in the production of ascites.     

Primary liver carcinoma -- clinical picture and diagnostic possibilities. A review of seventy-five cases.

A study was performed on a group of 75 patients with primary liver carcinoma (PLC) treated at the 1st Medical Department in Prague during past 24 years. The average age of patients when they died was 59.9 years. 86.7 per cent of the patients were men; in 88.0 per cent of cases PLC was associated with liver cirrhosis. It was found that the frequency of PLC incidence is increasing. Case histories, subjective complaints and laboratory findings were analyzed in these patients. The diagnostic contribution of some examination methods was evaluated (laparoscopy with the aimed liver biopsy in 50% of the cases, isotopic methods in 34.6% of cases, roentgenologic methods in 36.0% of cases, detection of alpha-1 fetoprotein in serum in 55.5% of cases). The analysis of causes of death was also performed. Histologic classification proved the hepatocellular carcinoma in 94.6 per cent of patients, the cholangiocellular carcinoma was found only in 4 patients. The agreement of clinical diagnoses with the pathologic-anatomical diagnosis was found in 70.6% of cases.     

Incidence of portal vein thrombosis in liver cirrhosis. An angiographic study in 708 patients

Portal vein thrombosis was thought to be a common complication of liver cirrhosis in the past. The incidence of angiographically demonstrable portal vein thrombosis was studied in 708 consecutive patients with unequivocal cirrhosis seen in the past 10 yr in whom either transhepatic portography or superior mesenteric arterial portography clearly delineated the major portal vein system. Excluding 2 cases that were thought to be associated with past splenectomy, there were 4 cases of portal vein thrombosis related to cirrhosis, all in a decompensated stage. The calculated incidence of portal vein thrombosis was 0.573% of all cirrhotic patients without splenectomy in the past. They constituted 23.5% of the 17 cases of extrahepatic portal vein obstruction encountered during the same period. There were 78 cases of idiopathic portal hypertension similarly studied angiographically, and the incidence of portal vein thrombosis unrelated to splenectomy was 2.86%. A statistical survey based on 247,728 necropsies recorded in the Japan Autopsy Registries of 1975-1982 showed a 0.05489% incidence of portal vein thrombosis and a 6.58857% incidence of cirrhosis of all types among them, suggesting that portal vein thrombosis is not a common complication of cirrhosis in Japan in recent years.     

Hepatitis B surface antigen in various liver diseases in Iraq

In a series of 221 patients with various liver diseases studied in Iraq using counterimmunoelectrophoresis and passive haemagglutination techniques, HBsAg was detected in 40.8 per cent of cases with acute viral hepatitis, in 40 per cent in cryptogenic cirrhosis, in 50 per cent in chronic hepatitis, in 100 per cent in active cirrhosis and 71.4 per cent in hepatoma. In acute hepatitis the antigenaemia was highest early in the course of the disease. The duration of antigenaemia ranged from three to 16 weeks. In 3.4 per cent of cases the antigenaemia persisted for more than 35 weeks. In 31.3 per cent of acute hepatitis there was no evidence of parenteral infection.     

Effect of Treatment for CHC on Liver Disease Progression and Hepatocellular Carcinoma Development in African Americans

Background and Aims: African Americans (AA) historically have a low response rate to hepatitis C therapies, and there is limited information available for this patient population regarding the development and treatment of chronic hepatitis C (CHC). The aim of this study was to evaluate liver disease progression and hepatocellular carcinoma (HCC) development in AA with CHC. Methods: Between 1995 and 2008, 246 AA patients with CHC were identified from a database of patients and followed until 2012-2013 (average 8 years) or the development of HCC after 2008. Results: Viral clearance (intent to treat; sustained virus response (SVR)) was achieved in 15% of patients with interferon based therapies with or without ribavirin. AA patients who achieved an SVR (n=22) did not develop HCC or new onset cirrhosis, whereas the HCC incidence in untreated AA patients was 23% (51/203). Patients who achieved an SVR also had improved fibrosis, as defined by the AST Platelet Ratio Index (APRI) and Fibrosis-4 (FIB-4) score, relative to nonresponders and untreated patients. Conclusions: The severity of liver disease at the first visit (except for cirrhosis) correlated with the development of HCC, but because of the overlap in values between patients, these measurements were not useful for predicting individual risk. Since cirrhosis at the first visit was not a predictive factor, treatment with newer antiviral therapies is the best option for reducing the incidence of advanced liver disease and its harmful outcomes in the AA population.     

The liver in consecutive patients with morbid obesity: a clinical, morphological, and biochemical study

Liver morphology and biochemistry were investigated in 61 morbidly obese subjects selected by defined criteria. Median overweight was 82 per cent (range 61 to 170 per cent), and median duration of overweight was 20 years (range two to 45 years). No patient had more than a moderate alcohol consumption and only one was diabetic. Four biopsies (7 per cent) showed normal liver tissue, while fatty change was the main diagnosis in most cases (85 per cent). Increasing degrees of fatty change was significantly (P less than 0.02) associated with presence of lipogranulomas (found in 54 per cent of the biopsies), focal necroses (found in 28 per cent), slight parenchymal inflammation (found in 33 per cent), and Kupffer cell proliferation (found in 49 per cent). Slight portal inflammation was seen in 23 per cent but portal fibrosis in only 2 per cent of the biopsies. No case of cirrhosis was registered. Patients with moderate or severe fatty change, lipogranulomas , focal necroses or with parenchymal inflammation were significantly more obese than patients without these changes (P less than 0.05). Even in absence of fatty change, obese subjects showed a markedly decreased serum albumin concentration and an elevated serum alkaline phosphatase activity (P less than 0.0001) compared with non-obese controls. Serum lactate dehydrogenase and aspartate aminotransferase were significantly raised only in patients with fatty change. With respect to serum bilirubin and plasma cholesterol concentrations no significant differences were detected between patient subgroups and controls.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hepatobiliary diseases associated with serum antimitochondrial antibody (AMA)

In an attempt to define the clinical spectrum of hepatobiliary disease associated with antimitochondrial antibody (AMA), 41 female and four male patients with AMA were investigated. On the basis of clinical criteria, 22 patients had primary biliary cirrhosis (group I), seven had extrahepatic biliary obstruction (group II) and 16 had other liver diseases including chronic active hepatitis, cryptogenic cirrhosis and minor abnormalities of liver function (group III). Elevations of serum cholesterol, alkaline phosphatase and bile acid levels separated the patients with primary biliary cirrhosis from those with miscellaneous liver disease, whereas in those with extrahepatic biliary obstruction results were intermediate. The cholestatic syndrome of primary biliary cirrhosis was further defined by a cholic to chenodoxycholic acid ratio > 1.0 which was found in 75 per cent of the patients with primary biliary cirrhosis but in none of those with miscellaneous liver disease. No significant differences in AMA titers or immunoglobulin M (IgM) levels were found between the groups, indicating that these tests are not correlated with cholestatic liver disease. Examination of liver tissue revealed features which were compatible with the clinical impression in the majority of cases. Cholelithiasis was present in 33 per cent of the patients. Common bile duct obstruction due to stones and/or stricture was found in six cases and carcinoma in one. Since four had fully developed cirrhosis at the time of presentation, extrahepatic biliary obstruction was probably a result of gallstone disease complicating AMA positive parenchymal liver disease. AMA seems to be a marker for idiopathic parenchymal liver disease, primarily in middle-aged women, but in itself gives no. further diagnostic information and does not exclude extrahepatic biliary obstruction.     

Further Observations on Polycythemia in Hepatocellular Carcinoma

Direct measurement of the red cell mass has confirmed a previous reportof the occurrence of polycythemia in patients with hepatocellular carcinoma.Twenty patients (17 males and 3 females) have been investigated. The redcell mass was increased in 11, normal in 8 and reduced in one. Because ofhypervolemia, present in 15 of the 20 patients investigated and attributable tothe associated cirrhosis of the liver, the hematocrit might be normal in thepresence of an increased red cell mass. A venous hematocrit of 48 per cent andabove was found invariably to be associated with an increase in the red cellmass. Using this criterion, 17 of 145 patients with hepatocellular carcinoma werefound to be polycythemic, an incidence of 11.7 per cent.

Plasma erythropoietic stimulating factor determined by Fe⁵⁹ incorporationinto red cells of fasted rats was not increased in 4 patients with hepatocarcinomaand polycythemia.

These findings are briefly discussed.

Submitted on June 6, 1961 Accepted on August 12, 1961     

Metabolic control of enzymes in normal, diabetic, and diabetic insulin-treated rats utilizing 1,3 butanediol

Diets containing 1,3 butanediol (BD) as a replacement of carbohydrate were fed to normal, diabetic, and diabetic insulintreated rats for two weeks. The diabetic animals fed BD survived longer than the diabetic animals on essentially the same diet without BD. The activities of malic enzyme in 105,000 × g. (1 hour) supernatant fractions of liver were determined. The PEPcK activity in liver was increased by 320 per cent in diabetic and by 240 per cent in diabetic rats fed the BD diet. Insulin decreased the PEPcK activity toward normal. In liver and adipose tissues malic enzyme activity was greatly decreased in diabetic and increased in diabetic insulin treated rats. The incorporation of radioactive bicarbonate into organic acids by liver mitochondrial pyruvate carboxylase and the formation of intermediates for gluconeogenesis were examined. The concentration of metabolites in liver was also examined and all changes were found to be minimal. Oral administration of BD greatly increased blood ketone levels and the ratio of β-hydroxybutyrate to acetoacetate. Normal animals fed BD had significantly lower blood glucose levels. Liver perfused with BD also showed decreased glucose production from lactate. Analysis of metabolites from livers perfused with BD showed a large increase in the lactate to pyruvate ratios (from 13.1 to 81.0). Malate and aspartate were increased, whereas pyruvate, PEP, 2 PGA, and 3 PGA were decreased. It is concluded that BD exerts its hypoglycemic effect at the conversion of malate to oxalacetate and hence to PEP.     

Polycythemia in primary carcinoma of the liver

In a series of 176 consecutive patients with hepatocarcinoma an increasein red cell count and in hemoglobin significantly above normal levels wereencountered in 17 (10 per cent).

An investigation of 28 patients with hepatocarcinoma developing in acirrhotic liver is reported. In three of the patients (10 per cent), the redcell counts and hemoglobin levels were significantly above those encounteredin healthy Chinese.

In these 28 patients it has been shown that the plasma volume is increased,and this increase does not differ significantly from that encountered in uncomplicated cirrhosis of the liver. The total red cell volume, on the otherhand, is significantly greater than in uncomplicated cirrhosis of the liver. Whilethe mean total red cell volume in hepatocarcinoma is not significantly different from that in healthy controls, consideration of this finding in individualpatients shows that it was above normal in 17, normal in six, and in the remaining five it was below normal.

It is concluded that the polycythemia encountered is a true polycythemiasecondary to the development of the hepatocarcinoma. The expanded plasmavolume is considered probably attributable to the pre-existing cirrhosis ofthe liver. Unfortunately, in the course of this investigation we did not encounter a patient in whom the carcinoma had developed in a liver whichwas not cirrhotic.

Submitted on April 8, 1957 Accepted on November 18, 1957     

The influence of diabetes and hypertension on the results of coronary revascularization.

The effects of diabetes and hypertension on the early postoperative course of patients undergoing coronary revascularization were studied by reviewing the records of 177 patients operated upon in 1972. There were 121 nondiabetic, nonhypertensive; 32 hypertensive; ten diabetic; and 14 diabetic-hypertensive patients. The incidence of postoperative low cardiac output, renal insufficiency and arrhythmia was significantly higher in the hypertensive patient. Operative mortality ranged from 0 in diabetic patients, to 0.8 per cent in nondiabetic, nonhypertensives, to 7.1 per cent in diabetic-hypertensives and 12.5 per cent in hypertensive patients, suggesting an increased risk for the hypertensive patient. The one- to two-year follow-up results documented symptomatic improvement in 90.7 per cent of patients with little adverse effect apparent from diabetes or hypertension. Pre- and postoperative coronary angiography was carried out in 103 patients between 1968 and 1973 with a mean elapsed time between operation and postoperative angiogram of 9.3 months. The progression of atherosclerosis was graded on a 0-4 basis in both grafted and ungrafted coronary arteries. While hypertension appeared to contribute to disease progression, the incidence of vein graft and internal mammary artery bypass occlusion was not significantly affected by either diabetes or hypertension. This study has shown that while hypertension contributes to increased morbidity and mortality in the early postoperative period and an increased rate of progression of atherosclerosis, neither diabetes nor hypertension appeared to influence the one- to two-year results of coronary revascularization.     

Incisional hernias following gallstone surgery. A population-based study

BackgroundThe aim of this study was to determine the incidence of incisional hernia (IH) in a population-based cohort following gallstone surgery and to identify associated risk factors.MethodsAll cholecystectomies registered in the Swedish register for cholecystectomy and ERCP from 2006 to 2014 were identified. Data regarding post-procedural development of IH was obtained from the National Patient Register.ResultsA total of 81 964 cholecystectomies were identified. A laparoscopic, open, and minilaparotomy technique was used in 70 031, 10 379 and 1554 procedures, respectively. The five-year cumulative incidence of IH was 1.04 per cent in the laparoscopic group, 3.37 per cent in the open group, and 2.11 per cent in the minilaparotomy group. Obesity (hazard ratio (HR) 4.11, 95 per cent confidence interval [CI] 3.37 to 5.01), open surgical technique (HR 2.97, CI 2.57 to 3.42), liver cirrhosis (HR 2.95, CI 1.58 to 5.51), chronic kidney disease (HR 1.95, CI 1.19 to 3.21), minilaparotomy (HR 1.79, CI 1.23 to 2.60), age > median (HR 1.43, CI 1.25 to 1.65), and chronic pulmonary disease (HR 1.28, CI 1.05 to 1.57) were found to significantly predict the development of IH.ConclusionLaparoscopic cholecystectomy comes with a lower risk of IH compared to open techniques.     

Incidence rates and causes of cirrhosis in a Norwegian population

Objective. To investigate the incidence rate and causes of cirrhosis in a Norwegian population. We also sought to assess the degree of underreporting of cirrhosis to the Norwegian Death Registry. Material and methods. All 1264 patients treated at Aker University Hospital in the period January 1999 to March 2004 who were given a diagnosis indicating cirrhosis, chronic liver disease or symptoms possibly attributable to cirrhosis were screened retrospectively. A search of the registry of histological diagnoses at Department of Pathology was also carried out. Based on the results of histological examinations and non-histological criteria, cirrhosis was confirmed in 194 patients. Calculations of the incidence rate of cirrhosis and frequencies of the various etiologies were based on 93 patients living in the catchment area of the hospital. Causes of death were retrieved from the Norwegian Death Registry. Results. The incidence rate of cirrhosis was 134 per million per year. The majority of cases were due to alcoholic liver disease (53%), followed by viral liver disease (12%), various autoimmune liver diseases (12%), hemochromatosis (4%) and non-alcoholic steatohepatitis (NASH) (3%). No etiology was established in 16%, a group with a high prevalence of diabetes mellitus, indicating that some of these cases were possibly caused by NASH. Among 105 deaths in this cohort of 194 cirrhotic patients, the diagnosis of cirrhosis was absent in the Norwegian Death Registry in 30% of cases. Conclusions. The incidence of cirrhosis in Norway is relatively low, with alcohol as the most important etiologic factor. Significant underreporting to the Norwegian Death Registry was observed.     

Incidence rates and causes of cirrhosis in a Norwegian population

OBJECTIVE: To investigate the incidence rate and causes of cirrhosis in a Norwegian population. We also sought to assess the degree of underreporting of cirrhosis to the Norwegian Death Registry. MATERIAL AND METHODS: All 1264 patients treated at Aker University Hospital in the period January 1999 to March 2004 who were given a diagnosis indicating cirrhosis, chronic liver disease or symptoms possibly attributable to cirrhosis were screened retrospectively. A search in the registry of histological diagnoses at Department of Pathology was also carried out. Based on the results of histological examinations and non-histological criteria, cirrhosis was confirmed in 194 patients. Calculations of the incidence rate of cirrhosis and frequencies of the various etiologies were based on 93 patients living in the catchment area of the hospital. Causes of death were retrieved from the Norwegian Death Registry. RESULTS: The incidence rate of cirrhosis was 134 per million per year. The majority of cases were due to alcoholic liver disease (53%), followed by viral liver disease (12%), various autoimmune liver diseases (12%), hemochromatosis (4%) and non-alcoholic steatohepatitis (NASH) (3%). No etiology was established in 16%, a group with a high prevalence of diabetes mellitus, indicating that some of these cases were possibly caused by NASH. Among 105 deaths in this cohort of 194 cirrhotic patients, the diagnosis of cirrhosis was absent in the Norwegian Death Registry in 30% of cases. CONCLUSIONS: The incidence of cirrhosis in Norway is relatively low, with alcohol as the most important etiologic factor. Significant underreporting to the Norwegian Death Registry was observed.     

The diagnosis of cardiovascular syphilis; analysis of clinical and post-mortem findings

The symptoms and signs of cardiovascular syphilis are discussed. An analysis was made of 61 clinical cases and 78 necropsies; statistics limited to the cases proved post-mortem are presented.The average age at death was 47.9 years. There were but 3 cases under thirty years of age, and only 2 above seventy years.Males outnumbered the females in the ratio of 5.5 to 1.The syphilitic lesions were associated with lesions of nonsyphilitic disease of the heart in 43 per cent of the necropsies.Symptoms of the disease were absent in about one-quarter of the patients in whom the disease was disclosed at necropsy.Pain was present in 28 per cent. It conformed to the syndrome of angina pectoris in but 4 per cent.The mouths of the coronary arteries were partially occluded in 10 patients; none of these had angina pectoris, and 8 were without pain of any sort.Neither the presence nor the character of the pain could be related to the condition of the coronary arteries or of the aorta.The coronary arteries were normal in 58.3 per cent of the series of 24 necropsies.Shortness of breath was common after the onset of congestive failure of the heart.The symptoms of weakness, hoarseness, dysphagia, and fever were absent or were present in a negligible number of these patients. Hoarseness of the voice was noted in but one of seven cases of aneurysm involving the transverse portion of the aortic arch.The duration of the symptoms rarely exceeded a few months in the necropsy cases; it was somewhat longer in the clinical series treated as out-patients. From these latter there is presumptive evidence that adequate therapy may relieve symptoms and prolong life.The manner of death was that of progressive failure of the heart in 79 per cent of the series of 24 necropsies. In 4 of these the actual death was sudden.The heart was enlarged in 22 cases, or 91.6 per cent, of the 24 necropsies. This enlargement was present in the absence of aortic insufficiency in 7, or about one-third of the group. The average weight of the heart was 555 gm.Increase in the supracardiac dulness and other findings above the heart are common, but too often not recorded in the physical examination.A systolic murmur over the precordia or more localized at the apex or base is common. That at the base is not due to roughening of theThe diastolic murmur of aortic insufficiency was noted in 47.4 per cent. In 50 per cent of the 16 aortic regurgitant cases in the series of 24 necropsies the diastolic murmur was transmitted to the apex. aortic valve.This diastolic murmur may be inconstant in its presence in its earlier stages. Its detection sometimes requires painstaking auscultation.Aortic insufficiency was recognizable in half again as many cases as were evident at post-mortem, and in at least three-fourths of the cases (murmur present in life) the regurgitation could not be attributed to lesions of the valve. The insufficiency of the valve is best explained as due to yielding of the muscular ring round the aortic orifice.The apical findings, known as those of Austin Flint, are occasionally present.The aortic second sound may be masked by the murmur of aortic insufficiency, or it may be accentuated in the absence of the murmur and even if the latter is present.A change in the quality (i.e., a tympanic note) may take place in the aortic second sound, but it is difficult to differentiate from that found in arteriosclerosis of nonsyphilitic causation.The Corrigan type of pulse was absent in 5 of 16 cases of aortic insufficiency. That such is possible does not appear to be generally recognized.There is nothing characteristic of the blood pressure save in the presence of aortic insufficiency.Careful physical examination may detect evidence suggestive of syphilis elsewhere in the body.The Wassermann reaction was negative in 10, or 23.87 per cent, of the 42 cases in which it was recorded.The roentgen ray findings are very important aids in the diagnosis. It is unreasonable, however, to expect that the slight lesions in early cases of cardiovascular syphilis can be detected by the roentgen ray. In advanced cases the differential diagnosis from nonsyphilitic conditions may be difficult or impossible solely from the roentgen ray findings.The presence of cardiovascular syphilis was not diagnosed in 44 per cent of this series, although the subsequent necropsy disclosed advanced lesions in one-third of these failures.About one in five of the cases in which the syphilitic lesions were of advanced degree remained undiagnosed in life.     

Prevention strategies and alcohol policy

This paper addresses the potentials of high risk strategy and population strategy far preventing mortality from liver cirrhosis, accidents and suicide. The methodological approach is based on an integration of an empirical distribution of consumption and the risk functions of the damages at issue. According to the findings, the rate of alcohol-induced mortality from the three causes combined would be halved either by a 25 per cent decrease in overall consumption or a 36 per cent decrease in the alcohol consumption of the heavy drinkers (the top 5 per cent). The high risk strategy is most efficient in preventing cirrhosis; however the effect of the population strategy is also quite substantial here. The comparative advantage of the population strategy is most marked in connection with accidents and suicide, but the high risk approach yields an appreciable impact in this context as well. That is, neither of the two strategies appears as dearly superior to the other in terms of efficiency. The high risk strategy thus seems to be a sensible complement to the population strategy, and should have the potential of yielding effects on the population level if implemented on a large scale.