Sarcoidosis in Europe: a cooperative study.

The data on the epidemiologic situation of sarcoidosis from 24 countries of Europe have been reviewed. The new facts seem to demonstrate that the differences between the frequency of this disease in the north and south are not real. The actual situation is dependent on the general knowledge of this disease and on the extent and intensity of the active detection of its asymptomatic stage. A new prospective cooperative study of the yearly incidence of all forms of sarcoidosis in the total population of at least some European countries would be desirable.

Sarcoidosis in Yugoslavia.

Although the first case of sarcoidosis in Yugoslavia was described immediately before the World War II, it was not before the 50's and the 60's that the disease started to be more frequently discovered. According to the evidence of pulmologic centres throughout the country, the incidence of sarcoidosis in 1988 was found to be the lowest in Macedonia (0.4 per 100,000 inhabitants). Since 1970, Yugoslavia has had its own Kveim-Siltzbach antigen, used in over 3000 patients. International World and European conferences on sarcoidosis aroused greater interest for sarcoidosis in Yugoslavia, particularly the Third European Conference on Sarcoidosis held in Novi Sad in 1980. Consequently, the Yugoslav Association on Sarcoidosis as an integral part of the WASOG has been organized this year.

Sarcoidosis in Eastern Europe.

When analysing the data on sarcoidosis in Eastern Europe, it is seen that the incidence of sarcoidosis considerably varies in respect to individual countries, as is also the case in West Europe. The highest incidence was observed in GDR (12.0) and the lowest one in Poland (1.26). Data on the incidence could be obtained for Hungary (4.3), Czechoslovakia (3.5) and Yugoslavia (2.5), while for the Soviet Union, Romania, Turkey (Istanbul), Bulgaria and Greece there are only data for certain districts, with the exception of Albania where these data are thoroughly unknown. In all countries of Eastern Europe, sarcoidosis generally appears in persons aged 29-50, predominantly in the group of those aged 29-40. In respect to sex, the disease is more frequently diagnosed in women, the incidence of which ranges from 53% in Lithuanian SSR to 69.5% in Hungary. Acute forms (Löfgren's syndrome) account for 9% in Poland and 24% in Yugoslavia.

Clinical and epidemiological aspects of allergic alveolitis.

Clinical and epidemiological aspects as well as classification of allergic alveolitis were discussed. Clinical features were divided into three stages: initial, chronic and terminal. Each stage was described with clinical signs, radiological, angiographical and with lung functional aspects. Epidemiological data of allergic alveolitis in Yugoslavia were given.

[Bronchoplastic surgery in bronchial cancer]. / Bronchoplastische Operation bei Bronchialkarzinom.

Conservative resection is applied in cases with central localisation of the tumour in the surrounding lymph nodes are not affected by the malignant process. This surgery is of great importance for patients with restricted respiratory function if pneumonectomy is contraindicated or is performed under enhanced risk. A total of 29 surgeries were performed on the bronchial system. Blood vessel resection was simultaneously done in two of the cases. Frozen section biopsy was obligatorily performed. In one case atelectasis was an early complication that was resolved by bronchoaspiration. In a thirty-day long postoperative period one (3.4%) of the patients died because of profound intrathoracic bleeding.

Where to incise and/or divide the cystic duct.

The study concern was to establish the position of cystic duct incision/division in circumstances of laparoscopic cholecystectomy. Seventy consecutive human cadavers were dissected. Corrosion casting (50) and post-mortem cholangiography (20) were employed. Cystic duct length was 34.6 mm, and in 88.6% cases its length was 1-5 cm. Mean cystic duct diameters next to the gallbladder neck, within the valve and 5 mm proximal to the junction with the common hepatic duct were 1.95, 0.42 and 1.85 mm, respectively. Lateral cysto-hepatic junction was identified in 78.6%, spiral in 10% and parallel in 10%. In 90% cases the cysto-hepatic junction is within 4 cm of the hepatic duct junction. One case (1.43%) of cystic duct entering the right hepatic duct was identified. The valve of Heisteri consisted of three spiral turns in 73% of the cases with a range from 0 to 5. In 3/70 specimens the spiral valve did not exist.

Is splenic lobe/segment dearterialization feasible for inferior pole trauma during left hemicolectomy?

We discuss splenic salvage by lobe/segment dearterialization, without resection, after intraoperative trauma, and present two cases. We performed a retrospective analysis of 163 patients in whom the colon splenic flexure was mobilized. Patients with ileo-rectal anastomosis or urgent cases were excluded. Surgical operations included left hemicolectomy and anterior resection of the rectum. Splenic procedures were splenorrhaphy, dearterialization and splenectomy. Spleen lesions occurred in 4 (2.45%) cases. One capsular tear was managed with splenorrhaphy. Three mechanical lesions to capsula and tissue of the inferior pole were managed by either splenectomy (the first case) or dearterialization. Overall mortality in the series was 4.3%. Among the patients with splenic procedures, the splenectomized patient died due to pulmonary embolism. The two cases treated by inferior splenic branch and inferior polar artery ligature are presented. In operative trauma to the inferior splenic pole, bleeding can be controlled by lobe/segment dearterialization and by methods of local hemostasis in most cases.

[Subclinical disorders of left ventricular function in diabetics detected by echocardiography]. / Supklinicki poremecaj funkcije leve komore srca kod dijabeticara otkriven ehokardiografskim ispitivanjem.

In diabetic patients, without coronary heart disease and hypertension, left ventricular filing dysfunction exist, that is registered by echocardiography. It is manifested as greater peak flow velocity during atrial systole and as shorter time from the aortic second heart sound to the peak of the early diastolic flow velocity curve. The diastolic dysfunction indicates increased left ventricular stiffness and may be the first maker of diabetic cardiomyopathy.

[The evaluation of the Kveim test in sarcoidosis diagnostics for out-patients (author's transl)]. / Der Wert des Kveimtestes in der ambulanten Diagnostik der Sarkoidose

In a total number of 113 cases the Kveim test was performed. The antigen used was produced in the institute for pulmonary diseases and tuberculosis, Novi Sad, Yugoslavia. Patients with sarcoidosis had positive results in 65.8%, including 19.5% doubtful positive cases. In a special group of patients with sarcoidosis, who received corticosteroids at the same time, only 25.7% showed positive results. In a control group of 24 cases no positive result was observed. The Kveim test is an useful method for diagnostic purpose in out-patients. Further investigations for improvement of this method will be necessary.

[Surgery of rectal ampulla adenoma]. / Hirursko lecenje adenoma ampule rektuma.

It is necessary to diagnose and excise the adenoma of the mucous of the large intestine as early as possible in order to prevent the development of rectal carcinoma. The surgery techniques (according to Kraske and Mason) applied by the authors make it possible. Over the period from 1983 to 1990 these techniques were carried out in 37 operations of rectal adenoma. The main symptom of the disease was the appearance of mucus and sometimes of blood in faeces. The following examinations were performed during the preoperative course: digital, rectoscopic, sigmoidoscopic; several biopsies of the lesion and its surrounding tissue were made. Histopathological diagnosis obtained preoperatively was confirmed postoperatively in 32 cases. Only in 5 patients preoperative findings did not coincide with the postoperative findings. In one case the final diagnosis was adenocarcinoma, and the preoperative finding was villous-uvular adenoma. In 4 cases the preoperative findings revealed the existence of tubulous-glandular tumour, while the final diagnosis showed the early invasive carcinoma. In later operations the rectal amputation was performed in 2 cases, and rectal anterion resection in 3 cases. The recidives appeared in 3 patients during the first year after the operation. Two of them were from the villous-uvular group, and one was from the gland-uvular group. During reintervention the rectal amputation was performed twice, and resection of rectosigma once. During the postoperative course 7 spontaneously disappeared fistulae reappeared. No incontinence. Postoperative electromyographic, laboratory and rectoscopic examinations of the patients were performed each third month, during the two following years. We used Kraske and Mason operative technique in the villous adenoma operations. These villous adenomas were 2-3.5 cm long and located in the middle of the upper third of rectal ampulla, while the upper verge did not cover more than 13 cm of dental line.

Demonstration of an antigenic component in Kveim antigen.

Anti-Kveim-antigen serum was obtained by immunizing rabbits with Kveim antigen from lymph nodes and spleen in complete Freund's adjuvant. In the Ouchterlony test and in counter-immuno electrophoresis, a precipitation band with Kveim antigen from spleen and lymph nodes was demonstrated after absorption of the antiserum with serum and extracts of normal lymph nodes and spleen.

[Local recidives after rectal tumour operations]. / Lokalni recidivi kod bolesnika operisanih od karcinoma rektuma.

Patients with recidives after operations for rectal tumours have better prognosis than those with recidives of other gastro-intestinal tumours. Over the period from 1 January 1983 to 1 January 1990 165 patients were operated for rectal tumours (76 females and 89 males) in Dr. Dragisha Mishovitsh Clinical and Hospital Centre. On the basis of the size of rectal tumours, their position, penetration into the wall and intraoperative status surgical treatment was carried out: local ecxision (15), posterior proctotomy (37), anterior resection (64) and rectal amputation (49). In our practice we used the international classification of the tumours (pathohistology and clinical stages), UNIA INTERNATIONALIS CONTRA CANCRUM, internationally recognized on 1.1.1984. We quarterly controlled our operated patients during the first two years: rectoscopic, laboratory, EMG anal sfincter, EHO and CT abdomen, IVP examinations were performed. In patients with rectal adenocarcinoma we performed immunological examinations (CEA and CA 50) before operation, after operation and in the second year (first month and sixth month). All postoperative control examinations were important in the early detection of recidives and future treatment. We detected recidives in our patients during the first year (12), and only two in the second year after operation. We established four recidives after rectal amputation: one UICC stage II and 3 UICC stage III; 5 recidives after anterior resection: 4 UICC stage II and 1 UICC stage III; 3 recidives after posterior proctotomy: 2 UICC stage I and 1 UICC stage II, and 2 recidives after transanal excision: both recidives UICC stage I.

[Histological findings after application of Kveim antigen in animals (author's transl)]. / Histologische Befunde nach Applikation von Kveimantigen im Tierversuch.

The frequence of local granulomatous changes after injection of kveim antigen and previous sensibilisation (Freund's adjuvant, BCG-vaccine, atypical mycobacteria, implantation of sarcoidotic lymph nodes, human-gamma-globulin of sarcoidotic patients) was investigated in 69 mice and 38 guinea pigs. Granulomata with epitheloid and giant cells, resembling a "positive Kveim reaction" were found in 26% of the mice and 18% of the guinea pigs. Doubtful positive results were observed in 7% of the mice and 5% of the guinea pigs. A high percentage of non-specific foreign body reactions was observed in guinea pigs (82%), relatively scarcely in mice (16%). The most effective method for sensibilisation of the animals is the administration of Mycobacterium avium to guinea pigs or of Kveim antigen with complete Freund's adjuvant and the intraabdominal implantation of sarcoidotic lymph node material to mice.

[Report on the application of various Kveim antigens in diagnostic of sarcoidosis (author's transl)]. / Bericht über die Anwendung verschiedener Kveim-Antigene in der Sarkoidose-Diagnostik.

In the Institute for Pulmonary Diseases and Tuberculosis, Novi Sad, a total number of 1500 patients was tested with a Kveim antigen prepared in this institute. Simultaneously these patients were tested with other antigens (SILTZBACH, BEHREND, DOUGLAS). Almost identical results could be found. In patients with sarcoidosis the Kveim test was positive in 60 to over 90%, depending on the stage of the disease. Within a cooperation 230 patients of the Research Institute for Pulmonary Diseases and Tuberculosis, Berlin-Buch, were tested with several Kveim antigens since 1972. 2/3 of these patients were suffering from sarcoidosis. All patients received Kveim antigen prepared in Novi Sad; one part of them was also tested with Kveim antigens prepared in Berlin-Buch. Dependent on the quality of the material processed the percentage of positive results was different. They varied from 65 to 30%. If there were less granulomas in the original material, as for the tissue of a spleen, used in Berlin-Buch, only 30% of sarcoidosis patients showed positive results. Therefore it is profitable to analyse the difficulties and the possibilities of improving the Kveim test as a valuable and rather simple diagnostical method.

[Sarcoidosis in children in East Germany compared to its frequency in the Yugoslavian Socialist Republic]. / Sarkoidoseerkrankungen bei Kindern in der DDR im Vergleich zur Häufigkeit in der SFR Jugoslawien.

Sarcoidosis in children is very rare. Especially asymptomatic cases are scarcely known. Sometimes extrapulmonary cases are found. These need a therapy with cortisone derivates. The danger of a false diagnosis is very high if it is based only on a X-ray film. A histological examination seems important. The cooperation between pediatrician and pneumologist is considered as important especially when the grown up patients pass on from pediatric care to the supervision of the pneumologist.