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.

The "athletic heart". Prevalence and physiological significance of left ventricular enlargement in distance runners

To evaluate the prevalence and importance of "physiological" left ventricular hypertrophy (LVH) in athletes, 30 marathon runners were studied. Electrocardiographic evidence of LVH, present in 24 subjects, was associated with concomitant echocardiographic evidence of a thickened left ventricular (LV) posterior wall in five, with an enlarged end-diastolic LV diameter in three, as well as with roentgenographic evidence of cardiomegaly in three subjects. Echocardiographic evidence of superior LV function was noted in six. Maximal treadmill stress provoked no ischemic change. Cardiac hypertrophy and dilatation commonly develop in well-conditioned athletes, but the changes in LV size are slight. This "physiological" type of LVH does not lead to an ischemic response during exercise, in contrast to that which is seen in pathological forms of LVH. Physiological LVH may, however, contribute to superior ventricular function.

Marked depth of ST-segment depression during treadmill exercise testing; indicator of severe coronary artery disease

This study was designed to evaluate whether treadmill stress testing would facilitate selection of patients with advanced coronary artery disease and, specifically, whether markedly abnormal ischemic responses could be used as indicators of severity of disease. Among 59 consecutive patients with documented coronary artery disease having both maximal treadmill testing and coronary angiographic studies, 15 (group 1) had normal responses to exercise, 18 (group 2) showed 1 to 2.9 mm "ischemic" (flat or downward-sloping) ST-segment depression, and 26 (group 3) demonstrated marked (or equal to 3 mm) ischemic responses. Group 3 had statistically significant higher incidences of triple-vessel disease (18/26; 69 percent) and proximal lesions of the left anterior descending coronary artery (24/26; 92 percent), compared with group 1 (2/15 and 10/15, respectively) and group 2 (6/18 and 12/18, respectively). Group 3 also manifested more extensive disease than groups 1 and 2 (judged by scoring system of Friesinger et al), with a score of 11 or more in 18 of 26 patients. We conclude that marked depth of "ischemic" ST-segment depression aids in identifying that subgroup of the coronary population with severe coronary artery disease and, therefore, serves as a useful means of culling out patients with a potentially serious prognosis who might benefit from intensive diagnostic or therapeutic interventions.

Amelioration of hypoglycemia in a patient with malignant insulinoma during the development of the ectopic ACTH syndrome

A patient with functioning islet cell carcinoma is described who had amelioration of her hypoglycemia during the development of ectopic ACTH syndrome. Moon facies and hyperkalemic metabolic acidosis were also present in this patient, features uncommonly seen in the actopic ACTH syndrome. At autopsy, she was found to have active tuberculosis. Prophylactic antituberculous therapy should be given to high-risk patients with the ectopic ACTH syndrome. High doses of ACTH may be palliative in refractory hypoglycemic states.

Inefficacy of "therapeutic" serum levels of digoxin in controlling the ventricular rate in atrial fibrillation

Although therapeutic and toxic serum concentrations of digoxin have been established, there is sparse information permitting correlation of drug level with clinical effect. This study was undertaken to assess the radioimmunoassay serum digoxin levels in 30 patients with acute atrial fibrillation (38 determinations) and 30 patients with chronic atrial fibrillation (54 determinations). Those with chronic fibrillation were subdivided into those in clinically stable condition (14 patients), and those seriously ill and in clinically unstable condition (16 patients). Slowing of ventricular rate in patients with stable, chronic atrial fibrillation was accomplished in 10 of 16 instances by "therapeutic" and "subtherapeutic" levels of digoxin (less than 2 ng/ml). Ventricular rate was "controlled" (65 to 95 beats/min) with therapeutic levels of serum digoxin in only five instances of acute atrial fibrillation and seven of unstable chronic atrial fibrillation. In 43 studies (23 of acute atrial fibrillation, 20 of chronic atrial fibrillation), a rapid ventricular rate (95 to 140 beats/min) persisted in the presence of "therapeutic" or high levels of digoxin. Thirty-nine of these were in patients who were seriously ill with conditions such as infection, hypoxia or recent thoracotomy. Slowing of the ventricular rate required "toxic" concentrations of digoxin (2.5 to 6 ng/ml) in 15 instances. We conclude that sufficient amounts of digoxin to achieve "therapeutic" serum concentrations may fall to lower the ventricular rate in atrial fibrillation to less than 100 beats/min, especially when a serious, complicating illness coexists.