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AMYLOID IN BALKAN NEPHROPATHY
676 AMYLOID IN BALKAN NEPHROPATHY
SIR,-Following up our previous papers on Balkan nephropathy, 1we briefly report here our observations with new techniques in 36 cases. When lesions
were not too
advanced,
a
few normal,
or even
hyperactive-looking, glomeruli adjoined greatly changed ones (fig. 1, a). These showed an almost completely fibrosed capillary tuft, a stratified fibrous capsule, and hardly any 1.
2.
Craciun, Em. C., Georgescu, L., Rosculescu, I., Cirnaru, S., Petrescu, G. Symposium on Endemic Nephropathy; p. 87. Sofia, 1965. Craciun, Em. C., Rosculescu, I. Revue med. chir., Jassy, 1967, 71, 157
Fig. 2-Fibrillar
structure
Male;
x
of
an
amyloid deposit
54,000.
The fibrotic layers often included homogeneous to be purely hyaline in composition, but we noticed that not all of it stained accordingly with haematoxylin-eosin, van Gieson’s stain, and periodicacid/Schiff. It contained remnants of argentaffin structures, and was negative to fibrin stains, but reacted as amyloid with methyl-violet, iodine, congo-red, and especially (fig. 1,b and c) thioflavine T and S. Inflammatory periglomerular or interstitial infiltrates were entirely absent in pure cases. Juxtamedullary lesions (fig. 1, a) were usually less advanced, and strongly contrasted with the outer glomeruli (fig. 1, b), were arranged in parallel, dense rows of shrunken, homogeneous bodies, intensively fluorescent with thioflavine. Large spaces remained where tubular rests and isolated abiotrophic epithelia were widely dissociated by acellular fibrosis and a polyblastic cell population. Atrophy and a scavenging cellular reaction (not infectious) were associated in an unusual sequence. Fluorescence decreased in intensity in the order amyloid, acellular fibrosis, basal membranes of shrunken or thyroidised tubules, and lastly the normal fluorescence of elastic tissue of arterial walls. Electron micrographs, performed in 6 cases, showed the structure characteristic for amyloid (fig. 2). Our staining techniques explained the contradictory findings4 on the ageing of pathological protides such as fibrin, hyaline, and amyloid, for the investigation of which fluorescence with thioflavine T seems especially useful,5 because it gives more consistent results than other staining techniques. The differences in amyloid reactions in various organs and conditions6 support the view that each organ and tissue reacts specifically. Whenever possible the diagnosis of Balkan nephropathy should be verified, not only by epidemiological data, but by a full pathological investigation. Only thus can it be differentiated from the reno-urinary complications of infectious, dystrophic, or neoplastic disease in patients from endemic regions. Pathologists should learn more about the earliest nephronic involvement, which might be a clue to the nature of the disease. We suggested that glomerular and peritubular capillaries would be susceptible to autoimmune attack.2 The name, " Balkan nephropathy ", is misleading, because 3. Cohen, A. S., Calkins, E. Nature, Lond. 1959, 183, 1202. Shirahama, T.,
capsular space.
materials; this has been supposed
which
Fig. 1-Renal
cortex
(reduced
to about
two-thirds from magnifica.
tions shown).
(a)-Three glomeruli with severe lesions. Glomerulus below shows apparently normal capillary tuft and unusually dilated capsular space. In between, the destruction oi tubules provoked a scavenging polyblastic reaction ending in sclerosis.
Female; heematin-eosin,
x
200.
(b)-End-stage of amyloid atrophy of glomeruli in intensely fluorescent. Male; thioflavine T; x 80. (c)-Deep renal cortex.
outer
cortex
Fluorescent amyloid is surrounded by less fluorescent, thid capsule, which is, however, more fluorescent than the interstitial tissue and the basal membranes of the shrunken,tubules. Male: thioflavine S: x 400.
Cohen, A. S. J. Cell. Biol. 1967, 33, 679. Lendrum, A. C. Pathologia Microbiol. 1967, 30, 681. Vassar, P., Culling, C. F. A. A.M.A. Archs Path. 1959, 68, 487. Nebut, M., Hartmann, L. Annls Biol. Clin. 1966, 5-6, 703. 6. Delarue, J., Banter, P., Chomette, G., Pinaudeau, Y. Annls. Anat. path. Anat. norm. med.-chir. 1963, 8, 27. 4. 5.
677 the thirty or so villages exclusively affected are situated north and south of the Iron Gates of the Danube, in a somewhat rectangular area of nearly 150 km. wide, in the adjoining parts of Bulgaria, Rumania, and Yugoslavia. The name Danubian endemic familial nephropathy (D.E.F.N.) might better reflect actual knowledge and suggest further inquiries in other countries and continents.’7 We thank Dr. Janet Niven (National Institute for Medical Research) and Prof. A. C. Lendrum (Queens College, Dundee) for
valuable information and practical suggestions.
E. C. CRACIUN S. NICOLESCO C. RAU E. TOMESCU.
V. Babes Institute of Pathology, Bucharest 35, Rumania.
POSTOPERATIVE DEEP-VEIN THROMBOSIS SIR,-Iread with interest the paper on postoperative deepvein thrombosis by Mr. Flanc and his colleagues (March 8, p. 477), particularly their demonstration that the incidence of this complication in elderly patients undergoing major operations is 61 %, and their remark that the thrombus often starts during the operation-I share this belief.
They kindly referred to my joint work on this subject, but I should be obliged if you would let me correct a mistake they have made with regard to it. They say we showed that venous stasis during anaesthesia was prevented by elevation of the legs. In 1964, in a carefully planned trial using one of the patients’ legs as a control to the other, we demonstrated that during a major operation the venous return often slowed as much as it does when the patient is confined to bed for two weeks, and that this stasis could be eliminated by electrically stimulating the calf muscles. We did not test elevation. Then in 1967, in a properly constructed clinical trial on 200 patients undergoing major operations, we proved mathematically that the incidence of deep-vein thrombosis in the control limb, which just lay flat on the table, was much greater than it was in the limb which was electrically stimulated. Moreover, both the fatal emboli in that series came from the unstimulated leg. F. S. A. DORAN. Kidderminster General Hospital, Worcs.
DIPLOMA IN THE HISTORY OF MEDICINE SIR,-Dr. Clarke (March 15, p. 572) rightly draws attention to the sub-department of the history of medicine at University College London where he has been developing teaching and research in the subject since it was established in October, 1966. The phrase which he quotes from my letter was used in the context of the resolution of the International Society of the History of Medicine that a course in the history of medicine should be a regular part of the medical undergraduate’s training. I was present at the discussion of this resolution and I took it to mean a course more closely integrated with the curriculum than the type of lecture course which Dr. Clarke mentions, such as has been given at other schools, including the Middlesex and King’s College. All who are interested in the subject are anxious to support and develop the initiative of the Wellcome Trustees in helping to establish academic departments. Far from competing in any way with this, the Apothecaries’ plans should make it possible for more medical students and others, in London and elsewhere, to learn something of the subject and so provide interested recruits for the sub-department at University College London and for any others which may be established in the coming years. W. S. C. COPEMAN The Worshipful Society of Apothecaries of London, London E.C.4. 7.
Chairman, Faculty of the History of Medicine and Pharmacy.
Lancet, 1966, i, 304.
FIBRINOLYSIS IN CHILDREN WITH CONGENITAL HEART-DISEASE have read with interest the report of Dr. Johnson and Sir her colleagues, who found no coagulation abnormalities in children with cyanotic congenital heart-disease. In 31 children with cyanotic congenital heart-disease (haematocrit 48-88%, arterial oxygen saturation 60-80%), I have studiedthe spontaneous fibrinolytic activity of plasma, plasminogen activity, and antiplasmin activity (all by Marbet’s TABLE I-SPONTANEOUS PLASMALYSIS IN 35 HEALTHY CHILDREN AND 31 CHILDREN WITH CYANOTIC CONGENITAL HEART-DISEASE (C.H.D.)
TABLE II-VALUES FOR AND
ANTIPLASMIN
PLASMINOGEN, IN 35
ACTIVITY
PLASMINOGEN NORMAL
PROACTIVATOR, AND 31
CHILDREN
CHILDREN WITH CYANOTIC C.H.D.
method 3), and the activity of plasminogen proactivator (Blix’s method 4) . The results are shown in tables i and 11. Compared with the healthy control group, I found increased fibrinolytic activity in the diseased children. Plasminogen activity and the activity of plasminogen proactivator also increased significantly. The antiplasmin titre was within normal limits. I did not find correlation between either ha:matocrit value and enzyme activity, or systemic arterial oxygen saturation and enzyme activity. 2nd Department of Pædiatrics, University of Budapest.
B. GOLDSCHMIDT.
FÆCAL BLOOD-LOSS AFTER SODIUM ACETYLSALICYLATE TAKEN WITH ALCOHOI SIR,-Ifeel some rebuttal is required of the rejoinder by Dr. Bouchier and Mr. Williams to Dr. Dobbing’s letter (March 8, p. 528). The points below deserve consideration. (i) Dr. Dobbing’s mean difference can hardly be challenged by citing an experimental error for individual observations of similar magnitude; the influence of the latter on 18 sets of differences of means from 6 sets of observations would be very much smaller. (ii) The inclusion or exclusion of subject 22 critically affects the results of any statistical evaluation; that the cause for the blood-loss was unknown does not mean that it was necessarily attributable to the drugs administered some days earlier, and Dr. Dobbing’s exclusion of this case seems to be the wisest course to follow. (iii) Since a mean daily loss is calculated by dividing the total loss by the number of days, the validity of restoring the mean 1. Johnson, C. A., Abildgaard, C. F., Schulman, I. Lancet, 1968, 2. Goldschmidt, B. Mschr.Kinderheilk. 1968, 116, 140. 3. Jurgens, J. Klinische Methoden der Blutgerinungsanalyse; Stuttgart, 1959. 4. Blix, S. Acta med. scand. 1964. 176. 649.
ii,
660.
p. 242.
SIR,-Following up our previous papers on Balkan nephropathy, 1we briefly report here our observations with new techniques in 36 cases. When lesions
were not too
advanced,
a
few normal,
or even
hyperactive-looking, glomeruli adjoined greatly changed ones (fig. 1, a). These showed an almost completely fibrosed capillary tuft, a stratified fibrous capsule, and hardly any 1.
2.
Craciun, Em. C., Georgescu, L., Rosculescu, I., Cirnaru, S., Petrescu, G. Symposium on Endemic Nephropathy; p. 87. Sofia, 1965. Craciun, Em. C., Rosculescu, I. Revue med. chir., Jassy, 1967, 71, 157
Fig. 2-Fibrillar
structure
Male;
x
of
an
amyloid deposit
54,000.
The fibrotic layers often included homogeneous to be purely hyaline in composition, but we noticed that not all of it stained accordingly with haematoxylin-eosin, van Gieson’s stain, and periodicacid/Schiff. It contained remnants of argentaffin structures, and was negative to fibrin stains, but reacted as amyloid with methyl-violet, iodine, congo-red, and especially (fig. 1,b and c) thioflavine T and S. Inflammatory periglomerular or interstitial infiltrates were entirely absent in pure cases. Juxtamedullary lesions (fig. 1, a) were usually less advanced, and strongly contrasted with the outer glomeruli (fig. 1, b), were arranged in parallel, dense rows of shrunken, homogeneous bodies, intensively fluorescent with thioflavine. Large spaces remained where tubular rests and isolated abiotrophic epithelia were widely dissociated by acellular fibrosis and a polyblastic cell population. Atrophy and a scavenging cellular reaction (not infectious) were associated in an unusual sequence. Fluorescence decreased in intensity in the order amyloid, acellular fibrosis, basal membranes of shrunken or thyroidised tubules, and lastly the normal fluorescence of elastic tissue of arterial walls. Electron micrographs, performed in 6 cases, showed the structure characteristic for amyloid (fig. 2). Our staining techniques explained the contradictory findings4 on the ageing of pathological protides such as fibrin, hyaline, and amyloid, for the investigation of which fluorescence with thioflavine T seems especially useful,5 because it gives more consistent results than other staining techniques. The differences in amyloid reactions in various organs and conditions6 support the view that each organ and tissue reacts specifically. Whenever possible the diagnosis of Balkan nephropathy should be verified, not only by epidemiological data, but by a full pathological investigation. Only thus can it be differentiated from the reno-urinary complications of infectious, dystrophic, or neoplastic disease in patients from endemic regions. Pathologists should learn more about the earliest nephronic involvement, which might be a clue to the nature of the disease. We suggested that glomerular and peritubular capillaries would be susceptible to autoimmune attack.2 The name, " Balkan nephropathy ", is misleading, because 3. Cohen, A. S., Calkins, E. Nature, Lond. 1959, 183, 1202. Shirahama, T.,
capsular space.
materials; this has been supposed
which
Fig. 1-Renal
cortex
(reduced
to about
two-thirds from magnifica.
tions shown).
(a)-Three glomeruli with severe lesions. Glomerulus below shows apparently normal capillary tuft and unusually dilated capsular space. In between, the destruction oi tubules provoked a scavenging polyblastic reaction ending in sclerosis.
Female; heematin-eosin,
x
200.
(b)-End-stage of amyloid atrophy of glomeruli in intensely fluorescent. Male; thioflavine T; x 80. (c)-Deep renal cortex.
outer
cortex
Fluorescent amyloid is surrounded by less fluorescent, thid capsule, which is, however, more fluorescent than the interstitial tissue and the basal membranes of the shrunken,tubules. Male: thioflavine S: x 400.
Cohen, A. S. J. Cell. Biol. 1967, 33, 679. Lendrum, A. C. Pathologia Microbiol. 1967, 30, 681. Vassar, P., Culling, C. F. A. A.M.A. Archs Path. 1959, 68, 487. Nebut, M., Hartmann, L. Annls Biol. Clin. 1966, 5-6, 703. 6. Delarue, J., Banter, P., Chomette, G., Pinaudeau, Y. Annls. Anat. path. Anat. norm. med.-chir. 1963, 8, 27. 4. 5.
677 the thirty or so villages exclusively affected are situated north and south of the Iron Gates of the Danube, in a somewhat rectangular area of nearly 150 km. wide, in the adjoining parts of Bulgaria, Rumania, and Yugoslavia. The name Danubian endemic familial nephropathy (D.E.F.N.) might better reflect actual knowledge and suggest further inquiries in other countries and continents.’7 We thank Dr. Janet Niven (National Institute for Medical Research) and Prof. A. C. Lendrum (Queens College, Dundee) for
valuable information and practical suggestions.
E. C. CRACIUN S. NICOLESCO C. RAU E. TOMESCU.
V. Babes Institute of Pathology, Bucharest 35, Rumania.
POSTOPERATIVE DEEP-VEIN THROMBOSIS SIR,-Iread with interest the paper on postoperative deepvein thrombosis by Mr. Flanc and his colleagues (March 8, p. 477), particularly their demonstration that the incidence of this complication in elderly patients undergoing major operations is 61 %, and their remark that the thrombus often starts during the operation-I share this belief.
They kindly referred to my joint work on this subject, but I should be obliged if you would let me correct a mistake they have made with regard to it. They say we showed that venous stasis during anaesthesia was prevented by elevation of the legs. In 1964, in a carefully planned trial using one of the patients’ legs as a control to the other, we demonstrated that during a major operation the venous return often slowed as much as it does when the patient is confined to bed for two weeks, and that this stasis could be eliminated by electrically stimulating the calf muscles. We did not test elevation. Then in 1967, in a properly constructed clinical trial on 200 patients undergoing major operations, we proved mathematically that the incidence of deep-vein thrombosis in the control limb, which just lay flat on the table, was much greater than it was in the limb which was electrically stimulated. Moreover, both the fatal emboli in that series came from the unstimulated leg. F. S. A. DORAN. Kidderminster General Hospital, Worcs.
DIPLOMA IN THE HISTORY OF MEDICINE SIR,-Dr. Clarke (March 15, p. 572) rightly draws attention to the sub-department of the history of medicine at University College London where he has been developing teaching and research in the subject since it was established in October, 1966. The phrase which he quotes from my letter was used in the context of the resolution of the International Society of the History of Medicine that a course in the history of medicine should be a regular part of the medical undergraduate’s training. I was present at the discussion of this resolution and I took it to mean a course more closely integrated with the curriculum than the type of lecture course which Dr. Clarke mentions, such as has been given at other schools, including the Middlesex and King’s College. All who are interested in the subject are anxious to support and develop the initiative of the Wellcome Trustees in helping to establish academic departments. Far from competing in any way with this, the Apothecaries’ plans should make it possible for more medical students and others, in London and elsewhere, to learn something of the subject and so provide interested recruits for the sub-department at University College London and for any others which may be established in the coming years. W. S. C. COPEMAN The Worshipful Society of Apothecaries of London, London E.C.4. 7.
Chairman, Faculty of the History of Medicine and Pharmacy.
Lancet, 1966, i, 304.
FIBRINOLYSIS IN CHILDREN WITH CONGENITAL HEART-DISEASE have read with interest the report of Dr. Johnson and Sir her colleagues, who found no coagulation abnormalities in children with cyanotic congenital heart-disease. In 31 children with cyanotic congenital heart-disease (haematocrit 48-88%, arterial oxygen saturation 60-80%), I have studiedthe spontaneous fibrinolytic activity of plasma, plasminogen activity, and antiplasmin activity (all by Marbet’s TABLE I-SPONTANEOUS PLASMALYSIS IN 35 HEALTHY CHILDREN AND 31 CHILDREN WITH CYANOTIC CONGENITAL HEART-DISEASE (C.H.D.)
TABLE II-VALUES FOR AND
ANTIPLASMIN
PLASMINOGEN, IN 35
ACTIVITY
PLASMINOGEN NORMAL
PROACTIVATOR, AND 31
CHILDREN
CHILDREN WITH CYANOTIC C.H.D.
method 3), and the activity of plasminogen proactivator (Blix’s method 4) . The results are shown in tables i and 11. Compared with the healthy control group, I found increased fibrinolytic activity in the diseased children. Plasminogen activity and the activity of plasminogen proactivator also increased significantly. The antiplasmin titre was within normal limits. I did not find correlation between either ha:matocrit value and enzyme activity, or systemic arterial oxygen saturation and enzyme activity. 2nd Department of Pædiatrics, University of Budapest.
B. GOLDSCHMIDT.
FÆCAL BLOOD-LOSS AFTER SODIUM ACETYLSALICYLATE TAKEN WITH ALCOHOI SIR,-Ifeel some rebuttal is required of the rejoinder by Dr. Bouchier and Mr. Williams to Dr. Dobbing’s letter (March 8, p. 528). The points below deserve consideration. (i) Dr. Dobbing’s mean difference can hardly be challenged by citing an experimental error for individual observations of similar magnitude; the influence of the latter on 18 sets of differences of means from 6 sets of observations would be very much smaller. (ii) The inclusion or exclusion of subject 22 critically affects the results of any statistical evaluation; that the cause for the blood-loss was unknown does not mean that it was necessarily attributable to the drugs administered some days earlier, and Dr. Dobbing’s exclusion of this case seems to be the wisest course to follow. (iii) Since a mean daily loss is calculated by dividing the total loss by the number of days, the validity of restoring the mean 1. Johnson, C. A., Abildgaard, C. F., Schulman, I. Lancet, 1968, 2. Goldschmidt, B. Mschr.Kinderheilk. 1968, 116, 140. 3. Jurgens, J. Klinische Methoden der Blutgerinungsanalyse; Stuttgart, 1959. 4. Blix, S. Acta med. scand. 1964. 176. 649.
ii,
660.
p. 242.