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INTRAMITOCHONDRIAL PARACRYSTALLINE INCLUSIONS IN HEPATOCYTES OF PATIENTS WITH BILIARY LITHIASIS
1417 effect of aspirin on metastatic growth in the two studies 3,4 may be due to an altered inflammatory response or other more complex mechanisms. The conflicting results of the effects of aspirin on metastasis formation stress the fact that the postulated role of platelets in tumour dissemination is not yet established. However, inhibitors of platelet aggregation may be a useful tool in further research to elucidate a possible interaction of platelets with tumour cells in vivo.
inhibitory recent
Department of Experimental Pathology, Merck Institute for
Therapeutic Research, Rahway, New Jersey 07065, U.S.A.
SUMNER WOOD, JR.
Department of Hæmatology, Royal Postgraduate Medical School, London W.12.
SIR,-Intramitochondrial paracrystalline inclusions havebeen described in hepatocytes, in association with changes in size or shape of the mitochondria, in several diseases, including disturbances of lipid metabolism (such as obesity,l diabetes,’and hyperlipoproteinaemia 1.3) and Intramitointrahepatic or extrahepatic cholestasis.4,5 chondrial inclusions have also been found in muscle-fibres in myopathies associated with metabolic disturbance. 6,7 We have studied ultrastructural changes in the livers of 24 patients with cholesterol-containing biliary stones, some of whom showed clinical and biological evidence of In 14
PETER HILGARD.
CLINICAL USE
SIR,-Professor Jaques (Dec. 9, p. 1262) sensibly advises the recording in both clinical and research papers of fuller details of the heparin used. Conflicting data are found in profusion in the heparin literature; who knows to what extent the differences relate to the various types of heparin
preparation employed ? The literature on the in-vitro incompatibilities of heparin is especially confused. Here, there are almost as many discordant results as concordant ones: failure to record comprehensive descriptions of the heparin preparations used could be a contributory factor. At best, this simply means that the different accounts cannot be accurately collated, but, at worst, it conceals differences which may actually account for the discrepancies (perhaps, for example, in the case of the disputed incompatibility with hydrocortisone). Indeed, not a few of the alleged incompatibilities may be due to the preservative (for example, the interaction of codeine and thiamine with chlorocresol). Clearly, the measure which Professor Jaques suggests is overdue, but, nevertheless, even at this late stage its very
INCLUSIONS IN HEPATOCYTES OF PATIENTS WITH BILIARY LITHIASIS
biliary hypertension.
STANDARDISATION OF HEPARIN FOR
imn]pmpnt::!tinn will hp
INTRAMITOCHONDRIAL PARACRYSTALLINE
cases
we
found
structures
in the mitochondria-
(fig. 1) independently of the presence or absence of biliary hypertension. Usually they were associated with other changes in size or shape of the mitochondria. The inclusions consisted of several straight strands of high electronic density, and some of these were square in cross-section (fig. 2). In sections we could count 25 strands approximately 200 A diameter, the breadth of the whole We did not see structure being about 1600-1800 A. intramitochondrial inclusions in 5 patients with peptic ulcer, who acted as controls. In these inclusions, which
some authors describe as and phospholipidic in nature, enzymes have been found, such as succinodehydrogenase and cytochrome oxidase.1 We suggest that the presence of inclusions is associated with some mitochondrial dysfunction which impairs the oxidative pathway of cellular metabolism, with
proteic
1. Bhagwat, A. G., Ross, R. C. Archs Path. 1971, 91, 70. 2. Popper, H., Schaffner, F. Ann. intern. Med. 1963, 59, 674. 3. Kowacs, K., Lee, R., Little, J. A. Lancet, 1972, i, 752. 4. Carruthers, J. S., Steiner, J. V. Gastroenterology, 1962, 42, 419. 5. Popper, H. Ann. Rev. Med. 1968, 19, 39. 6. Bradley, W. G., Hudgson, P., Gardner-Medwin, D., Walton, J. N. Lancet, 1969, i, 495. 7. Salmon, M. A., Esiri, M. M., Ruderman, N. B. ibid. 1971, ii, 290.
we.1cnmt--
Weddel Pharmaceuticals
Limited, Salisbury House, London Wall, London EC2M 5XD.
S. L. STOCK.
ACUPUNCTURE ANÆSTHESIA
SiR,—I have been following the medical-press reports on acupuncture with much interest and am surprised that many
physiologically or scientifically questionable statements go unchallenged. The article by Mr. Capperauld and his colleagues (Nov. 25, p. 1136) prompts me to write to you. They mention that a patient was able to " reflate his lung " during a lobectomy. This particular claim is commany reports on Chinese acupuncture anaesthesia. The lungs expand passively because of adhesion to the chest wall due to the existence of negative pressure in the interpleural space. Once the chest wall is opened, the result is a pneumothorax and collapse of the lung on that side. As long as the chest wall remains open there is no way that the patient can reinflate that lung through his own muscular efforts. Also, I would appreciate very much an explanation of how a " low-voltage low-amperage current " could cause needles inserted into the tissues to " vibrate ". mon to
Queen Street Mental Health Centre, 999 Queen Street West, Toronto 3,
Ontario,
Canada.
Fig. 1-Hepatocyte showing mitochondria with altered shapeand size (m).
Many inclusions
KENNETH KAROLS.
contain
abundant intramitochondrial
paracrystalline
(arrow).
D =Perisinusoidal space. (
x
25,200, reduced
to
two-thirds.)
1418
extensively used for this purpose in X-ray equipment and high-voltage circuit breakers. This effect begins to saturate when 10% SF is added to nitrogen. SF exposed to an electric discharge does decompose to form toxic compounds such as SF2, SF 4’ and S2F1o. Because of the small bolus volume and small fraction of expired gas sampled by the nitrogen meter, the concentration of these breakdown products is insisnmcantiv small. Cardiovascular Research Institute, University of California Medical Center, San Francisco, California 94122, U.S.A.
L. NEWBERG J. G. JONES.
Respiratory Unit, Hammersmith Hospital, London W.12.
Fig. 2-Paracrystalline inclusion in
transverse
section ( x
79,800). which acetyl-CoA would be diverted towards the synthesis of other substances, including cholesterol. Thus, without denying the possibility of the deleterious effect on the hepatocytes of the previous cholestatic episodes, this hypothesis could account for the genesis of cholesterol stones, although further investigations would be necessary to clarify the exact meaning of these intramitochondrial inclusions. C. GOMEZ LÁZARO A. CARO-PATON Department of Medicine, University of Valladolid, Spain.
J. A. NADEL.
PRIETO M. C. COCA.
J.
CHOLESTEROL-LOWERING DIET AND MORTALITY FROM CORONARY HEARTDISEASE
SIR,-Mr. Rivers and Professor Yudkin (Nov. 11, p. 1026) criticised certain aspects of our study (Oct. 21, p. 835) of the effect of cholesterol-lowering diet on mortality from coronary heart-disease. They believe that the observed differences in mortality could as well be ascribed to differences in sugar intake as to those in the quality of dietary fat. The mean figures for coronary heart-disease (c.H.D.) mortality, sucrose consumption, and the " diet factorcomputed from the fatty-acid composition and the cholesterol content of the dietare: Hospital N
CLOSING VOLUME SIR,-Current interest in the phenomenon of
mortality per 1000 Sucrose consumption (g./per day)
C.H.D. "
closing volume ", discussed in your leader (Oct. 28, p. 908) and in the paper of Dr. Green and Dr. Travis (p. 905), describing a helium-bolus method of measuring phase Iv of the alveolar plateau, prompted us to describe yet another method. Our technique is similar to that described by Fowler1 An in 1949, and popularised by Anthonisen et al.2 unmodified nitrogen meter is used to analyse expired nitrogen after a vital-capacity breath of oxygen. Having observed that low concentrations of sulphur hexafluoride (SF,) considerably amplify the nitrogen meter signal, we modified the Fowler technique by introducing a 50 ml. bolus of SF at residual volume which is washed into the lungs by the oxygen. The subsequent plot of expired nitrogen against expired volume is indistinguishable from studies in the same subject using boluses of argon analysed with the mass spectrometer.3 The small size of the bolus leads to a greater regional difference in distribution than that obtained with the larger volume of helium described by Dr. Green and Dr. Travis, and there is consequently a greater accentuation of the transition between phases III and Iv. Similar studies substituting helium, neon, argon, and nitrous oxide for SF produced only a small improvement in the quality of the trace. With the conventional technique 1,2 inhalation of a histamine aerosol resulted in a disappearance of phase iv with an increase of residual volume. The addition of a bolus of SF, at residual volume revealed a fourth phase in the alveolar plateau, the volume of this phase being in fact increased compared with the control before histamine. The large effect of SF, in amplifying the nitrogen signal is due to its well-known arc-quenching ability and it is 1. Fowler, W. S. J. appl. Physiol. 1949, 2, 283. 2. Anthonisen, N. R., Danson, J., Robertson, P. C., Ross, W. R. D. Resp. Physiol. 1969, 8, 58. 3. Jones, J. G., Clarke, S. W. Clin. Sci. 1969, 37, 343.
Diet factor1
Hospital K
Diet
Control
Diet
Control
period
period
period
period
5-72 69 20
12-97 79 59
7-50 87 22
15-18 102 66
As these figures indicate, the sucrose consumption has, indeed, in both hospitals been lower during the diet period, when the mortality also was lower. The differences in sucrose consumption, however, were only 10 and 15 g. per day, and it seems very unlikely that these small differences could have produced such great differences in mortality. If this would be the case, the regression had to be very steep and obviously exponential, the mortality being proportional to about the fifth power of the sucrose intake, and we could calculate that the reduction of the intake to below some 50 g. per day would bring the mortality from c.H.D. virtually to zero. We are not aware of any epidemiological or other evidence that would support such a concept. It is also worth noting that during the second period of the trial, when hospital K had the experimental diet and hospital N had the control diet, the mortality in the former hospital was much lower, although its sucrose intake was higher. From the above figures, it is clear that mortality is correlated far better with the fatty-acid composition and the cholesterol content of the diet (" diet factor ") than with sucrose intake. In view of the design of the experiment the variations in sugar intake were, of course, regrettable. They were due to the fact that, aside from the fatty-acid composition and the cholesterol content of the diets, the hospitals, for practical reasons, had to be granted certain freedom in dietary matters. However, these variations can hardly be regarded as anything more than a minor blemish which detracts from the impeccability of the experimental design without invalidating the conclusions. Mr. Rivers and Professor Yudkin have also expressed interest in seeing separately the results of only those patients who were included in the trial for the whole 1. Keys, A., Anderson, J. T., Grande, F. Metabolism, 1965, 14, 766.
inhibitory recent
Department of Experimental Pathology, Merck Institute for
Therapeutic Research, Rahway, New Jersey 07065, U.S.A.
SUMNER WOOD, JR.
Department of Hæmatology, Royal Postgraduate Medical School, London W.12.
SIR,-Intramitochondrial paracrystalline inclusions havebeen described in hepatocytes, in association with changes in size or shape of the mitochondria, in several diseases, including disturbances of lipid metabolism (such as obesity,l diabetes,’and hyperlipoproteinaemia 1.3) and Intramitointrahepatic or extrahepatic cholestasis.4,5 chondrial inclusions have also been found in muscle-fibres in myopathies associated with metabolic disturbance. 6,7 We have studied ultrastructural changes in the livers of 24 patients with cholesterol-containing biliary stones, some of whom showed clinical and biological evidence of In 14
PETER HILGARD.
CLINICAL USE
SIR,-Professor Jaques (Dec. 9, p. 1262) sensibly advises the recording in both clinical and research papers of fuller details of the heparin used. Conflicting data are found in profusion in the heparin literature; who knows to what extent the differences relate to the various types of heparin
preparation employed ? The literature on the in-vitro incompatibilities of heparin is especially confused. Here, there are almost as many discordant results as concordant ones: failure to record comprehensive descriptions of the heparin preparations used could be a contributory factor. At best, this simply means that the different accounts cannot be accurately collated, but, at worst, it conceals differences which may actually account for the discrepancies (perhaps, for example, in the case of the disputed incompatibility with hydrocortisone). Indeed, not a few of the alleged incompatibilities may be due to the preservative (for example, the interaction of codeine and thiamine with chlorocresol). Clearly, the measure which Professor Jaques suggests is overdue, but, nevertheless, even at this late stage its very
INCLUSIONS IN HEPATOCYTES OF PATIENTS WITH BILIARY LITHIASIS
biliary hypertension.
STANDARDISATION OF HEPARIN FOR
imn]pmpnt::!tinn will hp
INTRAMITOCHONDRIAL PARACRYSTALLINE
cases
we
found
structures
in the mitochondria-
(fig. 1) independently of the presence or absence of biliary hypertension. Usually they were associated with other changes in size or shape of the mitochondria. The inclusions consisted of several straight strands of high electronic density, and some of these were square in cross-section (fig. 2). In sections we could count 25 strands approximately 200 A diameter, the breadth of the whole We did not see structure being about 1600-1800 A. intramitochondrial inclusions in 5 patients with peptic ulcer, who acted as controls. In these inclusions, which
some authors describe as and phospholipidic in nature, enzymes have been found, such as succinodehydrogenase and cytochrome oxidase.1 We suggest that the presence of inclusions is associated with some mitochondrial dysfunction which impairs the oxidative pathway of cellular metabolism, with
proteic
1. Bhagwat, A. G., Ross, R. C. Archs Path. 1971, 91, 70. 2. Popper, H., Schaffner, F. Ann. intern. Med. 1963, 59, 674. 3. Kowacs, K., Lee, R., Little, J. A. Lancet, 1972, i, 752. 4. Carruthers, J. S., Steiner, J. V. Gastroenterology, 1962, 42, 419. 5. Popper, H. Ann. Rev. Med. 1968, 19, 39. 6. Bradley, W. G., Hudgson, P., Gardner-Medwin, D., Walton, J. N. Lancet, 1969, i, 495. 7. Salmon, M. A., Esiri, M. M., Ruderman, N. B. ibid. 1971, ii, 290.
we.1cnmt--
Weddel Pharmaceuticals
Limited, Salisbury House, London Wall, London EC2M 5XD.
S. L. STOCK.
ACUPUNCTURE ANÆSTHESIA
SiR,—I have been following the medical-press reports on acupuncture with much interest and am surprised that many
physiologically or scientifically questionable statements go unchallenged. The article by Mr. Capperauld and his colleagues (Nov. 25, p. 1136) prompts me to write to you. They mention that a patient was able to " reflate his lung " during a lobectomy. This particular claim is commany reports on Chinese acupuncture anaesthesia. The lungs expand passively because of adhesion to the chest wall due to the existence of negative pressure in the interpleural space. Once the chest wall is opened, the result is a pneumothorax and collapse of the lung on that side. As long as the chest wall remains open there is no way that the patient can reinflate that lung through his own muscular efforts. Also, I would appreciate very much an explanation of how a " low-voltage low-amperage current " could cause needles inserted into the tissues to " vibrate ". mon to
Queen Street Mental Health Centre, 999 Queen Street West, Toronto 3,
Ontario,
Canada.
Fig. 1-Hepatocyte showing mitochondria with altered shapeand size (m).
Many inclusions
KENNETH KAROLS.
contain
abundant intramitochondrial
paracrystalline
(arrow).
D =Perisinusoidal space. (
x
25,200, reduced
to
two-thirds.)
1418
extensively used for this purpose in X-ray equipment and high-voltage circuit breakers. This effect begins to saturate when 10% SF is added to nitrogen. SF exposed to an electric discharge does decompose to form toxic compounds such as SF2, SF 4’ and S2F1o. Because of the small bolus volume and small fraction of expired gas sampled by the nitrogen meter, the concentration of these breakdown products is insisnmcantiv small. Cardiovascular Research Institute, University of California Medical Center, San Francisco, California 94122, U.S.A.
L. NEWBERG J. G. JONES.
Respiratory Unit, Hammersmith Hospital, London W.12.
Fig. 2-Paracrystalline inclusion in
transverse
section ( x
79,800). which acetyl-CoA would be diverted towards the synthesis of other substances, including cholesterol. Thus, without denying the possibility of the deleterious effect on the hepatocytes of the previous cholestatic episodes, this hypothesis could account for the genesis of cholesterol stones, although further investigations would be necessary to clarify the exact meaning of these intramitochondrial inclusions. C. GOMEZ LÁZARO A. CARO-PATON Department of Medicine, University of Valladolid, Spain.
J. A. NADEL.
PRIETO M. C. COCA.
J.
CHOLESTEROL-LOWERING DIET AND MORTALITY FROM CORONARY HEARTDISEASE
SIR,-Mr. Rivers and Professor Yudkin (Nov. 11, p. 1026) criticised certain aspects of our study (Oct. 21, p. 835) of the effect of cholesterol-lowering diet on mortality from coronary heart-disease. They believe that the observed differences in mortality could as well be ascribed to differences in sugar intake as to those in the quality of dietary fat. The mean figures for coronary heart-disease (c.H.D.) mortality, sucrose consumption, and the " diet factorcomputed from the fatty-acid composition and the cholesterol content of the dietare: Hospital N
CLOSING VOLUME SIR,-Current interest in the phenomenon of
mortality per 1000 Sucrose consumption (g./per day)
C.H.D. "
closing volume ", discussed in your leader (Oct. 28, p. 908) and in the paper of Dr. Green and Dr. Travis (p. 905), describing a helium-bolus method of measuring phase Iv of the alveolar plateau, prompted us to describe yet another method. Our technique is similar to that described by Fowler1 An in 1949, and popularised by Anthonisen et al.2 unmodified nitrogen meter is used to analyse expired nitrogen after a vital-capacity breath of oxygen. Having observed that low concentrations of sulphur hexafluoride (SF,) considerably amplify the nitrogen meter signal, we modified the Fowler technique by introducing a 50 ml. bolus of SF at residual volume which is washed into the lungs by the oxygen. The subsequent plot of expired nitrogen against expired volume is indistinguishable from studies in the same subject using boluses of argon analysed with the mass spectrometer.3 The small size of the bolus leads to a greater regional difference in distribution than that obtained with the larger volume of helium described by Dr. Green and Dr. Travis, and there is consequently a greater accentuation of the transition between phases III and Iv. Similar studies substituting helium, neon, argon, and nitrous oxide for SF produced only a small improvement in the quality of the trace. With the conventional technique 1,2 inhalation of a histamine aerosol resulted in a disappearance of phase iv with an increase of residual volume. The addition of a bolus of SF, at residual volume revealed a fourth phase in the alveolar plateau, the volume of this phase being in fact increased compared with the control before histamine. The large effect of SF, in amplifying the nitrogen signal is due to its well-known arc-quenching ability and it is 1. Fowler, W. S. J. appl. Physiol. 1949, 2, 283. 2. Anthonisen, N. R., Danson, J., Robertson, P. C., Ross, W. R. D. Resp. Physiol. 1969, 8, 58. 3. Jones, J. G., Clarke, S. W. Clin. Sci. 1969, 37, 343.
Diet factor1
Hospital K
Diet
Control
Diet
Control
period
period
period
period
5-72 69 20
12-97 79 59
7-50 87 22
15-18 102 66
As these figures indicate, the sucrose consumption has, indeed, in both hospitals been lower during the diet period, when the mortality also was lower. The differences in sucrose consumption, however, were only 10 and 15 g. per day, and it seems very unlikely that these small differences could have produced such great differences in mortality. If this would be the case, the regression had to be very steep and obviously exponential, the mortality being proportional to about the fifth power of the sucrose intake, and we could calculate that the reduction of the intake to below some 50 g. per day would bring the mortality from c.H.D. virtually to zero. We are not aware of any epidemiological or other evidence that would support such a concept. It is also worth noting that during the second period of the trial, when hospital K had the experimental diet and hospital N had the control diet, the mortality in the former hospital was much lower, although its sucrose intake was higher. From the above figures, it is clear that mortality is correlated far better with the fatty-acid composition and the cholesterol content of the diet (" diet factor ") than with sucrose intake. In view of the design of the experiment the variations in sugar intake were, of course, regrettable. They were due to the fact that, aside from the fatty-acid composition and the cholesterol content of the diets, the hospitals, for practical reasons, had to be granted certain freedom in dietary matters. However, these variations can hardly be regarded as anything more than a minor blemish which detracts from the impeccability of the experimental design without invalidating the conclusions. Mr. Rivers and Professor Yudkin have also expressed interest in seeing separately the results of only those patients who were included in the trial for the whole 1. Keys, A., Anderson, J. T., Grande, F. Metabolism, 1965, 14, 766.