1307 FACTS ABOUT GLUTEN
SiR,—Iread with interest the letter from Dr Barnes and Dr Lynch, (Nov. 29, p. 1095) concerning the gluten content of cereals and your editorial in the same issue. Cereals belong to the grass family, and their protein
content
be chemically divided into albumins and globulins which are soluble in salt solution, prolamines which are soluble in 70% ethanol, and glutelins which are dissolved by an alkaline solution. Wheat gluten is comprised of a prolamine (gliadin) and a glutelin (glutenin) in roughly equal parts by weight. Only gliadin is regarded as toxic to coeliac patients, and it is better therefore to emphasise prolamine content when discussing cereal toxicity in coeliac disease. Tablemay be useful:
can
degree of cross-reactivity with gliadin. All titres were repeated three times and the mean was taken (table II). Of compounds cross-reacting with gliadin, only zein has never been shown to be harmful to coeliac patients. There does seem to be a correlation therefore between the cross-reactivity of a substance with gliadin and its potential toxicity to patients with coeliac disease. Perhaps this information will answer some of the questions posed by Dr Barnes and Dr Lynch. Department of Medicine, Frenchay Hospital, Bristol BS16 1LE.
P. G. BAKER
SUCCESS WITH LITHIUM IN A DISTURBED CHILD TABLE I-FRACTIONAL PROTEIN ANALYSIS OF CEREAL GRAINS a
SIR,-Lithium is little used in children. We describe below prepubertal boy who improved on lithium after other treat-
had failed. This 9-year-old boy was admitted to hospital when his children’s home could not contain his difficult behaviour; he displayed temper tantrums on slight frustration and was particularly disruptive in group situations. He first presented for psychiatric treatment when 4 years old, and by age 5 had been in hospital twice because of difficult behaviour and was taken into care. He was first excluded from his nursery school, then from a special school. After admission, treatment was by milieu therapy’ and drugs. For the first 5 months he was on thioridazine (up to 60 mg daily) and tricloryl (500 mg) at night. These drugs were then replaced by haloperidol (up to 2 mg daily). 2 months later chlorpromazine (75 mg) was given in addition when other methods failed. But after 9 months the patient was still severely disturbed. AnnelP3 has reported good results after treating periodic psychiatric disturbance in children with lithium, so, since our patient had periods of better behaviour we tried lithium, other drugs being discontinued. Lithium 200 mg daily was increased after a fortnight to 400 mg daily. His general behaviour improved. He became better able to tolerate frustration and peer-group pressures, and went back to the children’s home after 6 weeks on lithium. He attended a day school for maladjusted children and coped satisfactorily for 5 months. Then came a relapse with increasingly disruptive behaviour in and out of the classroom. The lithium dose was increased to 600 mg, and 3 months later to 800 mg because of another deterioration. 4 months later came the most serious relapse, when the headmaster suspended him for a week and said that the boy would be excluded if there was no radical change. Lithium was then increased to 1000 mg and a fortnight later to 1200 mg daily. A week later the school reported a striking change in behaviour, and 3 weeks later his teacher noted "a considerable change for the better". This improvement has been maintained for 6 months. There have been no complaints about his behaviour from the home since his discharge. According to Schouchildren tolerate and require relatively large doses because of their high renal clearance of lithium. Nevertheless close psychiatric surveillance is imperative during treatment and it was so in our patient. Side-effects were minimal even with 1200 mg daily. On this dose there was a radical change in the patient’s behaviour at school, and it is probably significant that only on this dose did the serum-lithium rise above 0.7 mmol/1 (0-78), the recommended range being 0.7-1.3mmol/1. The importance of establishing optimum serum concentrations has been stressed by Fry and Marks.6 Our patient, of average intelligence, having suffered profound multiple deprivations since early childhood, presented with a severe behaviour disorder and was about to be excluded
ments
oats contain only a quarter and rice tenth the amount of prolamine found in wheat, rye, or maize. This influences their relative potential toxici-
Weight for weight, about
a
barley,
ties. Since gliadin is harmful to coeliac patients, the extent to which other cereal prolamines resemble gliadin antigenically would also be expected to determine toxicity. I have studied this question using a tanned-red-cell technique. Group-0 human erythrocytes were subjected to tannic acid and coated with a peptic-tryptic digest of gliadin. Coeliac serum samples were then screened for the presence of gluten antibodies. Five samples in which the gluten-antibody titre was positive at greater than 1/128 were then set aside and divided into 0.3 ml volumes. Peptic-tryptic digests of gliadin, hordein (from barley), avenin (oats), zein (maize), rice protein, soy protein, tapioca protein, plus grated cheese, egg white, ’Oxo’ liquid (meat extract), milk, and bovine serum-albumin were then added in excess to these sera. The mixtures were left overnight at 4C and the gluten-antibody titres were repeated. A reduction in titre by addition of a compound was equated with its TABLE I!—CROSS-REACTIVITY WITH GLIADIN
1. 2.
Barker, P., Ward, P. A. Nursing Times, 1972, 68, 1579. Annell, A.-L. Acta psychiat. scand 1969, suppl. 207, p. 19. 3. Annell, A.-L. Acta pædopsychiat. 1969, 36, 292. 4. Schou, M. Proc. 4th Un. Eur. Pedopsychiat. Congr. 1971, p. 479. 5. Schou, M., Amdisen, A., Baastrup, P. C. Br. J Hosp Med. 1971, 6, 53. 6. Fry, D. E., Marks, V. Lancet, 1971, i, 886.
SiR,—Iread with interest the letter from Dr Barnes and Dr Lynch, (Nov. 29, p. 1095) concerning the gluten content of cereals and your editorial in the same issue. Cereals belong to the grass family, and their protein
content
be chemically divided into albumins and globulins which are soluble in salt solution, prolamines which are soluble in 70% ethanol, and glutelins which are dissolved by an alkaline solution. Wheat gluten is comprised of a prolamine (gliadin) and a glutelin (glutenin) in roughly equal parts by weight. Only gliadin is regarded as toxic to coeliac patients, and it is better therefore to emphasise prolamine content when discussing cereal toxicity in coeliac disease. Tablemay be useful:
can
degree of cross-reactivity with gliadin. All titres were repeated three times and the mean was taken (table II). Of compounds cross-reacting with gliadin, only zein has never been shown to be harmful to coeliac patients. There does seem to be a correlation therefore between the cross-reactivity of a substance with gliadin and its potential toxicity to patients with coeliac disease. Perhaps this information will answer some of the questions posed by Dr Barnes and Dr Lynch. Department of Medicine, Frenchay Hospital, Bristol BS16 1LE.
P. G. BAKER
SUCCESS WITH LITHIUM IN A DISTURBED CHILD TABLE I-FRACTIONAL PROTEIN ANALYSIS OF CEREAL GRAINS a
SIR,-Lithium is little used in children. We describe below prepubertal boy who improved on lithium after other treat-
had failed. This 9-year-old boy was admitted to hospital when his children’s home could not contain his difficult behaviour; he displayed temper tantrums on slight frustration and was particularly disruptive in group situations. He first presented for psychiatric treatment when 4 years old, and by age 5 had been in hospital twice because of difficult behaviour and was taken into care. He was first excluded from his nursery school, then from a special school. After admission, treatment was by milieu therapy’ and drugs. For the first 5 months he was on thioridazine (up to 60 mg daily) and tricloryl (500 mg) at night. These drugs were then replaced by haloperidol (up to 2 mg daily). 2 months later chlorpromazine (75 mg) was given in addition when other methods failed. But after 9 months the patient was still severely disturbed. AnnelP3 has reported good results after treating periodic psychiatric disturbance in children with lithium, so, since our patient had periods of better behaviour we tried lithium, other drugs being discontinued. Lithium 200 mg daily was increased after a fortnight to 400 mg daily. His general behaviour improved. He became better able to tolerate frustration and peer-group pressures, and went back to the children’s home after 6 weeks on lithium. He attended a day school for maladjusted children and coped satisfactorily for 5 months. Then came a relapse with increasingly disruptive behaviour in and out of the classroom. The lithium dose was increased to 600 mg, and 3 months later to 800 mg because of another deterioration. 4 months later came the most serious relapse, when the headmaster suspended him for a week and said that the boy would be excluded if there was no radical change. Lithium was then increased to 1000 mg and a fortnight later to 1200 mg daily. A week later the school reported a striking change in behaviour, and 3 weeks later his teacher noted "a considerable change for the better". This improvement has been maintained for 6 months. There have been no complaints about his behaviour from the home since his discharge. According to Schouchildren tolerate and require relatively large doses because of their high renal clearance of lithium. Nevertheless close psychiatric surveillance is imperative during treatment and it was so in our patient. Side-effects were minimal even with 1200 mg daily. On this dose there was a radical change in the patient’s behaviour at school, and it is probably significant that only on this dose did the serum-lithium rise above 0.7 mmol/1 (0-78), the recommended range being 0.7-1.3mmol/1. The importance of establishing optimum serum concentrations has been stressed by Fry and Marks.6 Our patient, of average intelligence, having suffered profound multiple deprivations since early childhood, presented with a severe behaviour disorder and was about to be excluded
ments
oats contain only a quarter and rice tenth the amount of prolamine found in wheat, rye, or maize. This influences their relative potential toxici-
Weight for weight, about
a
barley,
ties. Since gliadin is harmful to coeliac patients, the extent to which other cereal prolamines resemble gliadin antigenically would also be expected to determine toxicity. I have studied this question using a tanned-red-cell technique. Group-0 human erythrocytes were subjected to tannic acid and coated with a peptic-tryptic digest of gliadin. Coeliac serum samples were then screened for the presence of gluten antibodies. Five samples in which the gluten-antibody titre was positive at greater than 1/128 were then set aside and divided into 0.3 ml volumes. Peptic-tryptic digests of gliadin, hordein (from barley), avenin (oats), zein (maize), rice protein, soy protein, tapioca protein, plus grated cheese, egg white, ’Oxo’ liquid (meat extract), milk, and bovine serum-albumin were then added in excess to these sera. The mixtures were left overnight at 4C and the gluten-antibody titres were repeated. A reduction in titre by addition of a compound was equated with its TABLE I!—CROSS-REACTIVITY WITH GLIADIN
1. 2.
Barker, P., Ward, P. A. Nursing Times, 1972, 68, 1579. Annell, A.-L. Acta psychiat. scand 1969, suppl. 207, p. 19. 3. Annell, A.-L. Acta pædopsychiat. 1969, 36, 292. 4. Schou, M. Proc. 4th Un. Eur. Pedopsychiat. Congr. 1971, p. 479. 5. Schou, M., Amdisen, A., Baastrup, P. C. Br. J Hosp Med. 1971, 6, 53. 6. Fry, D. E., Marks, V. Lancet, 1971, i, 886.
