687 dose to what would be expected if the gene(s) involved in the synthesis of Zn-M.T. or a control mechanism were impaired in these disorders. Zn-M.T. may be the molecular basis of both 4.E. and F.H.Z. in humans.
ROBERT
J. COUSINS
PICA WITH ZINC DEFICIENCY
SIR,—The association of perversion of appetite (pica) with iron deficiency is well known. 12 Pica in association with other as zinc has not been reported. 10-year-old Black boy with sickle-cell disease, confirmed by haemoglobin electrophoresis, who had an intense desire to eat 4-6 oz (115-170 g) per day of "Comet", a scouring agent (Proctor and Gamble). The patient’s plasmazmc, measured by atomic-absorption spectrophotometry, was 27.3µg/dl (normal range3 100-370 µg/dl). The zinc content, among other ingredients, was about 2 µg/g comet powder. Because of the possibility that the zinc deficiency was related to the pica in this patient, we gave him 225 mg oral zinc sulphate twice daily. After 2 months of therapy, his serum-zinc
metal deficiencies such We investigated
motivated towards carbohydrate restriction. patients with even mild depressive features were treated with tricyclic antidepressants. Those with little or no sleep disturbance were given nortriptyline beginning with a dose of 20 mg twice daily and increasing it until the depression was controlled. Those who complained of troublesome intense dreams or nightmares were changed to amitriptyline which was the drug used in all patients with sleep disturbance. The initial dose was usually 25 mg twice daily and the highest dose was 200 mg per day." Even with the use of tricyclic antidepressants, some patients still need to be admitted to hospital and varying degrees of persuasion by medical and nursing staff need to be exerted to get the patients to put on weight. We showed that 75% of cases of anorexia nervosa originated in the year in which the patients were working for a major examination. They are able to cope with academic pressures and social problems much better when thev are maintained on tricvclic antidepressants. "In the present series all
Cook College,
New Brunswick, New Jersey 08903, U.S.A.
diet
come
Department of Nutrition,
Rutgers University,
their personality facilitates the obsessional adherence to a despite their depression. Alternatively the depressed girls who’start dieting may initially be those where loss of appetite was associated with the depression. In either case they be-
girls
a
had risen to 153 g/dl, and at 4 months the concentration was 342µg/dl.As the serum-zinc returned to normal, he no longer exhibited a desire to eat comet and was completely cured of his
University of Cambridge Clinical School, Department of Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
IVOR H. MILLS
pica, The effort to maintain homoeostasis is one of the most powerful of all behaviour urges. This is exemplified by our patient who had low serum-zinc caused by sickle-cell disease,3 and who exhibited an unusual form of pica which was corrected by oral zinc replacement. Department of Pediatrics, State University of New York
Stony Brook, Long Island Jewish-Hillside at
Medical Center, New Hyde Park, N.Y.
11040, U.S.A.
GUNGOR KARAYALCIN PHILIP LANZKOWSKY
AMITRIPTYLINE THERAPY IN ANOREXIA NERVOSA
SIR,.I was interested to see the report by Dr Needleman and Dr Waber (Sept. 11, p. 580) on their experience with amitriptyline in patients with anorexia nervosa. They tend to exaggerate the benefits of antidepressants in these patients. In 1973 we reported on the use of tricyclic antion endodepressants when we described 80 patients in a crine and social factors in self-starvation amenorrhoea and I wonder if I might repeat what we said there.4 "Prior to the present study the majority of patients were treated with chlorpromazine and the severely affected ones were taken into hospital and given insulin in addition. It became apparent however that this treatment failed in those with depressive features. Subsequently we looked carefully for depressive features and in the present series 81% of the patients had indications of depression which in some was very marked. The history of depression was most marked around the onset of the illness and it was often difficult to assess whether the depression or the dieting came first. Certainly in obese people the onset of depression may be the factor which prevents their keeping to a diet but in the case of the starving
paper
ALPHA-FETOPROTEIN AND TESTICULAR TUMOURS
SIR,—Dr Kohn and his colleagues (Aug. 28, p. 433) report serial measurements of serum &agr;1-fetoprotein in patients° with testicular tumours, and we should like to reinforce their statement on the need for this test in the diagnosis and monitoring of testicular tumours. As they mentioned, &agr;1-fetoprotein is suggested to be produced in yolk-sac cells of teratomatous tissue, so representing a distinct cell type by a marker protein. Since testicular tumours frequently represent mixtures of several tumour tissues (e.g., teratomatous, seminomatous, and trophoblastic) measurement of additional marker proteins or glycoproteins may be exploited in monitoring of the efficacy of therapeutic regimens as was indicated by Kohn et al. These materials include both carcinoembryonic antigen (C.E.A.) and human chorionic gonadotropin (H.C.G.). We have evaluated our results’ in serial measurement of H.C.G. in malignant teratomas with trophoblastic components and concluded that discordances between the disappearance of H.C.G. and the remission of clinically detectable disease are to be expected. This problem will still remain despite frequent measurements and despite replacing the less specific latex-particle immune test for the highly specific radioimmune assay for the -subunit Of H.C.G.2 Even using both &bgr;-H.C.G. and xl-fetoprotein for diagnosis and monitoring of testicular tumours these discrepancies may occur3 when only one cell line out of the mixed tumour tissue responds to therapy. This probably explains the 30% of falsenegative &agr;1-fetoprotein titres in Dr Kohn’s report and our false-negative H.c.G. measurement in the face of growing metastases. Cancer Research Campaign Laboratories, University of Nottingham, Nottingham NG7 2RD
Department of Internal University of Essen, D-4300 Essen, Federal
Archs Dis. Childl. 1959, 34, 140. 2 WcDonald, R., Binder, H. J., Miller, M. B., Chang, W. W. Y., Horan, S. Pediatrics, 1964, 34, 558. 3 Karayalcin, G., Rosner, F., Kim, K. Y., Chandra, P. Lancet, 1974, i, 217. 4 Mils, I H, Wilson, R. J., Eden, M. A. M., Lines, J. G. in Symposium: Anorexia Nervosa and Obesity; p. 31. Royal College of Physicians of
Medicine
K. HÖFFKEN
(Cancer Research),
Republic of Germany
C. G. SCHMIDT
1 Lanzkowsky, P
Edinburgh, 1973.
Høffken, K., Schmidt, C. G. Z Krebsforsch. (in the press). Vaitukaitis, J. L., Braunstein, G. D., Ross, G. T. Am. J. Obstet. Gynec. 1972, 113, 751. 3. Braunstem, G. D., Mclntire, K. R., Waldmann, T. A. Cancer, Philadelphia, 1973, 31, 1065.
1 2.
ROBERT
J. COUSINS
PICA WITH ZINC DEFICIENCY
SIR,—The association of perversion of appetite (pica) with iron deficiency is well known. 12 Pica in association with other as zinc has not been reported. 10-year-old Black boy with sickle-cell disease, confirmed by haemoglobin electrophoresis, who had an intense desire to eat 4-6 oz (115-170 g) per day of "Comet", a scouring agent (Proctor and Gamble). The patient’s plasmazmc, measured by atomic-absorption spectrophotometry, was 27.3µg/dl (normal range3 100-370 µg/dl). The zinc content, among other ingredients, was about 2 µg/g comet powder. Because of the possibility that the zinc deficiency was related to the pica in this patient, we gave him 225 mg oral zinc sulphate twice daily. After 2 months of therapy, his serum-zinc
metal deficiencies such We investigated
motivated towards carbohydrate restriction. patients with even mild depressive features were treated with tricyclic antidepressants. Those with little or no sleep disturbance were given nortriptyline beginning with a dose of 20 mg twice daily and increasing it until the depression was controlled. Those who complained of troublesome intense dreams or nightmares were changed to amitriptyline which was the drug used in all patients with sleep disturbance. The initial dose was usually 25 mg twice daily and the highest dose was 200 mg per day." Even with the use of tricyclic antidepressants, some patients still need to be admitted to hospital and varying degrees of persuasion by medical and nursing staff need to be exerted to get the patients to put on weight. We showed that 75% of cases of anorexia nervosa originated in the year in which the patients were working for a major examination. They are able to cope with academic pressures and social problems much better when thev are maintained on tricvclic antidepressants. "In the present series all
Cook College,
New Brunswick, New Jersey 08903, U.S.A.
diet
come
Department of Nutrition,
Rutgers University,
their personality facilitates the obsessional adherence to a despite their depression. Alternatively the depressed girls who’start dieting may initially be those where loss of appetite was associated with the depression. In either case they be-
girls
a
had risen to 153 g/dl, and at 4 months the concentration was 342µg/dl.As the serum-zinc returned to normal, he no longer exhibited a desire to eat comet and was completely cured of his
University of Cambridge Clinical School, Department of Medicine, Addenbrooke’s Hospital, Cambridge CB2 2QQ
IVOR H. MILLS
pica, The effort to maintain homoeostasis is one of the most powerful of all behaviour urges. This is exemplified by our patient who had low serum-zinc caused by sickle-cell disease,3 and who exhibited an unusual form of pica which was corrected by oral zinc replacement. Department of Pediatrics, State University of New York
Stony Brook, Long Island Jewish-Hillside at
Medical Center, New Hyde Park, N.Y.
11040, U.S.A.
GUNGOR KARAYALCIN PHILIP LANZKOWSKY
AMITRIPTYLINE THERAPY IN ANOREXIA NERVOSA
SIR,.I was interested to see the report by Dr Needleman and Dr Waber (Sept. 11, p. 580) on their experience with amitriptyline in patients with anorexia nervosa. They tend to exaggerate the benefits of antidepressants in these patients. In 1973 we reported on the use of tricyclic antion endodepressants when we described 80 patients in a crine and social factors in self-starvation amenorrhoea and I wonder if I might repeat what we said there.4 "Prior to the present study the majority of patients were treated with chlorpromazine and the severely affected ones were taken into hospital and given insulin in addition. It became apparent however that this treatment failed in those with depressive features. Subsequently we looked carefully for depressive features and in the present series 81% of the patients had indications of depression which in some was very marked. The history of depression was most marked around the onset of the illness and it was often difficult to assess whether the depression or the dieting came first. Certainly in obese people the onset of depression may be the factor which prevents their keeping to a diet but in the case of the starving
paper
ALPHA-FETOPROTEIN AND TESTICULAR TUMOURS
SIR,—Dr Kohn and his colleagues (Aug. 28, p. 433) report serial measurements of serum &agr;1-fetoprotein in patients° with testicular tumours, and we should like to reinforce their statement on the need for this test in the diagnosis and monitoring of testicular tumours. As they mentioned, &agr;1-fetoprotein is suggested to be produced in yolk-sac cells of teratomatous tissue, so representing a distinct cell type by a marker protein. Since testicular tumours frequently represent mixtures of several tumour tissues (e.g., teratomatous, seminomatous, and trophoblastic) measurement of additional marker proteins or glycoproteins may be exploited in monitoring of the efficacy of therapeutic regimens as was indicated by Kohn et al. These materials include both carcinoembryonic antigen (C.E.A.) and human chorionic gonadotropin (H.C.G.). We have evaluated our results’ in serial measurement of H.C.G. in malignant teratomas with trophoblastic components and concluded that discordances between the disappearance of H.C.G. and the remission of clinically detectable disease are to be expected. This problem will still remain despite frequent measurements and despite replacing the less specific latex-particle immune test for the highly specific radioimmune assay for the -subunit Of H.C.G.2 Even using both &bgr;-H.C.G. and xl-fetoprotein for diagnosis and monitoring of testicular tumours these discrepancies may occur3 when only one cell line out of the mixed tumour tissue responds to therapy. This probably explains the 30% of falsenegative &agr;1-fetoprotein titres in Dr Kohn’s report and our false-negative H.c.G. measurement in the face of growing metastases. Cancer Research Campaign Laboratories, University of Nottingham, Nottingham NG7 2RD
Department of Internal University of Essen, D-4300 Essen, Federal
Archs Dis. Childl. 1959, 34, 140. 2 WcDonald, R., Binder, H. J., Miller, M. B., Chang, W. W. Y., Horan, S. Pediatrics, 1964, 34, 558. 3 Karayalcin, G., Rosner, F., Kim, K. Y., Chandra, P. Lancet, 1974, i, 217. 4 Mils, I H, Wilson, R. J., Eden, M. A. M., Lines, J. G. in Symposium: Anorexia Nervosa and Obesity; p. 31. Royal College of Physicians of
Medicine
K. HÖFFKEN
(Cancer Research),
Republic of Germany
C. G. SCHMIDT
1 Lanzkowsky, P
Edinburgh, 1973.
Høffken, K., Schmidt, C. G. Z Krebsforsch. (in the press). Vaitukaitis, J. L., Braunstein, G. D., Ross, G. T. Am. J. Obstet. Gynec. 1972, 113, 751. 3. Braunstem, G. D., Mclntire, K. R., Waldmann, T. A. Cancer, Philadelphia, 1973, 31, 1065.
1 2.
