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Manganese intoxication has been described in children on long term parenteral nutrition presenting with liver and nervous system disorders. Cases are reported of a brother and sister on long term parenteral nutrition with hypermanganesaemia and basal ganglia manganese deposition, detected by magnetic resonance imaging (MRI), without overt neurological signs. Following reduction of manganese intake, basal ganglia manganese was monitored by repeated MRI, and neurological and developmental examinations. An MRI intensity index of the globus pallidus declined over a three year period from 0.318 and 0.385 to 0.205 and 0.134 with concomitant falls in whole blood manganese from 323 and 516 to 226 and 209 nmol/l (normal range, 73-210 nmol/l). Unlike adult experience these children developed normally without neurological signs. In conclusion, deposited manganese is removed from neural tissue over time and the prognosis is good when neurological manifestations and liver disease are absent.

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<p><strong>PICO question</strong></p><p>In dogs with generalised demodicosis, are isoxazolines as effective as a combined formulation of imidacloprid and moxidectin at reducing mite count and the severity of associated clinical signs?</p><p><strong>Clinical bottom line</strong></p><p>Five single-blinded, randomised, positive control trials, most under laboratory conditions, directly compared the use of isoxazolines against moxidectin/imidacloprid to treat canine generalised demodicosis. All of them showed comparable efficacy of isoxazolines. Three different isoxazolines were studied with two routes of administration (oral and topical) and four different dosing frequencies of moxidectin/imidacloprid. This made the papers more challenging to compare however, the evidence provided is sufficient to support their use. All of these trials were sponsored by the manufacturers of their respective isoxazoline products which may bias the study design and reporting of results. It is worth noting that sarolaner (Simparica™, Zoetis UK) was licensed in the UK for the treatment of canine demodicosis in January 2018 and that in the UK the Cascade should be followed when prescribing treatments. The licensed use of isoxazolines in other countries is beyond the scope of this article and the reader is urged to check local regulatory body advice before prescribing the below medications.</p><br /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/oa-icon.jpg" alt="Open Access" /> <img src="https://www.veterinaryevidence.org/rcvskmod/icons/pr-icon.jpg" alt="Peer Reviewed" />

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