Zinc poisoning from excessive denture fixative use masquerading as myelopolyneuropathy and hypocupraemia.

A 50-year-old man presented with a four-year history of unsteadiness, with recent falls and tingling in his fingers. Neurological examination found an ataxic gait, with a positive Romberg's sign. There was distal wasting and weakness in all four limbs and impaired co-ordination, with pseudoathetosis in the arms. Initial investigations showed a normochromic, normocytic anaemia, leucopenia, neutropenia and a low vitamin B(12) (172 ng/L). Treatment with intramuscular cobalamin injections showed no clinical improvement. Further investigations showed an undetectable caeruloplasmin (<0.085 g/L), a very low serum copper (1.1 µmol/L) and a markedly raised serum zinc concentration (36.2 µmol/L). On detailed questioning it became apparent that he had ill-fitting dentures requiring excessive use of denture fixative with high zinc content. The patient was switched to a non-zinc containing denture fixative and commenced copper supplementation. Although within three months the bone marrow suppression had resolved, there was no clinical improvement in neurological presentation. Questioning a patient about their denture fixative usage and checking if zinc is an ingredient may be considered during an investigation for myelopolyneuropathy when vitamin B(12) deficiency is not a cause.

Is bedtime supper necessary for older children with diabetes using glargine insulin in multiple daily injection regimens?

AIMS: Current guidelines for dietary management of Type 1 diabetes in children recommend a carbohydrate supper before bed. However, with the introduction of insulin analogues such as glargine (with a basal insulin profile), supper may be unnecessary. The purpose of this study was to investigate whether supper is required to prevent nocturnal hypoglycaemia when using multiple daily injections, with glargine as the basal insulin and rapid-acting insulin pre-meals, in older children with Type 1 diabetes. METHODS: Thirty-five children aged 10-18 years with Type 1 diabetes were recruited to a randomized cross-over trial (supper vs. no supper). Each phase consisted of three consecutive days of wearing a continuous glucose-monitoring system (CGMS) to record nocturnal blood glucose levels in the home setting. The supper phase included one 15-g carbohydrate dairy snack consumed before bed. The evening meals were standardized. Activity was restricted. RESULTS: Valid CGMS data were obtained for 163 nights (85 supper, 78 no supper). Nocturnal hypoglycaemia rates were similar in the supper and no-supper groups (32.9% vs. 33.3% of nights; P = 0.96). CONCLUSIONS: This study suggests that supper is not necessary for all children to prevent nocturnal hypoglycaemia when using glargine insulin. The recommendation for inclusion of supper should be individually tailored and not mandatory.

Selective media for detecting gastrointestinal carriage of vancomycin-resistant enterococci.

Nosocomial infection with vancomycin-resistant enterococci (VRE) has become a significant problem. Effective institution of infection control measures depends on rapid identification of carriage of the organism, especially in asymptomatic individuals. We compared two selective media for use in screening for the presence of VRE and found that an agar medium containing bile esculin azide supplemented with 8 mu g/ml of vancomycin was a useful and cost-effective means for primary screening for asymptomatic gastrointestinal carriage of VRE.

Iron and chronic viral hepatitis: emerging evidence for an important interaction.

Iron is an essential element for cell survival; it serves as a cofactor for essential enzymes in oxidative metabolism and (in the form of heme) as the major oxygen transporter in most forms of life on earth. Both deficiency and excess of iron often lead to disease. Iron is necessary for the proliferation of microorganisms and neoplastic cells. The presence of iron overload facilitates infection, as evidenced by the increased risk of persons with hemochromatosis to certain infections and by the fact that patients with lesser amounts of hepatic iron appear to respond better to interferon therapy for chronic viral hepatitis than those with larger amounts of hepatic iron. Viral hepatitis is a common cause of morbidity and mortality. Recent studies suggest that there is a key link between iron metabolism and the pathophysiology of viral hepatitis. The lobular and cellular distribution of iron in the liver may be as important as the total quantity of iron present. Whether iron removal will prove useful in the long-term management of chronic viral hepatitis is an issue in need of further well-designed, randomized, controlled trials.

Distribution of iron in the liver predicts the response of chronic hepatitis C infection to interferon therapy.

Recent evidence suggests that patients with chronic hepatitis C virus (CHCV) who respond to interferon-alpha (IFN) therapy have a lower hepatic iron concentration than those who do not. The object of this study was to assess the concentration and distribution of iron in liver biopsies from 15 patients with CHCV seen at the authors' medical center between June 1992 and March 1993. Patients with complete response to IFN were compared to those with non-complete response with respect to quantitative hepatic iron concentration, serum iron indices, and a detailed analysis of histologic features of hematoxylin-and-eosin and iron-stained pre-IFN biopsies. Patients with non-complete response had significantly higher scores for stainable iron in sinusoidal cells (P = .02) and portal tracts (P = .05) than did patients with complete response. Total hepatic iron scores, mean quantitative hepatic iron, and mean serum ferritin were higher in patients with noncomplete response, but the differences were not significant. In conclusion, iron deposition in sinusoidal cells and portal tracts is significantly less frequent in patients with complete response to IFN than in those with poor or no response, and may be a useful, objective predictor of response to IFN therapy.

A detailed analysis of the Knodell score and other histologic parameters as predictors of response to interferon therapy in chronic hepatitis C.

UNLABELLED: The Knodell score is inaccurate at predicting response to interferon alpha (IFN-alpha) therapy in patients with hepatitis C. Our aim was to see if specific histologic parameters, including iron deposition in liver biopsies, are better predictors of response to IFN-alpha than the total Knodell score. Thirty-five unselected patients were studied who had hepatitis C treated with IFN-alpha between 1990 and 1993, and pretreatment serum iron indices and liver needle biopsies performed. Biopsies were divided for light microscopy and quantitative iron determination. H&E-stained slides were graded for components I, II, III, IV, and total Knodell score. Quantitative determinations were percentage of portal triads with inflammation, piecemeal necrosis, lymphoid aggregates, and inflamed bile ducts; percentage of lobules with inflammation or acidophilic bodies; and percentage of triads with positive iron stain. Complete responders (CR) to IFN-alpha were defined by normalization of serum alanine aminotransferase (< or = 40 IU/liter), and noncomplete responders (NCR) by partial or no response. Data were analyzed statistically. CR had < 40% of triads positive for iron (P = 0.02) and lower serum ferritin (P = 0.05) and higher scores for lobular necrosis (P = 0.04). The percentage of iron-positive triads correlated only with cirrhosis. Addition of cirrhosis to percentage of iron-positive triads did not improve the predictive power of the portal iron. CR and NCR did not differ with respect to total Knodell score or any of the other individual parameters except Knodell II. CONCLUSIONS: (a) Individual features of lobular necrosis and iron staining in portal triads are better predictors of response to IFN-alpha than the total Knodell score.(ABSTRACT TRUNCATED AT 250 WORDS)