A Higher Concentration of Dialysate Magnesium to Reduce the Frequency of Muscle Cramps: A Narrative Review.

PURPOSE OF REVIEW: Strategies to mitigate muscle cramps are a top research priority for patients receiving hemodialysis. As hypomagnesemia is a possible risk factor for cramping, we reviewed the literature to better understand the physiology of cramping as well as the epidemiology of hypomagnesemia and muscle cramps. We also sought to review the evidence from interventional studies on the effect of oral and dialysate magnesium-based therapies on muscle cramps. SOURCES OF INFORMATION: Peer-reviewed articles. METHODS: We searched for relevant articles in major bibliographic databases including MEDLINE and EMBASE. The methodological quality of interventional studies was assessed using a modified version of the Downs and Blacks criteria checklist. KEY FINDINGS: The etiology of muscle cramps in patients receiving hemodialysis is poorly understood and there are no clear evidence-based prevention or treatment strategies. Several factors may play a role including a low concentration of serum magnesium. The prevalence of hypomagnesemia (concentration of <0.7 mmol/L) in patients receiving hemodialysis ranges from 10% to 20%. Causes of hypomagnesemia include a low dietary intake of magnesium, use of medications that inhibit magnesium absorption (eg, proton pump inhibitors), increased magnesium excretion (eg, high-dose loop diuretics), and a low concentration of dialysate magnesium. Dialysate magnesium concentrations of ≤0.5 mmol/L may be associated with a decrease in serum magnesium concentration over time. Preliminary evidence from observational and interventional studies suggests a higher dialysate magnesium concentration will raise serum magnesium concentrations and may reduce the frequency and severity of muscle cramps. However, the quality of evidence supporting this benefit is limited, and larger, multicenter clinical trials are needed to further determine if magnesium-based therapy can reduce muscle cramps in patients receiving hemodialysis. In studies conducted to date, increasing the concentration of dialysate magnesium appears to be well-tolerated and is associated with a low risk of symptomatic hypermagnesemia. LIMITATIONS: Few interventional studies have examined the effect of magnesium-based therapy on muscle cramps in patients receiving hemodialysis and most were nonrandomized, pre-post study designs.

CONTEXTE MOTIVANT LA REVUE: Les stratégies visant à atténuer les crampes musculaires sont parmi les principales priorités de recherche des patients hémodialysés. L'hypomagnésémie étant un possible facteur de risque, nous avons procédé à une revue de la littérature afin de mieux en comprendre l'épidémiologie, et d'examiner la physiologie et l'épidémiologie des crampes musculaires. Nous souhaitions également examiner les données probantes issues d'études interventionnelles portant sur l'effet des thérapies à base de dialysat de magnésium et de magnésium oral sur les crampes musculaires. SOURCES: Articles examinés par les pairs. MÉTHODOLOGIE: Nous avons cherché les articles pertinents dans les principales bases de données bibliographiques, notamment MEDLINE et EMBASE. La qualité méthodologique a été évaluée à l'aide d'une version modifiée des critères de contrôle de la qualité des études de Downs et Black. PRINCIPAUX RÉSULTATS: L'étiologie des crampes musculaires chez les patients hémodialysés est mal comprise et il n'existe aucune stratégie de prévention ou traitement clairement fondé sur des données probantes. Plusieurs facteurs pourraient jouer un rôle, notamment de faibles concentrations sériques de magnésium. La prévalence de l'hypomagnésémie (concentration inférieure à 0,7 mmol/L) chez les patients hémodialysés variait de 10 à 20 %. Une faible consommation de magnésium dans l'alimentation, la prise de médicaments inhibant l'absorption du magnésium (ex. les inhibiteurs de la pompe à protons), l'excrétion accrue du magnésium (ex. dose élevée de diurétiques de l'anse) et une faible concentration de dialysat de magnésium figuraient parmi les causes d'hypomagnésémie. Un taux de dialysat de magnésium inférieur ou égal à 0,5 mmol/L pourrait être associé à une diminution de la concentration sérique de magnésium au fil du temps. Les résultats préliminaires de certaines études observationnelles et interventionnelles suggèrent qu'une concentration sérique plus élevée de magnésium dans le dialysat augmenterait les concentrations sériques de magnésium et pourrait réduire la fréquence et la sévérité des épisodes de crampes musculaires. La qualité des preuves appuyant ce bienfait est cependant limitée. Des essais multicentriques et à plus vaste échelle sont nécessaires pour juger si un traitement à base de magnésium peut véritablement réduire les crampes musculaires chez les patients hémodialysés. Dans les études menées jusqu'à maintenant, l'augmentation de la concentration de dialysat de magnésium semblait bien tolérée et a été associée à un faible risque d'hypermagnésémie symptomatique. LIMITES: Peu d'études interventionnelles ont examiné l'effet de la prise de magnésium sur les crampes musculaires des patients hémodialysés, et la plupart de celles-ci constituaient des plans pré- ou post-études non randomisées.

Breast augmentation: A geographical comparison.

OBJECTIVE: To describe and compare physical characteristics and implant details of women undergoing primary cosmetic breast augmentation in different geographical locations. METHODS: Three cohorts of 100 consecutive breast augmentation cases in university settings were retrospectively reviewed for patient demographic and implant information in Kelowna (British Columbia), Loma Linda (California, USA) and Temple (Texas, USA). Statistical analysis was performed with a Kruskal-Wallis test without normality assumption (P<0.05 was considered to be significant). Pearson correlation coefficients were also determined for body mass index (BMI) versus implant volume at each of the sites. RESULTS: The three group medians were significantly different for weight, BMI and implant volume. Kelowna's average patient was 33 years of age, had a BMI of 20.8 kg/m(2) and an implant volume of 389 mL. Loma Linda's average patient was 32 years of age, had a BMI of 21.6 kg/m(2) and an implant volume of 385 mL. Temple's average patient was 36 years of age, had a BMI of 22.6 kg/m(2) and an implant volume of 335 mL. Pearson correlations for BMI versus implant volume were statistically significant in the Loma Linda and Temple groups. CONCLUSION: Patients from different geographical locations undergoing breast augmentation were similar in age, height and parity, but varied in weight, BMI and implant volume. A positive linear correlation between BMI and implant volume was found in the American cohorts.

Sweet's syndrome presenting as acute hand infection.

BACKGROUND: Sweet's syndrome, originally described as an acute febrile neutrophilic dermatosis, belongs to a class of skin lesions that histologically have intense epidermal and/or dermal inflammatory infiltrate of neutrophils without evidence of infection or vasculitis. Skin lesions of Sweet's syndrome most commonly present on the face, trunk, upper extremities, and hands. The presenting lesions are often confused with infections because of their clinical appearance. METHODS: A retrospective search of the electronic medical record was performed to identify patients with Sweet's syndrome from 1996 to the present. These records were then reviewed to identify those patients who had Sweet's syndrome that involved the hands. RESULTS: A total of 103 patients with Sweet's syndrome have been seen and treated at Scott and White Memorial Hospital since 1996. Of these, 49 patients had lesions on the hands. The presentation, treatment, and outcomes of several of these patients are presented. CONCLUSIONS: As physicians responsible for the treatment of hand lesions, it is important to consider the diagnosis of Sweet's syndrome because these wounds are unresponsive to antibiotics, do not benefit from débridement, and instead, require treatment with steroids.