Magnesium Disorders: Core Curriculum 2024.

Magnesium is ubiquitous in nature. It sits at the origin of the food chain, occupying the center of chlorophyl in plants. In humans, magnesium is critical to diverse molecular and catalytic processes, including energy transfer and maintenance of the genome. Despite its abundance, hypomagnesemia is common and often goes undiagnosed. This is in spite of epidemiologic data linking low magnesium with chronic diseases including diabetes mellitus. Clinically significant hypermagnesemia is encountered less frequently, but the presentation may be dramatic. Advances in molecular biology and the elucidation of the genetic causes of magnesium disorders have enhanced our understanding of their pathophysiology. Treatment approaches are also changing. The repurposing of newer medications, such as sodium/glucose cotransporter 2 inhibitors, offers new therapeutic options. In this review we integrate knowledge in this rapidly evolving field to provide clinicians and trainees with a resource for approaching common clinical scenarios involving magnesium disorders.

Type 4 renal tubular acidosis and uric acid nephrolithiasis: two faces of the same coin?

PURPOSE OF REVIEW: The present review summarizes findings of recent studies examining the epidemiology, pathophysiology, and treatment of type 4 renal tubular acidosis (RTA) and uric acid nephrolithiasis, two conditions characterized by an abnormally acidic urine. RECENT FINDINGS: Both type 4 RTA and uric acid nephrolithiasis disproportionately occur in patients with type 2 diabetes and/or chronic kidney disease. Biochemically, both conditions are associated with reduced renal ammonium excretion resulting in impaired urinary buffering and low urine pH. Reduced ammoniagenesis is postulated to result from hyperkalemia in type 4 RTA and from insulin resistance and fat accumulation in the renal proximal tubule in uric acid nephrolithiasis. The typical biochemical findings of hyperkalemia and systemic acidosis of type 4 RTA are rarely reported in uric acid stone formers. Additional clinical differences between the two conditions include findings of higher urinary uric acid excretion and consequent urinary uric acid supersaturation in uric acid stone formers but not in type 4 RTA. SUMMARY: Type 4 RTA and uric acid nephrolithiasis share several epidemiological, clinical, and biochemical features. Although both conditions may be manifestations of diabetes mellitus and thus have a large at-risk population, the means to the shared biochemical finding of overly acidic urine are different. This difference in pathophysiology may explain the dissimilarity in the prevalence of kidney stone formation.

Association between experiences of intimate partner sexual violence and cigarette smoking among women in union in Papua New Guinea: evidence from a nationally representative survey.

BACKGROUND: Intimate partner sexual violence (IPSV) is a prevalent public health problem affecting millions of people each year globally, particularly in developing countries like Papua New Guinea (PNG). Although over two-thirds of women in PNG are estimated to experience some form of sexual violence in their lifetime, empirical evidence is limited on the association between IPSV and cigarette smoking. Thus, the present study aims to examine the prevalence of IPSV and its association with cigarette smoking among women in union  in PNG. METHODS: This cross-sectional study used data from the first demographic and health survey of PNG conducted between 2016 and 2018. A total of 9,943 women aged 15-49 years in intimate unions were included in this study. We estimated the relative risk of smoking cigarette using modified Poisson regression models with a robust variance and 95% confidence intervals. RESULTS: The rates of IPSV and current cigarette smoking were 25.9% and 26.8%, respectively. The modified Poisson regression results showed that IPSV was significantly associated with an elevated risk for cigarette smoking. Women with IPSV history were more likely to smoke cigarette relative to their counterparts with no IPSV history (RR: 1.33, 95% CI: 1.18-1.50) in the absence of covariates. After controlling for demographic, social and economic factors, the association between IPSV and cigarette smoking remained statistically significant (RR: 1.24, 95% CI: 1.08-1.42). CONCLUSIONS: The rates of IPSV and cigarette smoking among women in union in PNG in the current study were relatively high. Irrespective of diverse demographic, social and economic factors, IPSV was still significantly associated with cigarette smoking among women in union in PNG. The findings presented call the attention of policy-makers and relevant authorities in PNG to an important association that needs to be addressed. Counseling, awareness creation, service provision and program design on IPSV are urgently required to minimize cigarette smoking and IPSV among women in union in PNG.

Spectrum of disease in HIV-positive patients presenting to a tertiary care hospital: a retrospective, cross-sectional review in Kumasi, Ghana.

BACKGROUND: HIV remains a significant public health dilemma in West and Central Africa. HIV-related morbidity and mortality are unjustly high, yet little is known about the spectrum of complicating comorbidities in HIV-positive patients who are admitted to hospitals in these regions. METHODS: This study involved a retrospective chart review to determine the common comorbidities and mortality rate of HIV-infected patients admitted over a six month period to the internal medicine service at the Komfo Anokye Teaching Hospital (KATH), a tertiary care center in Ghana. Patients admitted with a known or new HIV diagnosis from January to July 2016 were included. Data were collected regarding the number of new versus known cases admitted, the most common presenting complaints, final admitting diagnoses, and causes of mortality in these patients. RESULTS: During the six-month study period, 250 HIV-positive patients were admitted to KATH, and 245 of these individuals had valid survival time recorded. Of these patients, 145/245 (59.2%) were female. Median age of patients included in the study was 42 years old (IQR 35-51). The mortality rate for HIV patients admitted to the hospital was 35.5% (87 patients). One hundred and forty-five (59.4%) patients had a known history of HIV documented in their patient charts, while the remaining patients were newly diagnosed with HIV during their inpatient stay. Pulmonary tuberculosis predominated among diagnostic findings, with 40.4% of HIV-infected patients diagnosed with the condition while admitted. Patients presenting with neurological symptoms on admission were 2.14 (95% CI: 1.27-3.61) times more likely to die than those without neurological symptoms (p = .004). CONCLUSIONS: Over 40% of HIV-positive patients admitted to KATH were newly diagnosed with HIV at admission. While pulmonary tuberculosis was the most common co-morbidity, patients presenting with neurological symptoms were at higher risk of death. This study suggests that enhanced outpatient screening is needed for early diagnosis and prompt HAART initiation, as well as increased access to diagnostic modalities and treatment for HIV-positive patients with neurological symptoms.

Uric acid transport, transporters, and their pharmacological targeting.

Knowledge of uric acid (UA) crystallopathies preceded the identification of this compound. How the body handles and transports UA proved even more elusive. Over several decades, advances in molecular phenotyping have illuminated this hitherto nebulous field. Closely parallel to the characterization of the transport mechanisms of UA in the body was the development of drugs designed to manipulate UA levels. In this review, we highlight the study of UA transport and transporters. This is an evolving field, and we expect our knowledge of the transport mechanisms to both widen and deepen further. We focus on the best-characterized transporters rather than an exhaustive catalog of all suspected transporters. We review the established and novel compounds that modulate UA transport.

Challenges in diuretic therapy: A case-based discussion.

Diuretics are amongst the most prescribed medications in both the inpatient and outpatient settings. They are used extensively in diverse disease states including heart failure, acute and chronic kidney disease, cirrhosis, and diseases of excess capillary permeability such as sepsis, malignancy, and malnutrition. All are characterized by total body sodium overabundance which commonly manifests as edema. The use of diuretics is however not bereft of complications. These complications frequently limit the correction of hypervolemia, resulting in continued patient suffering and frustration for the clinician. In this review, we employ a case-based approach to discuss three common challenges encountered during diuretic therapy: diuretic resistance that characterizes the nephrotic syndrome, diuretic-induced metabolic alkalosis, and diuretic-associated hyponatremia. We empower the clinician to effectively meet these challenges by providing a mechanistic understanding of these complications and their solutions.

Impact of socio-demographic and economic factors on intimate partner violence justification among women in union in Papua New Guinea.

BACKGROUND: Justification of intimate partner violence (IPV) has several implications, including reduced likelihood of help-seeking, increased experiences episodes of partner abuses, and poor health status and outcomes. However, in Papua New Guinea (PNG), where IPV is among the highest globally, little is known about factors influencing IPV justification among women in union. This study aimed at examining the prevalence of IPV justification and associated factors among women in union in PNG. METHODS: Data from the nationally representative cross-sectional demographic and health survey conducted among women aged 15-49 years during 2016-2018 in PNG were used. In all 9,943 women aged 15-49 years who were married or cohabiting during the survey were included. Bivariate and multivariate logistic regressions were performed and the results reported as crude odds ratios (cOR) and adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS: Overall, almost 7 in 10 women (68.9%, 95%CI:68.0-69.9) justified IPV. Multiple regression analysis revealed that co-habitation (aOR: 1.33, 95%CI: 1.17-1.50, p < 0.001), polygyny (aOR: 1.36, 95%CI: 1.20-1.53, p < 0.001), exposure to television (aOR: 1.24, 95%CI: 1.08-1.42, p = 0.002) and richer wealth status (aOR: 1.19, 95%CI: 1.01-1.40, p = 0.035), significantly increased the odds of justifying IPV. We found significantly lower odds of IPV justification among women aged 45-49 years (aOR: 0.53, 95%CI: 0.37-0.77, p = 0.001) and those with higher level of education (aOR: 0.56, 95%CI: 0.42-0.74, p < 0.001). CONCLUSION: The prevalence of IPV justification was high among women in union in PNG. Women's justification of IPV was associated with socio-demographic and economic factors. Our findings call for appropriate strategies including public education and empowerment programmes that target IPV in PNG. Moreover, strategies and interventions to address IPV justification should target the women's socio-economic and demographic contexts that influence IPV justification.

Suffering in the Hands of a Loved One: The Endemic to Intimate Partner Violence and Consequences on Migrant Female Head-Load Carriers in Ghana.

The study contributed to filling a knowledge gap in the area of intimate partner violence (IPV). Previous studies conducted in Ghana have investigated the causes and types of IPV, leaving a gap on the consequences the violence had on the victims. Using a population of local economic migrants (hereafter, head-load carriers), a qualitative design with emphasis on phenomenology was employed to investigate the effects of IPV on 20 head-load carriers in two major cities in Ghana (Kumasi and Accra). The analysis performed on the data, using interpretive phenomenological analysis, revealed that IPV affected the head-load carriers' health, employment, and human relationships. Each of the participants spoke of one or more health complications, which they attributed to IPV. Among the health-related effects reported by the head-load carriers were body pains, wounds, depression, suicide ideation, headache, and abdominal pains that resulted from the termination of an unwanted pregnancy. All the head-load carriers recounted the detrimental outcomes of IPV on their job and human relationships. After they had experienced IPV, some of the victims could not go to work due to fear of stigmatization and those who were able to could not work as they usually do due to severe pain. At their workplace, some of the IPV victims became aggressive toward customers and coworkers, whereas others remained isolated. These negatively impacted on their human relationship skills and earnings. Based on the findings, there is the need for policies that seek to address IPV to consider the effects on victims' employment, earning, and behavior.

Supervisory practices and challenges faced by senior high school principals in Greater Monrovia, Liberia: implications for quality education.

Education is an inseparable development element that influences a nation's socio-economic growth and its citizenry for a quality life. This study aimed to explore the supervisory practices by senior high school principals in Greater Monrovia, Liberia and the challenges faced during supervision. The study employed qualitative design and included 30 participants. Findings indicated that senior high school principals used supervisory practices such as inspection of teachers' lesson notes, punctuality, organized in-service training and inspection of classroom managerial skills of teachers. Notwithstanding these supervisory practices by school principals, the study found that supervision was impeded by lack of resources for teaching and learning, limited teaching staff, inexperience teachers, and improper attitudes by teachers and students.

Living with albinism in an African community: exploring the challenges of persons with albinism in Lilongwe District, Malawi.

BACKGROUND: Albinism is a genetic condition caused by a deficit in the production of the pigment called melanin, which protects the skin against ultraviolet light and provides the skin with its color production. The condition may predispose persons with albinism (PWAs) to lifelong physical and health problems, such as visual impairment and ultra-violet induced skin damage. Due to this condition, we explored the challenges faced by persons living with albinism as they socialize in Lilongwe District, Malawi. METHOD: The study adopted an interpretative phenomenological approach and included 30 participants comprising 13 females and 14 males with albinism and three key informants from Association of People with Albinism in the Lilongwe district in Malawi. Data were collected through in-depth interviews and focus group discussions. Van Manen's (2014) six steps of phenomenological analysis was used to analyze all data. RESULTS: People with albinism face a variety of problems, the most common of which are financial constraints, health complications due to a lack of adequate medical care, a lack of community support leading to stigma and discrimination, and superstitious beliefs. CONCLUSIONS: People with albinism suffer socially as a result of misconceptions, behaviours, social isolation, labelling, and beliefs that are negatively correlated with their disorder. PWAs face these problems as a result of public misunderstanding about albinism.

The relationship between accurate knowledge on HIV/AIDS transmission and adolescent pregnancy in Ghana: A further analyses of the 2017 multiple cluster indicator survey.

BACKGROUND: The literature posits that HIV knowledge is associated with precautious sexual behaviour and practice. We hypothesised and investigated the association between knowledge of HIV transmission and adolescent pregnancy in Ghana, given that the relationship between HIV knowledge and adolescent pregnancy has not been extensively studied. METHODS: We did analyses on 5836 cases (weighted as 5121) of 15-24 years old reproductive age women in the female dataset of the 2017 Multiple Cluster Indicator Survey. Adolescent pregnancy was operationalized as reproductive age women between 15-24 years who became pregnant before the age of 18 years. Accurate HIV knowledge was measured by computing the scores of correct responses on six questions exploring women's knowledge about HIV transmission. We accounted for sample design and weight before performing a Chi-square test of independence and Poisson regression. RESULTS: The results indicate that having lower scores on the HIV transmission knowledge scale was correlated with a higher probability of girls becoming pregnant before their 18th birthday. After controlling for the moderating effect of socio-demographic characteristics of the participants, we found that accurate HIV transmission knowledge loses its statistical significance in determining adolescent pregnancy. The factors that remain significant in the adjusted model were formal education status, household wealth, and region of residence. HIV transmission knowledge was statistically significantly related to adolescent pregnancy in the model after the education level variable was omitted. This observation was due to the significant effect of school education on other variables in the model. This result demonstrates that HIV knowledge has a major impact on adolescent pregnancy, but this effect is predicated by formal education attainment of the adolescent girl. CONCLUSIONS: Given the results, adolescent pregnancy issues can be resolved by the government and other development partners by adequately educating adolescents about HIV transmissions. Also, because they have the potential to reduce pregnancy among adolescents in Ghana, we recommend that programs and initiatives should address existing disparities in formal educational attainment and household wealth.

Idiopathic Hypokalemia in Lupus Nephritis: A Newly Recognized Entity.

Background: Various causes of hypokalemia (HK) from renal potassium wasting, including distal renal tubular acidosis (RTA), have been described in lupus nephritis (LN). We report a phenomenon of otherwise unexplained HK among a population with LN. Methods: From our population of 403 patients with LN, we identified a cohort of 20 patients with idiopathic HK, defined by serum potassium <3.5 mmol/L without any apparent explanation. This cohort is compared with 90 LN controls (CON) and ten patients with LN with distal RTA from the same population. Results: The patients with HK had lower median serum potassium compared with CON and RTA subjects (3.26 versus 4.00 versus 3.75 mmol/L, respectively; P<0.001). The median serum bicarbonate was normal in HK and CON, but low in RTA (26.0 versus 25.0 versus 19.4 mmol/L; P<0.001). The median urine pH was abnormally high only in the RTA group (6.00 versus 6.25 versus 6.67; P=0.012). The median serum magnesium was modestly lower in HK compared with the CON and RTA groups (1.73 versus 2.00 versus 1.85 mg/dl; P=0.002). Although both HK and RTA showed a higher rate of seropositivity than CON for anti-Ro/SSA (79% and 80% versus 37%, respectively; P<0.001), only HK revealed a higher rate of seropositivity than CON for anti-RNP (84% versus 42%; P=0.003) and only RTA showed a higher rate of seropositivity than CON for anti-La/SSB (40% versus 12%; P=0.05). Conclusions: A syndrome of idiopathic HK was revealed in 20 out of 403 (5%) of patients within our LN population, and proved to be distinct from the RTA that occurs in LN. Furthermore, it was associated with a distinct pattern of autoantibodies. We speculate that idiopathic HK is the result of a novel target of autoimmunity in LN, affecting renal tubular potassium transport.

Uric Acid and Urate in Urolithiasis: The Innocent Bystander, Instigator, and Perpetrator.

Uric acid is an end product of purine metabolism in human beings. An unusual and still unexplained phenomenon is that higher primates have relatively high uric acid levels in body fluids owing to a combination of absence of degradation and renal retention. The physiologic purpose of high uric acid levels still is enigmatic, but the pathobiologic burden is a variety of crystallopathies owing to the low aqueous solubility of uric acid such as gouty arthritis and acute uric acid nephropathy. In the urinary space, three distinct conditions result from chronic uric acid and/or urate precipitation. The first and most common variety is uric acid urolithiasis. In this condition, urate is a victim of a systemic metabolic disease in which increased acid load to the kidney is coupled with diminished urinary buffer capacity owing to defective ammonium excretion, resulting in titration of urate to its sparingly soluble protonated counterpart, uric acid, and the formation of stones. Uric acid is the innocent bystander of the crime. The second variety is hyperuricosuric calcium urolithiasis, in which uric acid confers lithogenicity via promotion of calcium oxalate precipitation by multiple mechanisms involving soluble, colloidal, and crystalline urate salts. Uric acid is the instigator of the crime. The third and least common condition involves urate as an integral part of the urolith as an ammonium salt driven by high ammonium and high urate concentrations in urine. Here, uric acid is one of the perpetrators of the crime. Both known and postulated pathogenesis of these three types of urolithiasis are reviewed and summarized.

Splenic sequestration crisis as an index manifestation of heterozygous hemoglobinopathy in an adult.

Sickle ß+-thalassemia rarely manifests with acute splenic sequestration crisis in adults. We report a case of a 20-year-old female who presented with fever and left upper quadrant abdominal pain. Laboratory studies revealed hemolytic anemia. Tests for autoimmune hemolysis and hemolytic diseases were negative except for Hemoglobin (Hb) electrophoresis, which revealed sickle cell trait (Hb AS). Infectious workup was unremarkable. Computed tomography scan of the abdomen showed marked splenomegaly. The patient received blood transfusions and empiric antibiotics with no improvement; thus, splenectomy was performed. Pathology specimen revealed peripheral serpiginous infarcts alternating with surrounding acute inflammation and small capillaries plugged with sickle cell shaped red blood cells consistent with splenic sequestration. DNA test later revealed beta-globin mutations consistent with sickle cell-beta+ thalassemia. Post-splenectomy, there was a gradual improvement in her clinical symptoms with concomitant rise in Hb to 10.6 g/dl at discharge.

Safe use of NSAIDs and RAS-inhibitors at Agogo Presbyterian Hospital, Ghana.

BACKGROUND: Preventable adverse events of medication are an important cause of hospital admissions in the developed world, in which non-steroidal anti-inflammatory drugs (NSAIDs) and renin-angiotensin system (RAS-) inhibitors are frequently involved. NSAIDs and RAS-inhibitors are also often used in Ghana. The purpose of this study is to assess whether biochemical monitoring in patients on RAS-inhibitors, and co-administration of gastro protective agents (GPAs) in patients on NSAIDs, is done properly in Ghana. MATERIAL AND METHODS: Two retrospective cross-sectional studies were carried out at the Agogo Presbyterian Hospital, Ghana, in 2013. In 114 out-and inpatients who are on NSAIDs, the risk for gastrointestinal side effects and the frequency of co-administration of GPAs were determined. In 301 outpatients who are on RAS-inhibitors, the risk for renal dysfunction and the frequency of biochemical monitoring were determined. Fisher's exact test was used to determine the statistical strength. RESULTS: Co-administration of GPAs was done in 1.8% of patients on NSAIDs. Serum creatinine and potassium monitoring within one month after initiation of treatment with RAS-inhibitors were performed in 6.3% and 3.7%, respectively. Risk factors were neither associated with prescription of a GPA in patients on NSAIDs (p=0.134), nor in performing biochemical monitoring in patients on RAS-inhibitors (p=0.219 for creatinine, p=0.062 for potassium). CONCLUSIONS: Biochemical monitoring in patients on RAS-inhibitors and use of GPAs in patients on NSAIDs is poorly performed at the Agogo Presbyterian Hospital in Ghana. Improving the already existing Ghanaian guidelines, especially those for RAS-inhibitors, and encouraging their widespread use among prescribers should be pursued.