Direct Observation (DO) for Drug-Resistant Tuberculosis: Do We Really DO?

Introduction

Directly-observed therapy (DOT) is recommended for drug-resistant tuberculosis (DR-TB) patients during their entire treatment duration. However, there is limited published evidence on implementation of direct observation (DO) in the field. This study aims to detail whether DO was followed with DR-TB patients in a Médecins Sans Frontières (MSF) tuberculosis program in Mumbai, India.

Methods

This was a cross-sectional, mixed-methods study. Existing qualitative data from a purposively-selected subset of 12 patients, 5 DOT-providers and 5 family members, were assessed in order to determine how DO was implemented. A questionnaire-based survey of DR-TB patients, their DOT-providers and MSF staff was completed between June and August 2014. Patients were defined as”following Strict DO” and “following DO” if a DOT-provider had seen the patient swallow his/her medications “every day” or “most of the days” respectively. If DO was not followed, reasons were also recorded. The qualitative data were analysed for theme and content and used to supplement the questionnaire-based data.

Results

A total of 70 DR-TB patients, 65 DOT-providers and 21 MSF health staff were included. Fifty-five per cent of the patients were HIV-co-infected and 41% had multidrug-resistant-TB plus additional resistance to a fluoroquinolone. Among all patients, only 14% (10/70) and 20% (14/70) self-reported “following Strict DO” and “following DO” respectively. Among DOT-providers, 46% (30/65) reported that their patients “followed DO”. MSF health staff reported none of the patients “followed DO”. Reasons for not implementing DO included the unavailability of DOT-provider, time spent, stigma and treatment adverse events. The qualitative data also revealed that “Strict DO” was rarely followed and noted the same reasons for lack of implementation.

Conclusion

This mixed-methods study has found that a majority of patients with DR-TB in Mumbai did not follow DO, and this was reported by patients and care-providers. These data likely reflect the reality of DO implementation in many high-burden settings, since this relatively small cohort was supported and closely monitored by a skilled team with access to multiple resources. The findings raise important concerns about the necessity of DO as a “pillar” of DR-TB treatment which need further validation in other settings. They also suggest that patient-centred adherence strategies might be better approaches for supporting patients on treatment.     

Booking patients for hospital admissions: evaluation of a pilot programme for day cases

Problem NHS patients requiring elective surgery usually have to wait before being treated and are usually told when a date becomes available.Design 18 month pilot programme to enable day case patients to book date of hospital admission at time of decision to operate.Background and setting 24 pilot sites in England with relatively short waiting times and some experience of booking appointments.Key measures for improvement Proportion of patients with booked or “to come in” date during and after pilot programme, proportion not attending for admission, and proportion waiting ≥ 6 months. Comparison of pilot sites with non-pilot sites.Strategies for change National Patients'' Access Team established to help pilot sites enable patients to book admission dates. Provision of £9.9m to pilot sites to employ project managers, purchase equipment, buy extra time from clinical and other staff, and invest in information and communications technology.Effects of change Proportion of patients with booked or “to come in” date increased from 51.1% to 72.7% between end of March 1999 and end of March 2000, and then fell to 66.2% by end of March 2001. Over the same periods, the proportion of patients waiting ≥ 6 months fell from 10.9% to 10.5% and then increased to 11.9%. The proportion of patients failing to attend fell from 5.7% to 3.1% between the first quarter of 1999 and the first quarter of 2000, and then increased to 4.0% in the first quarter of 2001. Pilot sites varied widely in performance during and after the pilot phase. Pilot sites had higher proportions of patients with booked or “to come in” date than non-pilot sites at end of each period.Lessons learnt Increasing the proportion of patients who book their date of hospital admission is possible, but there are difficulties in sustaining this. Several factors facilitated or hindered the implementation of booking, and the roll out of the programme across the NHS is seeking to incorporate these factors.     

Quality along the Continuum: A Health Facility Assessment of Intrapartum and Postnatal Care in Ghana

Objective

To evaluate quality of routine and emergency intrapartum and postnatal care using a health facility assessment, and to estimate “effective coverage” of skilled attendance in Brong Ahafo, Ghana.

Methods

We conducted an assessment of all 86 health facilities in seven districts in Brong Ahafo. Using performance of key signal functions and the availability of relevant drugs, equipment and trained health professionals, we created composite quality categories in four dimensions: routine delivery care, emergency obstetric care (EmOC), emergency newborn care (EmNC) and non-medical quality. Linking the health facility assessment to surveillance data we estimated “effective coverage” of skilled attendance as the proportion of births in facilities of high quality.

Findings

Delivery care was offered in 64/86 facilities; only 3-13% fulfilled our requirements for the highest quality category in any dimension. Quality was lowest in the emergency care dimensions, with 63% and 58% of facilities categorized as “low” or “substandard” for EmOC and EmNC, respectively. This implies performing less than four EmOC or three EmNC signal functions, and/or employing less than two skilled health professionals, and/or that no health professionals were present during our visit. Routine delivery care was “low” or “substandard” in 39% of facilities, meaning 25/64 facilities performed less than six routine signal functions and/or had less than two skilled health professionals and/or less than one midwife. While 68% of births were in health facilities, only 18% were in facilities with “high” or “highest” quality in all dimensions.

Conclusion

Our comprehensive facility assessment showed that quality of routine and emergency intrapartum and postnatal care was generally low in the study region. While coverage with facility delivery was 68%, we estimated “effective coverage” of skilled attendance at 18%, thus revealing a large “quality gap.” Effective coverage could be a meaningful indicator of progress towards reducing maternal and newborn mortality.     

The Fate of Threatened Coastal Dune Habitats in Italy under Climate Change Scenarios

Coastal dunes worldwide harbor threatened habitats characterized by high diversity in terms of plant communities. In Italy, recent assessments have highlighted the insufficient state of conservation of these habitats as defined by the EU Habitats Directive. The effects of predicted climate change could have dramatic consequences for coastal environments in the near future. An assessment of the efficacy of protection measures under climate change is thus a priority. Here, we have developed environmental envelope models for the most widespread dune habitats in Italy, following two complementary approaches: an “indirect” plant-species-based one and a simple “direct” one. We analyzed how habitats distribution will be altered under the effects of two climate change scenarios and evaluated if the current Italian network of protected areas will be effective in the future after distribution shifts. While modeling dune habitats with the “direct” approach was unsatisfactory, “indirect” models had a good predictive performance, highlighting the importance of using species’ responses to climate change for modeling these habitats. The results showed that habitats closer to the sea may even increase their geographical distribution in the near future. The transition dune habitat is projected to remain stable, although mobile and fixed dune habitats are projected to lose most of their actual geographical distribution, the latter being more sensitive to climate change effects. Gap analysis highlighted that the habitats’ distribution is currently adequately covered by protected areas, achieving the conservation target. However, according to predictions, protection level for mobile and fixed dune habitats is predicted to drop drastically under the climate change scenarios which we examined. Our results provide useful insights for setting management priorities and better addressing conservation efforts to preserve these threatened habitats in future.     

Diagnosis and Treatment of Delirium

Delirium is not a clinical entity but a symptom-complex of manifold etiology. Its presence signifies acute cerebral insufficiency and often represents a medical and/or psychiatric emergency.Though some forms of delirium have distinctive features, the fundamental phenomena are common to all, with clouding of consciousness the sine qua non. The condition has two major components: (1) the basic “acute brain syndrome” and (2) associated release phenomena.Clinicians must first make the vital differentiation between delirium and “functional” mental disorder, then proceed with the elucidation of the underlying diagnosis and the concurrent organization of symptomatic and etiologic treatment.Proper treatment combines management of the acute brain syndrome with general and specific procedures for control of the underlying condition. Dealing with the symptom-complex itself involves the principles and practice of sedation, hydration, and nutrition, nursing care and supportive measures. Provided the basic organic condition is treatable, the prognosis today is usually good.     

Molecular Diagnostics of Fine Needle Aspiration for the Presurgical Screening of Thyroid Nodules

“The incidence of thyroid cancer, the most common endocrine malignancy, is rising. The two most common types of thyroid cancer are papillary and follicular” thyroid carcinomas. “Fine-needle aspiration (FNA) of thyroid nodules” can permit to detect many genetic mutations and other molecular alterations, including RAS and BRAF point mutations, PAX8/peroxisome proliferator-activated receptor (PPAR)γ and “RET/PTC rearrangements, occurring in thyroid papillary and follicular carcinomas” (more than 70% of cases), which can be used successfully to improve the diagnosis “and the management of patients with thyroid nodules”. The most extensive experience has been accumulated with “the diagnostic use of BRAF mutation”, which is highly specific for malignancy. “Testing FNA samples for a panel of mutations” that typically includes RAS, BRAF, PAX8/PPARγ and RET/PTC could permit to achieve the biggest diagnostic impact. “The accuracy of cancer diagnosis in thyroid nodules could be improved significantly using these and other emerging molecular markers”.     

Barriers and Enablers of Kangaroo Mother Care Practice: A Systematic Review

Kangaroo mother care (KMC) is an evidence-based approach to reducing mortality and morbidity in preterm infants. Although KMC is a key intervention package in newborn health initiatives, there is limited systematic information available on the barriers to KMC practice that mothers and other stakeholders face while practicing KMC. This systematic review sought to identify the most frequently reported barriers to KMC practice for mothers, fathers, and health practitioners, as well as the most frequently reported enablers to practice for mothers. We searched nine electronic databases and relevant reference lists for publications reporting barriers or enablers to KMC practice. We identified 1,264 unique publications, of which 103 were included based on pre-specified criteria. Publications were scanned for all barriers / enablers. Each publication was also categorized based on its approach to identification of barriers / enablers, and more weight was assigned to publications which had systematically sought to understand factors influencing KMC practice. Four of the top five ranked barriers to KMC practice for mothers were resource-related: “Issues with the facility environment / resources,” “negative impressions of staff attitudes or interactions with staff,” “lack of help with KMC practice or other obligations,” and “low awareness of KMC / infant health.” Considering only publications from low- and middle-income countries, “pain / fatigue” was ranked higher than when considering all publications. Top enablers to practice were included “mother-infant attachment” and “support from family, friends, and other mentors.” Our findings suggest that mother can understand and enjoy KMC, and it has benefits for mothers, infants, and families. However, continuous KMC may be physically and emotionally difficult, and often requires support from family members, health practitioners, or other mothers. These findings can serve as a starting point for researchers and program implementers looking to improve KMC programs.     

USE OF THE ARTIFICIAL KIDNEY—Its Place in the Treatment of Acute Renal Failure

Of 57 patients with severe, but potentially reversible, acute renal failure who were observed during a recent four-year period, some had dialysis with an artificial kidney and some did not.Twenty survived with the standard “conservative” management alone; 19 survived with a combination of “conservative” and “intensive” (that is, artificial kidney) treatment; 18 patients died.One error that was made in the management of all 18 patients who died, was excessive delay in the use of the artificial kidney.Hemodialysis should be used whenever serious electrolyte abnormality exists, whenever the blood urea nitrogen exceeds 150 mg. per 100 cc. or whenever clinical signs of uremia first appear. One or more of these indications will usually, but not always, become evident between the fifth and the eighth day of virtual anuria.     

Erythropoietic Protoporphyria IV. Protection from Sunlight

Dihydroxyacetone and lawsone, in a vanishing cream base, applied to the skin was found to protect patients with erythropoietic protoporphyria against sunlight. The use of the same ingredients in a 50% isopropyl alcohol/water solution did not induce adequate light protection. The chemically induced ultraviolet light filter in the stratum corneum allowed these patients to change their lives from an “indoor” to an “outdoor” environment.     

Surgical aspects of international drug smuggling

The internal concealment of cocaine and other drugs in packets by “body packers”—those who swallow packets of drugs or hide them in their vagina or rectum—to avoid detection by customs officials has been increasing in both the United States and Europe. The types of package and how they are concealed are changing as the traffickers become more sophisticated in their methods. The latest parcels are less likely to burst, but obstruction of the bowel may occur.Awareness of the problem is important for staff of emergency medical services near international ports of arrival.     

THE WORK OF AN Rh COMMITTEE—Experiences in a Private General Hospital

An Rh committee was formed at Saint John''s Hospital in Santa Monica to provide preadmission consultation on all potential Rh and ABO problems and to maintain a file of information on Rh-negative patients in the delivery room. It is urged that no patient go to the delivery room without the known Rh-ABO type as part of the labor record. All obstetrical patients at the hospital are given “obstetrical information cards” for use as a memorandum on the labor record. A pink card identifies the Rh-negative patient.The program keeps the staff “Rh-conscious” and has improved teamwork among the obstetricians, pediatricians, nurses and the laboratory.     

Helicobacter pylori test and treat versus proton pump inhibitor in initial management of dyspepsia in primary care: multicentre randomised controlled trial (MRC-CUBE trial)

Objective To determine the cost effectiveness of Helicobacter pylori “test and treat” compared with empirical acid suppression in the initial management of patients with dyspepsia in primary care.Design Randomised controlled trial.Setting 80 general practices in the United Kingdom.Participants 699 patients aged 18-65 who presented to their general practitioner with epigastric pain, heartburn, or both without “alarm symptoms” for malignancy.Intervention H pylori ¹³C urea breath test plus one week of eradication treatment if positive or proton pump inhibitor alone; subsequent management at general practitioner’s discretion.Main outcome measures Cost effectiveness in cost per quality adjusted life year (QALY) (EQ-5D) and effect on dyspeptic symptoms at one year measured with short form Leeds dyspepsia questionnaire.Results 343 patients were randomised to testing for H pylori, and 100 were positive. The successful eradication rate was 78%. 356 patients received proton pump inhibitor for 28 days. At 12 months no significant differences existed between the two groups in QALYs, costs, or dyspeptic symptoms. Minor reductions in costly resource use over the year in the test and treat group “paid back” the initial cost of the intervention.Conclusions Test and treat and acid suppression are equally cost effective in the initial management of dyspepsia. Empirical acid suppression is an appropriate initial strategy. As costs are similar overall, general practitioners should discuss with patients at which point to consider H pylori testing.Trial registration Current Controlled Trials ISRCTN87644265.     

The most unkindest cut

When universities need to make staffing cuts to balance the books, do they always do so in the fairest and most rational manner?

Universities, like most other large organizations, undergo periodic restructuring, expansions and contractions, driven largely by changes in their balance sheet. The contractions are often abrupt and painful. Typically, this outcome is preceded by a period when the top management already perceived a growing problem but postponed action because of its debilitating effects on morale and on the organization’s core functions, in the hope that “something might turn up” that would obviate the need for drastic cuts. Most often, something does not turn up, and the cuts end up being even more severe.The first sign of trouble is usually a “message to all staff” that seems to come out of the blue, couched in the most anodyne of terms, or even trying to put a positive spin on what is a fundamentally destructive process. But staff about to be made redundant do not appreciate being referred to as “person‐years”. It also seems completely pointless to dress up more or less arbitrary decisions on whom to terminate as “negotiations”, thus apportioning a share of blame to the union representatives who have not much say in these “negotiations” anyway. Although the cuts typically affect non‐academic staff, such as lab technicians, IT and audiovisual support, financial administrators, providers of student welfare services or travel and hospitality arrangers, academic staff at all levels are sometimes affected as well.Most of us can read between the lines and find disingenuous statements of this type insulting rather than reassuring. Let me translate this for you into plain English:“Due to the fact that our senior management has totally screwed up the university’s finances, we need to decrease our staff costs by 20%. Since most staff would not accept to do the same work for 20% less pay, we will instead just fire 20% of the staff. If you are one of the 20% who are able to do your job and have been properly trained, we strongly advise you to immediately seek employment elsewhere. After all, you might find yourselves fired in the next round of cuts, if these ones don’t prove sufficient”.The duties of the 20% who leave will be transferred to the 80% who remain. Since they will be required to carry out additional tasks beyond those that they currently undertake but were never trained to perform in the first place, it is natural that many of them will go on permanent sick leave or retire early, thus reducing our staff costs further and avoiding undue stress on persons we have failed to train properly.As a result, academic staff currently engaged on less quantifiable activities such as research and teaching must shoulder some of the burden. We hope to avoid firing academic staff but be aware that you may also be terminated if performance targets are missed, especially if you are unable to undertake simple obligations to help the university to function properly instead of wasting all your energy on research and teaching.The next phase of this process will be the outsourcing of many of the duties that the poorly trained 80% of staff and academics cannot do or are unwilling to do. We will invite tenders from different companies and always pick the lowest bidder, regardless of the quality of the services they are able to perform. However, be aware that academic staff who make use of these services must employ the companies contracted by the university and no others. You will also have to pay for these services from research grants or other income.Spin‐off companies that you have created could also bid for some of these services, which might enable you to cover the costs during the 2–3 years before your fledgling company goes bankrupt.Please also consider if and how you can outsource your own research and teaching, which would enable us to fire academic staff as well, in any future cost‐cutting exercise.If this process is successful, the university hopes to recycle any excess savings into a new round of Strategic Interconvertibility and Sustainable Innovation (SISI) grants.And above all, please do remember and implement our university’s new slogan “The only useful research is market research”. Kit from HR, aka Howy Jacobs     

Experiences of Community-Living Older Adults Receiving Integrated Care Based on the Chronic Care Model: A Qualitative Study

BackgroundIntegrated care models aim to solve the problem of fragmented and poorly coordinated care in current healthcare systems. These models aim to be patient-centered by providing continuous and coordinated care and by considering the needs and preferences of patients. The objective of this study was to evaluate the opinions and experiences of community-living older adults with regard to integrated care and support, along with the extent to which it meets their health and social needs.MethodsSemi-structured interviews were conducted with 23 older adults receiving integrated care and support through “Embrace,” an integrated care model for community-living older adults that is based on the Chronic Care Model and a population health management model. Embrace is currently fully operational in the northern region of the Netherlands. Data analysis was based on the grounded theory approach.ResultsResponses of participants concerned two focus areas: 1) Experiences with aging, with the themes “Struggling with health,” “Increasing dependency,” “Decreasing social interaction,” “Loss of control,” and “Fears;” and 2) Experiences with Embrace, with the themes “Relationship with the case manager,” “Interactions,” and “Feeling in control, safe, and secure”. The prospect of becoming dependent and losing control was a key concept in the lives of the older adults interviewed. Embrace reinforced the participants’ ability to stay in control, even if they were dependent on others. Furthermore, participants felt safe and secure, in contrast to the fears of increasing dependency within the standard care system.ConclusionThe results indicate that integrated care and support provided through Embrace met the health and social needs of older adults, who were coping with the consequences of aging.     

The Brain’s Response to the Human Voice Depends on the Incidence of Autistic Traits in the General Population

Optimal brain sensitivity to the fundamental frequency (F0) contour changes in the human voice is important for understanding a speaker’s intonation, and consequently, the speaker’s attitude. However, whether sensitivity in the brain’s response to a human voice F0 contour change varies with an interaction between an individual’s traits (i.e., autistic traits) and a human voice element (i.e., presence or absence of communicative action such as calling) has not been investigated. In the present study, we investigated the neural processes involved in the perception of F0 contour changes in the Japanese monosyllables “ne” and “nu.” “Ne” is an interjection that means “hi” or “hey” in English; pronunciation of “ne” with a high falling F0 contour is used when the speaker wants to attract a listener’s attention (i.e., social intonation). Meanwhile, the Japanese concrete noun “nu” has no communicative meaning. We applied an adaptive spatial filtering method to the neuromagnetic time course recorded by whole-head magnetoencephalography (MEG) and estimated the spatiotemporal frequency dynamics of event-related cerebral oscillatory changes in beta band during the oddball paradigm. During the perception of the F0 contour change when “ne” was presented, there was event-related de-synchronization (ERD) in the right temporal lobe. In contrast, during the perception of the F0 contour change when “nu” was presented, ERD occurred in the left temporal lobe and in the bilateral occipital lobes. ERD that occurred during the social stimulus “ne” in the right hemisphere was significantly correlated with a greater number of autistic traits measured according to the Autism Spectrum Quotient (AQ), suggesting that the differences in human voice processing are associated with higher autistic traits, even in non-clinical subjects.     

Hepatitis-associated antigen in sporadic cases of acute viral hepatitis

Serum specimens collected during the period from September 1970 to April 1971 from hospitalized patients and apparently healthy staff members at risk were tested for the presence of hepatitis-associated antigen (HAA) by the parallel use of three techniques: the complement fixation test, crossover-electrophoresis and immuno-electronmicroscopy.Out of a total of 204 persons investigated 63 (30.9%) were found to harbour the antigen. The HAA-positive sera originated almost exclusively from sporadic cases of acute viral hepatitis (clinically diagnosed as “infectious hepatitis” or “serum hepatitis”). The great majority of the hepatitis cases studied had a history of drug addiction.     

“Complications” of the Landry-Guillain-Barré-Strohl syndrome

Prognosis for life in the Landry-Guillain-Barré-Strohl syndrome is dependent upon the development of respiratory and non-respiratory “complications” and their successful management. Review of the literature, a case history, and a study of 14 patients with this syndrome at the University Hospital, Edmonton, indicate that “complications” can be anticipated in virtually all areas of acute care management, including respiratory, gastrointestinal, urinary tract, central and autonomic nervous systems, metabolic, cardiovascular, and infectious disease. The proper management of patients with the Landry-Guillain-Barré-Strohl syndrome demands an awareness of the totality of care required and the presence of a hospital system that provides for vital system monitoring and support, and for ready interdisciplinary consultation.     

Weighting of Criteria for Disease Prioritization Using Conjoint Analysis and Based on Health Professional and Student Opinion

Disease prioritization exercises have been used by several organizations to inform surveillance and control measures. Though most methodologies for disease prioritization are based on expert opinion, it is becoming more common to include different stakeholders in the prioritization exercise. This study was performed to compare the weighting of disease criteria, and the consequent prioritization of zoonoses, by both health professionals and students in Switzerland using a Conjoint Analysis questionnaire. The health professionals comprised public health and food safety experts, cantonal physicians and cantonal veterinarians, while the student group comprised first-year veterinary and agronomy students. Eight criteria were selected for this prioritization based on expert elicitation and literature review. These criteria, described on a 3-tiered scale, were evaluated through a choice-based Conjoint Analysis questionnaire with 25 choice tasks. Questionnaire results were analyzed to obtain importance scores (for each criterion) and mean utility values (for each criterion level), and the latter were then used to rank 16 zoonoses. While the most important criterion for both groups was “Severity of the disease in humans”, the second ranked criteria by the health professionals and students were “Economy” and “Treatment in humans”, respectively. Regarding the criterion “Control and Prevention”, health professionals tended to prioritize a disease when the control and preventive measures were described to be 95% effective, while students prioritized a disease if there were almost no control and preventive measures available. Bovine Spongiform Encephalopathy was the top-ranked disease by both groups. Health professionals and students agreed on the weighting of certain criteria such as “Severity” and “Treatment of disease in humans”, but disagreed on others such as “Economy” or “Control and Prevention”. Nonetheless, the overall disease ranking lists were similar, and these may be taken into consideration when making future decisions regarding resource allocation for disease control and prevention in Switzerland.     

Foetal Blood Sampling. Practical Approach to Management of Foetal Distress

The practical application of foetal blood sampling in the routine management of patients in labour has been reviewed in a six-month survey, during which time 1,668 patients were delivered at Queen Charlotte''s Hospital.Foetal acidaemia (pH 7·25 or less) occurred in 45 of the 295 patients who showed clinical signs of foetal distress. Foetal tachycardia was the presenting sign in 33 of these 45 patients, underlining the importance of this physical sign. Foetal acidaemia in association with clinical foetal distress occurred twice as often in patients who had complications of pregnancy and who were therefore regarded as obstetrically “at risk” as it did in patients who were obstetrically “normal” No cases of acidaemia were detected in any of the foetal blood samples performed routinely on “at-risk” patients in the absence of clinical foetal distress.     

The Association between the Use of Proton Pump Inhibitors and the Risk of Hypomagnesemia: A Systematic Review and Meta-Analysis

Background

Although many case reports have described patients with proton pump inhibitor (PPI)-induced hypomagnesemia, the impact of PPI use on hypomagnesemia has not been fully clarified through comparative studies. We aimed to evaluate the association between the use of PPI and the risk of developing hypomagnesemia by conducting a systematic review with meta-analysis.

Methods

We conducted a systematic search of MEDLINE, EMBASE, and the Cochrane Library using the primary keywords “proton pump,” “dexlansoprazole,” “esomeprazole,” “ilaprazole,” “lansoprazole,” “omeprazole,” “pantoprazole,” “rabeprazole,” “hypomagnesemia,” “hypomagnesaemia,” and “magnesium.” Studies were included if they evaluated the association between PPI use and hypomagnesemia and reported relative risks or odds ratios or provided data for their estimation. Pooled odds ratios with 95% confidence intervals were calculated using the random effects model. Statistical heterogeneity was assessed with Cochran’s Q test and I ² statistics.

Results

Nine studies including 115,455 patients were analyzed. The median Newcastle-Ottawa quality score for the included studies was seven (range, 6–9). Among patients taking PPIs, the median proportion of patients with hypomagnesemia was 27.1% (range, 11.3–55.2%) across all included studies. Among patients not taking PPIs, the median proportion of patients with hypomagnesemia was 18.4% (range, 4.3–52.7%). On meta-analysis, pooled odds ratio for PPI use was found to be 1.775 (95% confidence interval 1.077–2.924). Significant heterogeneity was identified using Cochran’s Q test (df = 7, P<0.001, I ² = 98.0%).

Conclusions

PPI use may increase the risk of hypomagnesemia. However, significant heterogeneity among the included studies prevented us from reaching a definitive conclusion.