Peterborough Regional Health Centre

OBJECTIVES:Most ICUs use protocolized magnesium supplementation, yet the clinical effect of this practice is unknown. DESIGN:Pseudo-randomized retrospective study comparing patients who were and were not assigned to receive magnesium supplementation, using a protocol where supplementation occurs when serum levels are less than or equal to 0.95 mmol/L (2.31 mg/dL). Primary outcome was atrial fibrillation or flutter within 24 hours. Secondary outcomes were tachyarrhythmia (supraventricular tachycardia or ventricular arrhythmia) and death within 24 hours. SETTING:ICUs with a shared magnesium supplementation protocol, in five hospitals in Ontario, Canada, from January 1, 2022, to December 31, 2024. PATIENTS:Adults (18 yr old or older) admitted to ICU with a magnesium protocol order, at their first magnesium level of 0.92-0.99 mmol/L (2.24-2.41 mg/dL). To minimize confounding, we included only patients with a level near the supplementation threshold. INTERVENTIONS:None. EXPOSURE:Magnesium level 0.92-0.95 mmol/L (2.24-2.31 mg/dL, supplementation group) vs. 0.96-0.99 mmol/L (2.32-2.41 mg/dL, no supplementation group). MEASUREMENTS AND MAIN RESULTS:We identified 4198 patients; median age 70 years, 41% female, 39% invasively ventilated; 2144 (51%) in the supplementation group, of whom 77% received magnesium, and 2054 (49%) in the no supplementation group, of whom 9% received magnesium. Atrial fibrillation or flutter occurred within 24 hours in 355 (16.6%) in the supplementation group and 375 (18.3%) in the no supplementation group. Bayesian logistic regression, adjusted for hospital, showed a 1.6% absolute risk reduction associated with supplementation (95% credible interval, 3.8% reduction to 0.8% increase; probability of reduction, 0.91). For the composite outcome of atrial fibrillation and flutter, tachyarrhythmia, and death, the absolute risk reduction associated with supplementation was 2.2% (CrI, 4.3% reduction to 0.1% increase; probability of risk reduction, 0.97). CONCLUSIONS:Protocolized magnesium supplementation at a threshold of 0.95 mmol/L (2.31 mg/dL) may be associated with reduced 24-hour incidence of atrial fibrillation and flutter in critically ill patients.

Purpose of review: Cardiovascular disease (CVD) accounts for nearly half of deaths among people receiving maintenance hemodialysis. Observational and interventional data suggest that higher serum magnesium, achieved through higher dialysate magnesium concentrations or oral supplementation, may improve cardiovascular outcomes and survival. This review synthesizes current evidence and provides context for an ongoing cluster-randomized trial that is testing whether a center-wide dialysate magnesium concentration of 0.75 mmol/L, versus ≤0.50 mmol/L, delivered as a policy and sustained for up to four years, reduces the risk of major cardiovascular-related hospitalizations. Sources of information: Peer-reviewed articles. Methods: We searched MEDLINE and EMBASE for observational and interventional studies evaluating serum or dialysate magnesium concentrations and cardiovascular outcomes in patients with chronic kidney disease and/or kidney failure. We appraised the methodological quality of interventional trials. This review is divided into four sections: (1) epidemiological associations between serum magnesium concentrations and CVD outcomes, (2) the impact of a higher concentration of dialysate magnesium on CVD outcomes, (3) the impact of oral magnesium supplementation on CVD outcomes, and (4) ongoing trials. Key findings: Twenty studies, including 10 randomized controlled trials, were reviewed. Systematic reviews and meta-analyses show that hypomagnesemia is associated with higher risks of cardiovascular events and all-cause mortality in hemodialysis. Interventional studies indicate that higher dialysate magnesium concentrations or oral supplementation can improve surrogate markers of vascular health, including less vascular calcification and stiffness. Higher dialysate concentrations may also lower cardiovascular mortality. Given encouraging but predominantly surrogate-based evidence, adequately powered randomized trials are warranted. Limitations: Most trials were small, single-center, and of short duration. They relied on surrogate endpoints, and there was heterogeneity in interventions and outcome measures.

Imposter phenomenon is common in healthcare professionals and other high-achieving fields. It is exhibited as persistent self-doubt in one's abilities, fear of being labeled as a fraud despite evidence of achievements, and the belief that one's successes have been a result of luck rather than having been earned. Downstream effects of imposter phenomenon include impacts on mental health, job progression, and leadership potential. Some groups are disproportionately affected, including underrepresented minorities, women, and trainees/early career faculty. It affects all ages and career stages, yet often exists in a culture of silence. The authors designed a one-day, in-person symposium ("short course") in 2024 to address repeated self-descriptions of "imposter syndrome" in their colleagues. The purpose of the short course was to define imposter phenomenon, explore and identify contributing intrinsic and extrinsic factors, and provide tools for mitigating imposter phenomenon locally. There were 73 attendees who provided real-time aggregate, anonymized feedback. Eighty percent of respondents indicated they likely had imposter phenomenon or had moments of self-doubt. Themes on contributing factors included feeling different, lack of mentorship or social support, hierarchies and lack of leadership support, feeling actual or perceived pressure or going through a change, lack of confidence, taking on new tasks, and being an early career genetic counselor. Although not designed as a scientific study, our findings are the first reported from a cross section of genetic counselors, revealing similarities to those in other high-achieving healthcare professionals. We describe reported strategies and highlight the need for mitigation of feelings of imposter phenomenon on a personal and professional level. This is particularly relevant in light of advances in medical genetics, and genetic counselor leadership needed to incorporate these advances into broader areas of healthcare delivery.

Purpose: To explore what socially just dietetic practice means and how it is enacted in Registered Dietitians' (RDs) day-to-day work. Methods: We used qualitative interpretive description to design this study, for which we interviewed 19 Canadian RDs who engage in what they describe as socially just practice and/or advocacy. Results: Participants felt strongly that socially just practice is a responsibility of all practitioners and is rooted in a broader understanding of social justice. Participants described socially just dietetic practice as multidimensional and intersectional and asserted that it necessitates diverse voices and advocacy. The enactment of socially just practice varied across workplace settings and is shaped by the distinct worldviews, orientations to practice, day-to-day tasks, and demands that characterize different areas of practice, as well as by the attendant knowledge, skills, and experiences of practitioners employed therein. Conclusions: Acting on the commitments, competencies, and calls to action for socially just dietetic practice requires orienting the profession at a fundamental level to a collective and operationalizable vision of socially just dietetic practice and advocacy.

High-risk benign breast lesions are histological abnormalities that present in breast tissue, typically identified by screening or diagnostic imaging. The presence of invasive or in situ breast cancer can be confirmed or ruled out within these lesions, and the risk of developing breast cancer can be reduced by their appropriate management. These potential high-risk lesions reviewed include atypical ductal hyperplasia, mucocele-like lesions, papillary lesions with or without atypia, radial scar/complex sclerosing lesion with or without atypia, atypical lobular hyperplasia, classical lobular carcinoma in situ, pleomorphic/florid lobular carcinoma in situ, flat epithelial atypia, columnar cell change, fibroepithelial lesions with stromal cellularity, spindle cell lesions/mesenchymal lesions, and microglandular adenosis. The lack of a clear consensus on the management of many of these lesions led the Ontario Health (Cancer Care Ontario) (OH-CCO) Breast Cancer Pathway Map Working Group and Breast Cancer Advisory Committee to identify the need for a recommendation document. A multidisciplinary working group was formed, with members representing surgical oncology, radiology, pathology, medical oncology, and genetic counselling. The working group developed a list of high-risk benign lesions to be included in this recommendation report. An updated literature review was completed, and these publications were reviewed by the working group, and recommendations were drafted. When evidence was lacking, the expert opinion was included. These draft recommendations were subjected to an extensive review by experts both within Cancer Care Ontario and across Canada. The recommendations included in this report are relevant to clinicians, primary care physicians, oncologists, radiologists, and pathologists who treat breast cancer and manage breast conditions.