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Stanojević M, Djuricic N, Parezanovic M, Biorac M, Pathak D, Spasic S, Lopicic S, Kovacevic S, Nesovic Ostojic J. The Impact of Chronic Magnesium Deficiency on Excitable Tissues-Translational Aspects. Biol Trace Elem Res 2024:10.1007/s12011-024-04216-2. [PMID: 38709369 DOI: 10.1007/s12011-024-04216-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 04/28/2024] [Indexed: 05/07/2024]
Abstract
Neuromuscular excitability is a vital body function, and Mg2+ is an essential regulatory cation for the function of excitable membranes. Loss of Mg2+ homeostasis disturbs fluxes of other cations across cell membranes, leading to pathophysiological electrogenesis, which can eventually cause vital threat to the patient. Chronic subclinical Mg2+ deficiency is an increasingly prevalent condition in the general population. It is associated with an elevated risk of cardiovascular, respiratory and neurological conditions and an increased mortality. Magnesium favours bronchodilation (by antagonizing Ca2+ channels on airway smooth muscle and inhibiting the release of endogenous bronchoconstrictors). Magnesium exerts antihypertensive effects by reducing peripheral vascular resistance (increasing endothelial NO and PgI2 release and inhibiting Ca2+ influx into vascular smooth muscle). Magnesium deficiency disturbs heart impulse generation and propagation by prolonging cell depolarization (due to Na+/K+ pump and Kir channel dysfunction) and dysregulating cardiac gap junctions, causing arrhythmias, while prolonged diastolic Ca2+ release (through leaky RyRs) disturbs cardiac excitation-contraction coupling, compromising diastolic relaxation and systolic contraction. In the brain, Mg2+ regulates the function of ion channels and neurotransmitters (blocks voltage-gated Ca2+ channel-mediated transmitter release, antagonizes NMDARs, activates GABAARs, suppresses nAChR ion current and modulates gap junction channels) and blocks ACh release at neuromuscular junctions. Magnesium exerts multiple therapeutic neuroactive effects (antiepileptic, antimigraine, analgesic, neuroprotective, antidepressant, anxiolytic, etc.). This review focuses on the effects of Mg2+ on excitable tissues in health and disease. As a natural membrane stabilizer, Mg2+ opposes the development of many conditions of hyperexcitability. Its beneficial recompensation and supplementation help treat hyperexcitability and should therefore be considered wherever needed.
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Affiliation(s)
- Marija Stanojević
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia.
| | - Nadezda Djuricic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Miro Parezanovic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
- Institute for Mother and Child Healthcare of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Marko Biorac
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Dhruba Pathak
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Svetolik Spasic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Srdjan Lopicic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Sanjin Kovacevic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
| | - Jelena Nesovic Ostojic
- University of Belgrade, Faculty of Medicine, Institute for Pathological Physiology "Ljubodrag Buba Mihailović", 9, Dr Subotića Street, 11000, Belgrade, Serbia
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Khadse S, Takalikar VS, Ghildiyal R, Shah N. Rare cause of recurrent hypocalcaemia and functional hypoparathyroidism due to hypomagnesaemia caused by TRPM6 gene mutation. BMJ Case Rep 2024; 17:e257505. [PMID: 38413141 PMCID: PMC10900374 DOI: 10.1136/bcr-2023-257505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Magnesium is essential for the functioning and release of parathyroid hormone. Therefore, its deficiency can present as functional hypoparathyroidism. This case report describes a rare inherited disorder called congenital hypomagnesaemia with secondary hypocalcaemia due to TRPM6 gene mutation. This disease clinically and biochemically mimics hypoparathyroidism. However, unlike hypoparathyroidism, it can be treated only by long-term oral magnesium supplements. The patient presented to us with recurrent hypocalcaemic convulsions. The laboratory picture in each admission was similar to that of hypoparathyroidism. However, the hypocalcaemia persisted, and it was noticed to be associated with persistent hypomagnesaemia. A defect in the tubular magnesium reabsorption was postulated and a genetic analysis of the patient was done, which revealed a TRPM6 mutation causing hypomagnesaemia by excessive renal excretion of magnesium. The child responded well to oral magnesium supplements and is currently developmentally appropriate for her age and thriving well.
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Affiliation(s)
- Savita Khadse
- Pediatrics, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Vrushali Satish Takalikar
- Pediatrics, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Radha Ghildiyal
- Pediatrics, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
| | - Nikhil Shah
- Pediatrics, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
- Division Of Pediatric Endocrinology, Department of Pediatrics, Surya Children's Hospital, Mumbai, India
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Kamali F, Jamee M, Sayer JA, Sadeghi-Bojd S, Golchehre Z, Dehghanzad R, Keramatipour M, Mohkam M. Intestinal hypomagnesemia in an Iranian patient with a novel TRPM6 variant: a case report and review of the literature. CEN Case Rep 2023; 12:413-418. [PMID: 36967423 PMCID: PMC10620355 DOI: 10.1007/s13730-023-00785-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
TRPM6 is predominantly expressed in the kidney and colon and encodes a protein containing an ion channel domain and a protein kinase domain. It is crucial for magnesium homeostasis and plays important roles in epithelial magnesium transport and the active magnesium absorption. In this study, we present a 70-day-old Iranian female patient from consanguineous parents with hypomagnesemia and secondary hypocalcemia. She presented with seizures 19 days after birth and refractory watery non-bloody diarrhea. She consequently had failure to thrive. Other features included hypotonia, wide anterior fontanel, ventriculomegaly, and pseudotumor cerebri following administration of nalidixic acid. She had severe hypomagnesemia and hypocalcemia which were treated with magnesium and calcium supplementation. Despite initial unstable response to supplemental magnesium, she eventually improved and the diarrhea discontinued. The patient was discharged by magnesium and calcium therapy. At the last follow-up at age 2.5 years, the patient remained well without any recurrence or complication. Genetic testing by whole-exome sequencing revealed a novel homozygous frameshift insertion-deletion (indel) variant in exon 26 of the TRPM6 gene, c.3693-3699del GCAAGAG ins CTGCTGTTGACATCTGCT, p.L1231Ffs*36. Segregation analysis revealed the TRPM6 heterozygous variant in both parents. Patients with biallelic TRPM6 pathogenic variants typically exhibit hypomagnesemia with secondary hypocalcemia and present with neurologic manifestations including seizures. In some patients, this is also complicated by chronic diarrhea and failure to thrive. Long-term complications are rare and most of the patients show a good prognosis with supplemental magnesium therapy.
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Affiliation(s)
- Farnaz Kamali
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Mahnaz Jamee
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - John A Sayer
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Central Parkway, Newcastle Upon Tyne, NE1 3BZ, UK
- Renal Services, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN, UK
- NIHR Newcastle Biomedical Research Centre, Newcastle University, Newcastle Upon Tyne, NE45PL, Tyne and Wear, UK
| | - Simin Sadeghi-Bojd
- Genetics of Non-Communicable Disease Research Center, Zahedan University of Medical Sciences, Zahedan, Iran
| | - Zahra Golchehre
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Dehghanzad
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Keramatipour
- Watson Genetic Laboratory, North Kargar Street, Tehran, Iran.
- Department of Medical Genetics, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
| | - Masoumeh Mohkam
- Pediatric Nephrology Research Center, Research Institute for Children's Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Pandey AK, Nigwekar P. Familial Hypomagnesemia with Secondary Hypocalcemia Presenting as Refractory Seizures. Ann Indian Acad Neurol 2023; 26:599-601. [PMID: 37970287 PMCID: PMC10645241 DOI: 10.4103/aian.aian_38_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 11/17/2023] Open
Affiliation(s)
- Amit Kumar Pandey
- Department of Pediatrics, Rural Medical College and Pravara Rural Hospital, PIMS, Loni, Maharashtra, India
| | - Prashant Nigwekar
- Department of Pediatrics, Rural Medical College and Pravara Rural Hospital, PIMS, Loni, Maharashtra, India
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Liu M, Liu H, Feng F, Krook-Magnuson E, Dudley SC. TRPM7 kinase mediates hypomagnesemia-induced seizure-related death. Sci Rep 2023; 13:7855. [PMID: 37188671 DOI: 10.1038/s41598-023-34789-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 05/08/2023] [Indexed: 05/17/2023] Open
Abstract
Hypomagnesemia (HypoMg) can cause seizures and death, but the mechanism is unknown. Transient receptor potential cation channel subfamily M 7 (TRPM7) is a Mg transporter with both channel and kinase function. In this study, we focused on the kinase role of TRPM7 in HypoMg-induced seizures and death. Wild type C57BL/6J mice and transgenic mice with a global homozygous mutation in the TRPM7 kinase domain (TRPM7K1646R, with no kinase function) were fed with control diet or a HypoMg diet. After 6 weeks of HypoMg diet, mice had significantly decreased serum Mg, elevated brain TRPM7, and a significant rate of death, with females being most susceptible. Deaths were immediately preceded by seizure events. TRPM7K1646R mice showed resistance to seizure-induced death. HypoMg-induced brain inflammation and oxidative stress were suppressed by TRPM7K1646R. Compared to their male counterparts, HypoMg female mice had higher levels of inflammation and oxidative stress in the hippocampus. We concluded that TRPM7 kinase function contributes seizure-induced deaths in HypoMg mice and that inhibiting the kinase reduced inflammation and oxidative stress.
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Affiliation(s)
- Man Liu
- Cardiovascular Division, Department of Medicine, The Lillehei Heart Institute, University of Minnesota at Twin Cities, 2231 6th Street SE, CCRB 4-141, Minneapolis, MN, 55455, USA
| | - Hong Liu
- Cardiovascular Division, Department of Medicine, The Lillehei Heart Institute, University of Minnesota at Twin Cities, 2231 6th Street SE, CCRB 4-141, Minneapolis, MN, 55455, USA
| | - Feng Feng
- Cardiovascular Division, Department of Medicine, The Lillehei Heart Institute, University of Minnesota at Twin Cities, 2231 6th Street SE, CCRB 4-141, Minneapolis, MN, 55455, USA
| | - Esther Krook-Magnuson
- Department of Neuroscience, University of Minnesota at Twin Cities, Minneapolis, MN, USA
| | - Samuel C Dudley
- Cardiovascular Division, Department of Medicine, The Lillehei Heart Institute, University of Minnesota at Twin Cities, 2231 6th Street SE, CCRB 4-141, Minneapolis, MN, 55455, USA.
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Sande R, Doshi G, Godad A. Deciphering the role of metal and non-metals in the treatment of epilepsy. Neurochem Int 2023; 167:105536. [PMID: 37178926 DOI: 10.1016/j.neuint.2023.105536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/24/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023]
Abstract
Metals and non-metals have known to play a significant role in various physiological roles in the body including the central nervous system (CNS). The alterations in their concentration in the CNS leads to abnormalities in the normal functions which may lead to various neurological conditions including epilepsy. Manganese is a cofactor required for antioxidant enzymes such as Superoxide dismutase, Glutamine synthetase, etc. The accumulation of iron leads to formation of reactive oxygen species (ROS) and reactive nitrogen species (RNS) which have the potential to cause ferroptosis, one of the reasons for epileptogenesis. Zinc has biphasic response, both neurotoxic and neuroprotective, based on concentration levels in the CNS. Selenium is a main element for selenoproteins which is responsible for the regulation of oxidative state and antioxidant defence mechanism. The reduction in the phosphorous levels in the CNS is widely observed after generalised tonic clonic seizures (GTC), which can be a potential diagnostic biomarker. Copper acts in the CNS in an identical manner, i.e., by blocking both AMPA mediated and GABA mediated neuronal transmission. Magnesium blocks calcium channels in the NMDA receptor and prevents glutamatergic transmission, thus inhibiting excitotoxicity. Lithium acts as a proconvulsive agent and is used in combination with pilocarpine to induce seizures. The identified potential of metals and non-metals in epilepsy can be utilised in order to devise new adjuvant therapies for the management of epilepsy. The article summaries in depth the role of metals and non-metals in the treatment of epilepsy supported with special paragraph on author perspective on to the topic. Furthermore, an update of preclinical and clinical evidences are discussed in the review to give evidence on metal and non-metal based therapies in epilepsy.
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Affiliation(s)
- Ruksar Sande
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, V L M Road, Vile Parle (w), Mumbai, 400056, India
| | - Gaurav Doshi
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, V L M Road, Vile Parle (w), Mumbai, 400056, India
| | - Angel Godad
- Department of Pharmacology, SVKM's Dr. Bhanuben Nanavati College of Pharmacy, V L M Road, Vile Parle (w), Mumbai, 400056, India.
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Saleem A, Santos AC, Aquilino MS, Sivitilli AA, Attisano L, Carlen PL. Modelling hyperexcitability in human cerebral cortical organoids: Oxygen/glucose deprivation most effective stimulant. Heliyon 2023; 9:e14999. [PMID: 37089352 PMCID: PMC10113787 DOI: 10.1016/j.heliyon.2023.e14999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 03/13/2023] [Accepted: 03/23/2023] [Indexed: 03/31/2023] Open
Abstract
Epilepsy is a common neurological disorder that affects 1% of the global population. The neonatal period constitutes the highest incidence of seizures. Despite the continual developments in seizure modelling and anti-epileptic drug development, the mechanisms involved in neonatal seizures remain poorly understood. This leaves infants with neonatal seizures at a high risk of death, poor prognosis of recovery and risk of developing neurological disorders later in life. Current in vitro platforms for modelling adult and neonatal epilepsies - namely acute cerebral brain slices or cell-derived cultures, both derived from animals-either lack a complex cytoarchitecture, high-throughput capabilities or physiological similarities to the neonatal human brain. Cerebral organoids, derived from human embryonic stem cells (hESCs), are an emerging technology that could better model neurodevelopmental disorders in the developing human brain. Herein, we study induced hyperexcitability in human cerebral cortical organoids - setting the groundwork for neonatal seizure modelling - using electrophysiological techniques and pharmacological manipulations. In neonatal seizures, energy failure - specifically due to deprivation of oxygen and glucose - is a consistent and reliable seizure induction method that has been used to study the underlying cellular and molecular mechanisms. Here, we applied oxygen-glucose deprivation (OGD) as well as common chemoconvulsants in 3-7-month-old cerebral organoids. Remarkably, OGD resulted in hyperexcitability, with increased power and spontaneous events compared to other common convulsants tested at the population level. These findings characterize OGD as the stimulus most capable of inducing hyperexcitable changes in cerebral organoid tissue, which could be extended to future modelling of neonatal epilepsies in cerebral organoids.
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AL-Omairi A, Alfarsi A. Hypomagnesemia-Induced Seizures Post Severe Acute Kidney Injury. Cureus 2022; 14:e26142. [PMID: 35891828 PMCID: PMC9301612 DOI: 10.7759/cureus.26142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/21/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in children admitted to pediatric intensive care units. It is known to be associated with increased morbidity and mortality. Here, we report prolonged, transient, increased renal magnesium (Mg) wasting after severe acute kidney injury presenting with a generalized tonic-clonic seizure.
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Alhasan K, D'Alessandri-Silva C, Mongia A, Topaloglu R, Tasic V, Filler G. Young Adults With Hereditary Tubular Diseases: Practical Aspects for Adult-Focused Colleagues. Adv Chronic Kidney Dis 2022; 29:292-307. [PMID: 36084976 DOI: 10.1053/j.ackd.2021.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/11/2022]
Abstract
Recent advances in the management of kidney tubular diseases have resulted in a significant cohort of adolescents and young adults transitioning from pediatric- to adult-focused care. Most of the patients under adult-focused care have glomerular diseases, whereas rarer tubular diseases form a considerable proportion of pediatric patients. The purpose of this review is to highlight the clinical signs and symptoms of tubular disorders, as well as their diagnostic workup, including laboratory findings and imaging, during young adulthood. We will then discuss more common disorders such as cystinosis, cystinuria, distal kidney tubular acidosis, congenital nephrogenic diabetes insipidus, Dent disease, rickets, hypercalciuria, and syndromes such as Bartter, Fanconi, Gitelman, Liddle, and Lowe. This review is a practical guide on the diagnostic and therapeutic approach of tubular conditions affecting young adults who are transitioning to adult-focused care.
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Affiliation(s)
- Khalid Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Cynthia D'Alessandri-Silva
- Department of Pediatrics, University of Connecticut School of Medicine, Farmington, and Nephrology, Connecticut Children's Medical Center, Hartford, CT
| | - Anil Mongia
- Department of Pediatrics, SUNY Downstate Medical Center, Brooklyn, NY
| | - Rezan Topaloglu
- Department of Paediatrics, Division of Pediatric Nephrology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Velibor Tasic
- University Children's Hospital, Medical School, Skopje, North Macedonia
| | - Guido Filler
- Department of Paediatrics, Division of Pediatric Nephrology, Western University, London, ON, Canada; Department of Medicine, Western University, London, ON, Canada; Department of Pathology and Laboratory Medicine, Western University, London, ON, Canada.
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Gerges SE, El Rakawy MH, El Khayat NM, Abdelhamid YAE, Hazzou AM, Shokri HM, Wahid El din MM. Predictive factors of epilepsy outcome in a sample of Egyptian pre-elderly and elderly population. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2021. [DOI: 10.1186/s41983-021-00297-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Elderly people with epilepsy are large, but neglected group. Data on the predictive factors for recurrent seizures in the elderly population are inconclusive or are not known for the majority of patients. This is especially true for the Egyptian population as no specific study was concluded to address this issue before.
Objectives
The aim of this study was to detect the predictive factors of epilepsy outcome in a sample of Egyptian aged population.
Materials and methods
A total of 100 patients aged 50 years or older with epilepsy diagnosed according to International League Against Epilepsy (ILAE) latest definition were included in the study and followed up for 6 months as regards seizure control. All participants were prospectively evaluated for epidemiological, clinical, radiological, electrodiagnostic, and laboratory data.
Results
The outcome was statistically significant affected in relation to absence of medical comorbidities (P = 0.037), seizure etiology (P = 0.007), history of status epilepticus (P < 0.001), MRI brain findings (P = 0.005), EEG changes (P < 0.001), Ca (P = 0.01), and Mg level (P = 0.046).
Conclusion
We conclude that aged Egyptian epileptic population with no medical comorbidities, normal MRI brain, or normal EEG can be predicted to have good outcome of their epilepsy while patients with post stroke epilepsy, abnormal MRI brain, and abnormal EEG, with low serum Ca or Mg level can be predicted to have poor outcome.
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Lee DA, Jun KR, Lee JH, Chung WY, Seo GH, Park KM. Hypomagnesemia and seizures in a patient with an SOS1 mutation. Seizure 2021; 92:234-235. [PMID: 34607272 DOI: 10.1016/j.seizure.2021.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/16/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022] Open
Affiliation(s)
- Dong Ah Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Kyung Ran Jun
- Department of Laboratory Medicine, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Jun Ho Lee
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Woo Yeong Chung
- Department of Pediatrics, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea
| | - Go Hun Seo
- 3billion Inc., 416 Teheran-ro, Dachi-dong, Gangnam-Gu, Seoul, South Korea
| | - Kang Min Park
- Department of Neurology, Haeundae Paik Hospital, Inje University College of Medicine, Busan, South Korea.
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Fiorentini D, Cappadone C, Farruggia G, Prata C. Magnesium: Biochemistry, Nutrition, Detection, and Social Impact of Diseases Linked to Its Deficiency. Nutrients 2021; 13:1136. [PMID: 33808247 PMCID: PMC8065437 DOI: 10.3390/nu13041136] [Citation(s) in RCA: 107] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Magnesium plays an important role in many physiological functions. Habitually low intakes of magnesium and in general the deficiency of this micronutrient induce changes in biochemical pathways that can increase the risk of illness and, in particular, chronic degenerative diseases. The assessment of magnesium status is consequently of great importance, however, its evaluation is difficult. The measurement of serum magnesium concentration is the most commonly used and readily available method for assessing magnesium status, even if serum levels have no reliable correlation with total body magnesium levels or concentrations in specific tissues. Therefore, this review offers an overview of recent insights into magnesium from multiple perspectives. Starting from a biochemical point of view, it aims at highlighting the risk due to insufficient uptake (frequently due to the low content of magnesium in the modern western diet), at suggesting strategies to reach the recommended dietary reference values, and at focusing on the importance of detecting physiological or pathological levels of magnesium in various body districts, in order to counteract the social impact of diseases linked to magnesium deficiency.
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Affiliation(s)
| | | | - Giovanna Farruggia
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum—University of Bologna, 40126 Bologna, Italy; (D.F.); (C.C.); (C.P.)
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Yücel H, Genç Sel Ç, Kasapkara ÇS, Karacan Küçükali G, Savas-Erdeve S, Öztoprak Ü, Ceylaner S, Şenel S, Akçaboy M. Treatment Difficulties in Hypomagnesemia Secondary to the Transient Receptor Potential Melastatin 6 Gene: A Case Report with Novel Mutation. J Clin Res Pediatr Endocrinol 2021; 13:114-118. [PMID: 32302086 PMCID: PMC7947728 DOI: 10.4274/jcrpe.galenos.2020.2020.0004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Hypomagnesemia is a rare cause of seizures in childhood but should be kept in mind in recurrent and intractable seizures and hypocalcemia in communities where consanguineous marriages are common. Familial hypomagnesemia with secondary hypocalcemia is a rare genetic cause of hypomagnesemia, due to variants in the transient receptor potential melastatin 6 (TRPM6) genes. Here, a three year-old boy with a novel variant in this gene and had difficulties with enteral hypomagnesemia treatment is presented. He had recurrent seizures since two years of age and was diagnosed with epilepsy and treated with multiple antiepileptic drugs. Subsequently, he was diagnosed with rickets due to severe hypocalcemia at another center. The patient was hypotonic and neurodevelopmentally poor. The most prominent laboratory finding was of hypomagnesemia with secondary hypocalcemia. The genetic analysis revealed a novel variant in the TRPM6 gene. After parental treatment of intravenous magnesium (Mg2+) sulfate and calcium, the treatment was switched to enteral Mg2+ medications, due to persistent hypomagnesemia and the gastrointestinal side-effects, different oral preparations were used. The patient was stable on an oral maintenance dose of Mg2+ oxide with borderline blood Mg2+ levels and resolution of hypocalcemia. Hypomagnesemia is one of the causes of hypocalcemia. Enteral replacement is the key treatment but the treatment should be individualized for each patient. Normalization of hypomagnesemia is not always easy and should not be the aim of the treatment.
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Affiliation(s)
- Hüsniye Yücel
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatrics, Ankara, Turkey
| | - Çiğdem Genç Sel
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatric Neurology, Ankara, Turkey
| | - Çiğdem Seher Kasapkara
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatric Metabolism, Ankara, Turkey
| | - Gülin Karacan Küçükali
- Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Senay Savas-Erdeve
- Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatric Endocrinology, Ankara, Turkey
| | - Ülkühan Öztoprak
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatric Neurology, Ankara, Turkey
| | | | - Saliha Şenel
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatrics, Ankara, Turkey
| | - Meltem Akçaboy
- Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatrics, Ankara, Turkey,* Address for Correspondence: Dr. Sami Ulus Maternity and Children’s Health and Diseases Training and Research Hospital, Clinic of Pediatrics, Ankara, Turkey Phone: +90 312 305 60 00 E-mail:
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Neurologic Manifestations of Systemic Disease: Seizure. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00638-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Grochowski C, Blicharska E, Baj J, Mierzwińska A, Brzozowska K, Forma A, Maciejewski R. Serum iron, Magnesium, Copper, and Manganese Levels in Alcoholism: A Systematic Review. Molecules 2019; 24:E1361. [PMID: 30959950 PMCID: PMC6480471 DOI: 10.3390/molecules24071361] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/03/2019] [Accepted: 04/06/2019] [Indexed: 01/03/2023] Open
Abstract
The aim of this paper was to review recent literature (from 2000 onwards) and summarize the newest findings on fluctuations in the concentration of some essential macro- and microelements in those patients with a history of chronic alcohol abuse. The focus was mainly on four elements which the authors found of particular interest: Iron, magnesium, copper, and manganese. After independently reviewing over 50 articles, the results were consistent with regard to iron and magnesium. On the other hand, data were limited, and in some cases contradictory, as far as copper and manganese were concerned. Iron overload and magnesium deficiency are two common results of an excessive and prolonged consumption of alcohol. An increase in the levels of iron can be seen both in the serum and within the cells, hepatocytes in particular. This is due to a number of factors: Increased ferritin levels, lower hepcidin levels, as well as some fluctuations in the concentration of the TfR receptor for transferrin, among others. Hypomagnesemia is universally observed among those suffering from alcoholism. Again, the causes for this are numerous and include malnutrition, drug abuse, respiratory alkalosis, and gastrointestinal problems, apart from the direct influence of excessive alcohol intake. Unfortunately, studies regarding the levels of both copper and manganese in the case of (alcoholic) liver disease are scarce and often contradictory. Still, the authors have attempted to summarize and give a thorough insight into the literature available, bearing in mind the difficulties involved in the studies. Frequent comorbidities and mutual relationships between the elements in question are just some of the complications in the study of this topic.
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Affiliation(s)
- Cezary Grochowski
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland; (J.B.); (R.M.)
- Department of Neurosurgery and Pediatric Neurosurgery, Medical University of Lublin, 20-090 Lublin, Poland
| | - Eliza Blicharska
- Department of Analitical Chemistry, Medical University of Lublin, 20-090 Lublin, Poland;
| | - Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland; (J.B.); (R.M.)
| | - Aleksandra Mierzwińska
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (A.M.); (K.B.); aforma@o2pl (A.F.)
| | - Karolina Brzozowska
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (A.M.); (K.B.); aforma@o2pl (A.F.)
| | - Alicja Forma
- Department of Forensic Medicine, Medical University of Lublin, 20-090 Lublin, Poland; (A.M.); (K.B.); aforma@o2pl (A.F.)
| | - Ryszard Maciejewski
- Chair and Department of Anatomy, Medical University of Lublin, 20-090 Lublin, Poland; (J.B.); (R.M.)
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Toffa DH, Magnerou MA, Kassab A, Hassane Djibo F, Sow AD. Can magnesium reduce central neurodegeneration in Alzheimer's disease? Basic evidences and research needs. Neurochem Int 2019; 126:195-202. [PMID: 30905744 DOI: 10.1016/j.neuint.2019.03.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/15/2019] [Accepted: 03/18/2019] [Indexed: 12/26/2022]
Abstract
Magnesium (Mg) is a crucial divalent cation with more than 300 cellular functions. This ion shows therapeutic properties in several neurological diseases. Although there are numerous basic evidences showing that Mg can inhibit pathological processes involved in neuroglial degeneration, this low-cost option is not well-considered in clinical research and practice for now. Nevertheless, none of the expensive drugs currently recommended by the classic guidelines (in addition to physiological rehabilitation) had shown exceptional effectiveness. Herein, focusing on Alzheimer's disease (AD), we analyze the therapeutic pathways that support the use of Mg for neurogenesis and neuroprotection. According to experimental findings reviewed, Mg shows interesting abilities to facilitate toxin clearance, reduce neuroinflammation, inhibit the pathologic processing of amyloid protein precursor (APP) as well as the abnormal tau protein phosphorylation, and to reverse the deregulation of N-methyl-D-aspartate receptors. Currently, some crucial details of the mechanisms involved in these proved effects remain elusive and clinical background is poor. Therefore, further studies are required to enable a better overview on pharmacodynamic targets of Mg and thus, to find optimal pharmacologic strategies for clinical use of this ion.
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Affiliation(s)
- Dènahin Hinnoutondji Toffa
- Epilepsy Lab, CRCHUM, Université de Montréal, Montreal, Canada; Neurology Division, CHUM, Université de Montréal, Montreal, Canada.
| | | | - Ali Kassab
- Epilepsy Lab, CRCHUM, Université de Montréal, Montreal, Canada
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Wang PZT, Prasad C, Rodriguez Cuellar CI, Filler G. Nephrological and urological complications of homozygous c.974G>A (p.Arg325Gln) OSGEP mutations. Pediatr Nephrol 2018; 33:2201-2204. [PMID: 30141175 DOI: 10.1007/s00467-018-4060-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 08/15/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Galloway-Mowat syndrome (GAMOS) (OMIM #251300) is a severe autosomal recessive disease characterized by the combination of early-onset steroid-resistant nephrotic syndrome (SRNS) and microcephaly with brain anomalies caused by WDR73 as well as OSGEP, TP53RK, TPRKB, or LAGE3 mutations. OBJECTIVE We report on the hitherto undescribed urological and nephrological complications of the homozygous c.974G>A (p.Arg325Gln) OSGEP mutations in a 7-year-old Caucasian girl. CASE DIAGNOSIS The patient came to the attention of pediatric nephrology at the age of 3 years and 11 months, when she presented with status epilepticus due to profound hypomagnesemia (0.31 mmol/L, normal 0.65-1.05). A 24-h urine demonstrated a magnesium loss of 0.6 mmol/kg/day with associated proteinuria suggesting renal tubulopathy. Subsequently, she developed recurrent urinary tract infections (UTIs) and was diagnosed with neurogenic bladder dysfunction. The patient continued to have UTIs associated with seizures and sequential cultures growing multi-drug-resistant organisms despite of antibiotic prophylaxis. In addition, the proteinuria (median microalbumin/creatinine ratio 647 mg/mmol) increased, and she developed partial Fanconi syndrome. At age 7, she developed a large bladder calculus (3.3 × 3.2 cm) and three left non-obstructing renal calculi associated with elevated urinary cystine, hypercalciuria, and ongoing hypomagnesemia and required surgical intervention. Glomerular filtration rate (GFR) remained normal and she never developed frank nephrotic syndrome (average albumin 31 g/L). CONCLUSIONS It is unclear if patients with OSGEP mutations with tubular symptoms rather than nephrotic syndrome should be considered a different entity. Nephrological and urological complications of OSGEP mutations can be challenging and require a multidisciplinary approach.
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Affiliation(s)
- Peter Zhan Tao Wang
- Department of Surgery, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5W9, Canada
| | - Chitra Prasad
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Hospital, London Health Science Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
- Children's Health Research Institute, University of Western Ontario, London, ON, N6C 2V5, Canada
| | - Carmen Inés Rodriguez Cuellar
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Hospital, London Health Science Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, Children's Hospital, London Health Science Centre, 800 Commissioners Road East, London, ON, N6A 5W9, Canada.
- Children's Health Research Institute, University of Western Ontario, London, ON, N6C 2V5, Canada.
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N5A 5A5, Canada.
- Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5W9, Canada.
- Lilibeth Caberto Kidney Clinical Research Unit, London Health Sciences Centre, London, ON, Canada.
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18
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Peng J, Pang N, Wang Y, Wang XL, Chen J, Xiong J, Peng P, Zhu CH, Kessi MB, He F, Yin F. Next-generation sequencing improves treatment efficacy and reduces hospitalization in children with drug-resistant epilepsy. CNS Neurosci Ther 2018; 25:14-20. [PMID: 29933521 DOI: 10.1111/cns.12869] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The purposes of this study were three-fold: (i) to determine the contribution of known genes to the causation of a broad-spectrum of pediatric drug-resistant epilepsy (DRE), (ii) to compare the diagnostic yield and cost among different next-generation sequencing (NGS) approaches, and especially (iii) to assess how NGS approaches can benefit patients by improving diagnosis and treatment efficiency. METHODS This study enrolled 273 pediatric DRE patients with no obvious acquired etiology. Seventy-four patients underwent whole-exome sequencing (WES), 141 patients had epilepsy-related gene panel testing, and another 58 patients had clinical WES gene panel testing. We obtained these patients' seizure and hospitalization frequency by periodic follow-up phone calls and outpatient visits. RESULTS Genetic diagnosis was achieved in 86 patients (31.5%) and involved 93 likely disease-causing mutations in 33 genes. In this study, the detection rates of the epilepsy-related gene panel, the clinical WES gene panel, and WES were 32.6% (46/141), 44.8% (26/58), and 17.3% (13/74), respectively. Moreover, 34 patients accepted corrective therapy according to their mutant genes, after which 52.9% (18/34) became seizure-free and 38.2% (13/34) achieved seizure reduction. In the end, patients with either positive or negative genetic results had significantly fewer hospitalization incidents (times/half year) than before (positive genetic results group 0.58 ± 1.14 vs 0.10 ± 0.26; negative genetic results group 0.72 ± 1.65 vs 0.12 ± 0.33). CONCLUSIONS These results offer further proof that NGS approaches represent powerful tools for establishing a definitive diagnosis. Moreover, this study indicated how NGS can improve treatment efficacy and reduce hospitalization in children with DRE.
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Affiliation(s)
- Jing Peng
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Nan Pang
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Ying Wang
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiao-Le Wang
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Chen
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Juan Xiong
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Pan Peng
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Can-Hui Zhu
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Miriam Barakael Kessi
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fang He
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Fei Yin
- Department of Pediatric Neurology, Xiangya Hospital, Central South University, Changsha, China
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Kirkland AE, Sarlo GL, Holton KF. The Role of Magnesium in Neurological Disorders. Nutrients 2018; 10:E730. [PMID: 29882776 PMCID: PMC6024559 DOI: 10.3390/nu10060730] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/30/2018] [Accepted: 06/04/2018] [Indexed: 12/14/2022] Open
Abstract
Magnesium is well known for its diverse actions within the human body. From a neurological standpoint, magnesium plays an essential role in nerve transmission and neuromuscular conduction. It also functions in a protective role against excessive excitation that can lead to neuronal cell death (excitotoxicity), and has been implicated in multiple neurological disorders. Due to these important functions within the nervous system, magnesium is a mineral of intense interest for the potential prevention and treatment of neurological disorders. Current literature is reviewed for migraine, chronic pain, epilepsy, Alzheimer’s, Parkinson’s, and stroke, as well as the commonly comorbid conditions of anxiety and depression. Previous reviews and meta-analyses are used to set the scene for magnesium research across neurological conditions, while current research is reviewed in greater detail to update the literature and demonstrate the progress (or lack thereof) in the field. There is strong data to suggest a role for magnesium in migraine and depression, and emerging data to suggest a protective effect of magnesium for chronic pain, anxiety, and stroke. More research is needed on magnesium as an adjunct treatment in epilepsy, and to further clarify its role in Alzheimer’s and Parkinson’s. Overall, the mechanistic attributes of magnesium in neurological diseases connote the macromineral as a potential target for neurological disease prevention and treatment.
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Affiliation(s)
- Anna E Kirkland
- Department of Psychology, Behavior, Cognition and Neuroscience Program, American University, Washington, DC 20016, USA.
| | - Gabrielle L Sarlo
- Department of Psychology, Behavior, Cognition and Neuroscience Program, American University, Washington, DC 20016, USA.
| | - Kathleen F Holton
- Department of Health Studies, American University, Washington, DC 20016, USA.
- Center for Behavioral Neuroscience, American University, Washington, DC 20016, USA.
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Al Alawi AM, Majoni SW, Falhammar H. Magnesium and Human Health: Perspectives and Research Directions. Int J Endocrinol 2018; 2018:9041694. [PMID: 29849626 PMCID: PMC5926493 DOI: 10.1155/2018/9041694] [Citation(s) in RCA: 144] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 02/22/2018] [Accepted: 03/05/2018] [Indexed: 12/13/2022] Open
Abstract
Magnesium is the fourth most abundant cation in the body. It has several functions in the human body including its role as a cofactor for more than 300 enzymatic reactions. Several studies have shown that hypomagnesemia is a common electrolyte derangement in clinical setting especially in patients admitted to intensive care unit where it has been found to be associated with increase mortality and hospital stay. Hypomagnesemia can be caused by a wide range of inherited and acquired diseases. It can also be a side effect of several medications. Many studies have reported that reduced levels of magnesium are associated with a wide range of chronic diseases. Magnesium can play important therapeutic and preventive role in several conditions such as diabetes, osteoporosis, bronchial asthma, preeclampsia, migraine, and cardiovascular diseases. This review is aimed at comprehensively collating the current available published evidence and clinical correlates of magnesium disorders.
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Affiliation(s)
- Abdullah M. Al Alawi
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
| | - Sandawana William Majoni
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
- Northern Territory Medical Program, Flinders University School of Medicine, Darwin, NT, Australia
| | - Henrik Falhammar
- Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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