Low serum magnesium levels are associated with increased risk of fractures: a long-term prospective cohort study

Magnesium, which is an essential trace element that plays a key role in several cellular processes, is a major component of bone; however, its relationship with risk of major bone fractures is uncertain. We aimed to investigate the association of baseline serum magnesium concentrations with risk of incident fractures. We analyzed data on 2245 men aged 42–61 years in the Kuopio Ischemic Heart Disease prospective cohort study, with the assessment of serum magnesium measurements and dietary intakes made at baseline. Hazard ratios [95% confidence intervals (CI)] for incident total (femoral, humeral, and forearm) and femoral fractures were assessed. During a median follow-up of 25.6 years, 123 total fractures were recorded. Serum magnesium was non-linearly associated with risk of total fractures. In age-adjusted Cox regression analysis, the hazard ratio (HR) (95% CIs) for total fractures in a comparison of the bottom quartile versus top quartile of magnesium concentrations was 2.10 (1.30–3.41), which persisted on adjustment for several established risk factors 1.99 (1.23–3.24). The association remained consistent on further adjustment for renal function, socioeconomic status, total energy intake, and several trace elements 1.80 (1.10–2.94). The corresponding adjusted HRs for femoral fractures were 2.56 (1.38–4.76), 2.43 (1.30–4.53) and 2.13 (1.13–3.99) respectively. There was no evidence of an association of dietary magnesium intake with risk of any fractures. In middle-aged Caucasian men, low serum magnesium is strongly and independently associated with an increased risk of fractures. Further research is needed to assess the potential relevance of serum magnesium in the prevention of fractures.     

One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies

One-stage and two-stage revision strategies are the two main options for treating established chronic peri-prosthetic joint infection (PJI) of the hip; however, there is uncertainty regarding which is the best treatment option. We aimed to compare the risk of re-infection between the two revision strategies using pooled individual participant data (IPD). Observational cohort studies with PJI of the hip treated exclusively by one- or two-stage revision and reporting re-infection outcomes were retrieved by searching MEDLINE, EMBASE, Web of Science, The Cochrane Library, and the WHO International Clinical Trials Registry Platform; as well as email contact with investigators. We analysed IPD of 1856 participants with PJI of the hip from 44 cohorts across four continents. The primary outcome was re-infection (recurrence of infection by the same organism(s) and/or re-infection with a new organism(s)). Hazard ratios (HRs) for re-infection were calculated using Cox proportional frailty hazards models. After a median follow-up of 3.7 years, 222 re-infections were recorded. Re-infection rates per 1000 person-years of follow-up were 16.8 (95% CI 13.6–20.7) and 32.3 (95% CI 27.3–38.3) for one-stage and two-stage strategies respectively. The age- and sex-adjusted HR of re-infection for two-stage revision was 1.70 (0.58–5.00) when compared with one-stage revision. The association remained consistently absent after further adjustment for potential confounders. The HRs did not vary importantly in clinically relevant subgroups. Analysis of pooled individual patient data suggest that a one-stage revision strategy may be as effective as a two-stage revision strategy in treating PJI of the hip.     

Similar risk of complete revision for infection with single-dose versus multiple-dose antibiotic prophylaxis in primary arthroplasty of the hip and knee: results of an observational cohort study in the Dutch Arthroplasty Register in 242,179 patients

Background and purpose — The optimal type and duration of antibiotic prophylaxis for primary arthroplasty of the hip and knee are subject to debate. We compared the risk of complete revision (obtained by a 1- or 2-stage procedure) for periprosthetic joint infection (PJI) after primary total hip or knee arthroplasty between patients receiving a single dose of prophylactic antibiotics and patients receiving multiple doses of antibiotics for prevention of PJI.Patients and methods — A cohort of 130,712 primary total hip and 111,467 knee arthroplasties performed between 2011 and 2015 in the Netherlands was analyzed. We linked data from the Dutch arthroplasty register to a survey collected across all Dutch institutions on hospital-level antibiotic prophylaxis policy. We used restricted cubic spline Poisson models adjusted for hospital clustering to compare the risk of revision for infection according to type and duration of antibiotic prophylaxis received.Results — For total hip arthroplasties, the rates of revision for infection were 31/10,000 person-years (95% CI 28–35), 39 (25–59), and 23 (15–34) in the groups that received multiple doses of cefazolin, multiple doses of cefuroxime, and a single dose of cefazolin, respectively. The rates for knee arthroplasties were 27/10,000 person-years (95% CI 24–31), 40 (24–62), and 24 (16–36). Similar risk of complete revision for infection among antibiotic prophylaxis regimens was found when adjusting for confounders.Interpretation — In a large observational cohort we found no apparent association between the type or duration of antibiotic prophylaxis and the risk of complete revision for infection. This does question whether there is any advantage to the use of prolonged antibiotic prophylaxis beyond a single dose.

Annually around 1 million patients receive a total hip or total knee prosthesis in the United States and over 190,000 hip and knee replacements are performed in England and Wales (Maradit et al. 2015, National Joint Registry for England and Wales 2018). The incidences of prosthetic replacement of the hip and knee are expected to increase (Kurtz et al. 2014). Prosthetic joint infection (PJI) following total hip or knee arthroplasty and the treatment thereof are catastrophic for patients and pose tremendous costs to healthcare systems (Poultsides et al. 2010, Zmistowski et al. 2013, Moore et al. 2015). Perioperative antibiotic prophylaxis remains an effective method of reducing the risk of PJI (Illingworth et al. 2013, Thornley et al. 2015). The type and duration of antibiotic prophylaxis are subject to debate.Both single-dose and multiple-dose antibiotic prophylaxis regimens have been advocated with comparable results (Thornley et al. 2015, Tan et al. 2019). The recommendations provided by the Second International Consensus Meeting of the MusculoSkeletal Infection Society (MSIS) and the European Bone and Joint Infection Society (EBJIS) advise that antibiotic prophylaxis should be administered 30–60 minutes before incision and discontinued within 24 hours after surgery (Hansen et al. 2014, Parvizi and Gehrke 2018). Large variation in prophylaxis regimens has been observed in the United Kingdom (Hickson et al. 2015). The Dutch national orthopedic association advises administration of antibiotic prophylaxis using a first- or second-generation cephalosporin starting 30–60 minutes preoperatively and discontinuing the antibiotic prophylaxis within 24 hours (Swierstra et al. 2009, Nederlandse Orthopaedische Vereniging 2018). The World Health Organization and, in the USA, the Centers for Disease Control and Prevention (CDC) recommend against the use of postoperative continuation of antibiotic prophylaxis and advocate for a single dose of antibiotics delivered preoperatively (Berrios-Torres et al. 2017). This recommendation is vehemently challenged by the American Association of Hip and Knee Surgeons and the International Consensus Meeting, which encourage their members to proceed with the current common practice of multiple-dose antibiotic prophylaxis protocols until more evidence is available (Yates 2018).We compared the risk of complete revision for infection in the 1st year following primary hip and knee arthroplasty according to the perioperatively administered antibiotic prophylaxis regimen by using data from the Dutch Arthroplasty Register (LROI).     

Acute tubulointerstitial nephritis,treatment with steroid and impact on renal outcomes

Background: The use and timing of steroids in the management of acute tubulointerstitial nephritis (ATIN) remains debatable. Aims: To determine the incidence and aetiology of ATIN in our unit, and to examine trends in the use of steroids and their impact on renal outcomes. Methods: Patients with a histological diagnosis of ATIN over a 9‐year period were identified and divided into steroid‐treated (StG) and steroid‐naïve groups (SnG). Mean change in estimated glomerular filtration rate (eGFR) was determined. Results: Forty‐nine patients had ATIN as their main diagnosis, 67% of cases were drug‐induced, and proton pump inhibitors (PPI) were the second commonest implicated drug category. Majority (75%) of patients received steroids, and eGFR improved to a significantly greater degree in these steroid‐treated patients (3.4‐fold improvement vs 2.0‐fold in SnG; P < 0.05, unpaired t‐test). Despite comparable eGFR at presentation (StG: 11.7; SnG: 15.4), steroid‐treated patients were less likely to receive dialysis, although not significantly so (OR 0.27; 95% CI 0.06–1.15, P = 0.066, chi‐squared test). However, there was no significant relation between the degree of eGFR improvement and delay in starting steroids (Pearson r = ?0.25, P > 0.45), and no difference in eGFR at the time of last follow‐up (StG: 33 ± 3; SnG: 32 ± 7; P > 0.9, unpaired t‐test). Conclusion: StG patients had a greater degree of improvement in renal function, but with no correlation between degree of improvement in eGFR and delay in starting steroids, and similar eGFR values at final follow‐up. PPI were the second commonest drug category among drug‐induced cases.