Francisco Ibarra

Magnesium is an essential mineral involved in numerous physiological processes, including energy metabolism, neuromuscular function, protein synthesis, and inflammatory regulation. Given these roles, magnesium supplementation has received increasing attention as a potential strategy to support exercise performance and recovery. This review aimed to evaluate the current evidence regarding magnesium intake and its effects on exercise performance, skeletal muscle recovery, body composition, and inflammatory responses. A focused narrative literature review was conducted using PubMed to identify studies published between 2000 and 2025 that contained the terms “magnesium” and “muscle” in the title. Review articles, meta-analyses, animal studies, commentaries, guidelines, and studies lacking clinical muscle-related outcomes were excluded. Outcomes of interest included exercise performance, recovery measures, body composition, and inflammatory markers. Of 108 records identified, 10 studies met inclusion criteria, including six randomized controlled trials and four observational studies. Evidence regarding exercise performance was inconsistent. Some randomized trials demonstrated improvements in muscular strength, functional mobility, perceived exertion, and repetitions to failure, whereas others reported no performance benefit or reductions in maximal oxygen uptake (VO₂max) and sprint power with higher-dose supplementation. Recovery-related outcomes were generally more favorable, with several studies reporting reduced muscle soreness, improved perceived recovery, and lower markers of exercise-induced muscle damage. Magnesium intake was also associated with lower concentrations of inflammatory biomarkers, including high-sensitivity C-reactive protein, tumor necrosis factor-α, and interleukin-6. Observational studies consistently demonstrated associations between higher dietary magnesium intake and greater skeletal muscle mass, improved body composition, and lower systemic inflammation. Current evidence suggests that magnesium supplementation may provide greater benefit for exercise recovery and inflammatory regulation than for direct enhancement of athletic performance. Variability in study design, magnesium formulation, supplementation dose, participant characteristics, and baseline magnesium status likely contributed to the inconsistent performance findings observed across studies. Magnesium supplementation may be most appropriately considered an adjunct recovery-support strategy rather than a primary ergogenic aid. Large, well-designed randomized controlled trials are needed to clarify optimal dosing strategies, identify populations most likely to benefit, and further elucidate the mechanisms through which magnesium influences muscle function and exercise adaptation.

The optimal fixed-dose strategy for managing warfarin-associated hemorrhages remains unknown and few studies have evaluated the use of Factor VIII Inhibitor Bypass Activity (FEIBA). This retrospective cohort study’s primary efficacy outcome was the percentage of patients who achieved a post-FEIBA INR ≤ 1.5 following receipt of the old and new dosing regimens. In the old group patients received 500 or 1000 units for an INR < 5 or ≥5, respectively. In the new group patients received 1000, 1500, or 2000 units for an INR < 5, 5–9.9, or ≥10, respectively. Eighteen patients were included in each group. The median (IQR) pre-FEIBA INR in the old and new groups was 6.1 (3.1–12.9) and 5.3 (3.4–13.0), respectively [difference: −0.8 (95 CI%, −7.2 to 6.5)]. The median (IQR) post-FEIBA INR in the old and new groups was 1.6 (1.4–2.1) and 1.4 (1.2–1.5), respectively [difference: −0.2 (95% CI: −0.6 to 0.0)]. A post-FEIBA INR ≤ 1.5 was achieved in 14 (78%) patients in the new group and 9 (50%) patients in the old group (relative risk: 1.56; 95% CI, 0.91 to 2.7; p = 0.16). The post-FEIBA INR values in the patients who did not achieve a post-FEIBA INR ≤ 1.5 in the new group were 1.6, 1.6, 1.8, and 2.4. Among patients with a baseline INR ≥ 10, significantly more patients in the new group achieved a post-FEIBA INR ≤ 1.5 compared to the old group (86% vs. 17%, respectively). These findings suggest that the new FEIBA dosing regimen may improve INR reversal compared with the previous regimen, particularly among patients with a baseline INR ≥ 10, but larger studies are needed to confirm this observation.

Background: Awareness with paralysis is a growing concern in emergency department (ED) intubated patients who receive rocuronium for intubation. Following an internal audit that identified suboptimal adherence with postintubation sedation (PIS) practices, our institution launched an initiative to improve adherence to PIS standards. Objective: Determine whether the multidisciplinary initiative decreased the time to initiation of PIS at institutionally recommended doses. Methods: This pre-post intervention study was conducted at 2 institutions within a health care system, including an academic-affiliated hospital (site A) and a nonacademic-affiliated hospital (site B). The primary endpoint was the rate of PIS adherence before and after a multidisciplinary intervention that included education, order set modifications, and the establishment of clinical champions. Outcomes were compared across 3 groups: site AM (PIS managed by ED resident and supervising physicians), site AT (PIS managed by trauma resident and supervising physicians), and site B (PIS managed by ED supervising physicians). The order set changes were implemented at sites AM and B, but education and designation of clinical champions occurred only at site AM. Results: PIS adherence rates at site AM increased from 1% in the preintervention period to 20% in the postintervention period ( P < 0.001). There were no significant differences in PIS adherence rates between the preintervention and postintervention periods at sites AT and B. During the preintervention period, no significant differences in PIS adherence rates were observed across the groups, whereas during the postintervention period, site AM demonstrated significantly higher PIS adherence rates than sites AT and B. Conclusion and Relevance: This study demonstrated that a focused, multidisciplinary strategy can significantly improve adherence to PIS best practices in the ED. The marked improvements seen only at the site receiving the full intervention underscores the importance of combining education, workflow optimization, and clinical champions for successful practice change.

Background: Few studies have assessed the safety and efficacy of discharging emergency department patients with alcohol withdrawal after receiving parenteral phenobarbital. This study aimed to validate this practice and delineate the role of intramuscular phenobarbital for this indication. Methods: This single-center retrospective chart review included adult patients with non-severe alcohol withdrawal, as diagnosed by treating providers based on clinical judgment, who were managed in the emergency department’s low-acuity provider at triage zone, received parenteral phenobarbital, and were discharged within 12 h of arrival. The primary safety and efficacy endpoints were the percentages of patients who expired or re-presented to the emergency department for an alcohol-related diagnosis within seven days of the initial presentation, respectively. A subgroup analysis was performed to compare outcomes between those who only received intramuscular or intravenous phenobarbital. Results: Of the 192 patient encounters included, no deaths were reported. Twenty-one (10.9%) patients re-presented after the initial visit, received treatment, and were discharged home. One (0.52%) patient was admitted following re-presentation. The percentages of patients who re-presented in the intramuscular-only and intravenous-only groups were 8% and 13.5%, respectively (p = 0.25). The total and weight-based doses received were not significantly different between those who did and did not re-present in both the intramuscular-only and intravenous-only groups. The median length of stay in the intramuscular-only and intravenous-only groups was 3.97 h and 5.87 h, respectively (p < 0.001). Conclusions: Our findings suggest that patients presenting with non-severe alcohol withdrawal symptoms may be discharged from the emergency department following receipt of parenteral phenobarbital, without requiring additional outpatient alcohol withdrawal medications. Intramuscular phenobarbital appears to be a viable alternative route of administration and warrants further investigation.

Background: Management of severe hyponatremia requires rapid correction with 100–150 mL of 3% sodium chloride (HTS), but the lack of commercially available, ready‐to‐use HTS doses may contribute to delays and dosing errors. In contrast, 8.4% sodium bicarbonate (HTB) is available as a 50 mL prefilled syringe and provides a comparable sodium load, though it is not a guideline‐endorsed intervention. This study evaluated whether HTB produces a serum sodium increase comparable to HTS. Methods: The primary purpose of this retrospective cohort study was to determine the number of patients whose serum sodium concentrations increased ≥ 4 mEq/L following administration of HTB or HTS. Patients were included if they were adults, had an initial serum sodium concentration ≤ 120 mEq/L, and received a single dose of HTB (50 mL) or HTS (100 mL) from January 2019 through December 2024. Results: A total of 21 patients were included in each group. The number of patients whose post‐intervention serum sodium concentration increased by ≥ 4 mEq/L in the HTB and HTS groups was 10 (48%) and 2 (10%), respectively ( p = 0.01). The median (IQR) change in serum sodium concentrations following study drug administration in the HTB and HTS groups was 3 mEq/L (1 to 5) and 0 mEq/L (−0.5 to 2), respectively ( p = 0.005). There were no significant differences between the groups in the change in serum bicarbonate concentrations, chloride concentrations, and anion gap levels following study drug administration. No osmotic demyelination syndrome events were reported in the total population. Conclusions: This study found that a single 50 mL dose of HTB more often resulted in obtainment of guideline‐recommended post‐intervention serum sodium goal concentrations than a 100 mL HTS dose. Additional studies are needed to confirm these findings and provide a more comprehensive assessment of safety and efficacy outcomes.

Objective: Summarize the pharmacological options available for managing burning mouth syndrome (BMS). Data sources: A PubMed literature search was conducted for articles published between January 2000 and September 2025, which contained the following terms in their title: (1) burning mouth syndrome or (2) stomatodynia. Study selection and data extraction: Review articles, meta-analysis, commentaries, studies not related to the management of BMS, studies not including pharmacological interventions, animal studies, and non-English texts were excluded. The electronic search identified 797 articles. Following the initial screening, 529 articles were excluded and 16 were added after bibliography review. Of the 284 articles assessed for eligibility, 209 were excluded. A total of 75 articles were included. Data synthesis: Clonazepam, alpha lipoic acid, capsaicin, and amitriptyline were the most evaluated interventions. Clonazepam was effective, but its use is limited to the acute management of BMS. Alpha lipoic acid was well tolerated, but ineffective when given as monotherapy. Capsaicin was effective, but associated with patient discomfort. Amitriptyline was effective, but its use is limited by its adverse effect profile. Cannabis sativa, ultramicronized palmitoylethanolamide, pramipexole, and naltrexone were effective, but only evaluated in few studies. Most patients reported symptom recurrence upon therapy discontinuation, suggesting patients with BMS require lifelong management. Combining interventions often resulted in increased effectiveness, but with an increased risk for adverse effects. Relevance to patient care and clinical practice: BMS is a challenging condition to manage because there are no established treatment guidelines. Consequently, providers may be uncertain how to manage their patients. This review summarizes the available pharmacological options for managing BMS and serves as a resource to guide clinical decisions. Conclusion: Multiple agents with different mechanisms of action may be beneficial in the management of BMS. In the absence of treatment guidelines, providers may refer to this review when managing their patients.

Background: To minimize the risk of cerebral edema in the management of hyperglycemic emergencies, guidelines recommend gradually decreasing serum glucose levels, but there is limited literature validating these reduction goals or evaluating outcomes associated with different correction rates. Objective: This study evaluated cerebral edema rates associated with 2 different serum glucose correction rates in adults with hyperglycemic emergencies. Methods: This retrospective study’s primary endpoint was the incidence of cerebral edema. Secondary endpoints included average hourly changes in sodium, potassium, chloride, bicarbonate, anion gap, glucose, blood urea nitrogen, creatinine, and calculated osmolality, over the treatment course. Patients were divided into 2 groups based on their average hourly serum glucose correction rate (> 75 mg/dL and ≤ 75 mg/dL), and their outcomes were compared. Patients were included if they were ≥18 years old, received the institutions’ diabetic ketoacidosis or hyperglycemic hyperosmolar state insulin infusion order set within 12 hours of presenting to the hospital, and had a pre-insulin infusion glucose > 600 mg/dL. Results: One hundred thirty-four patients had a slow correction rate, and 51 had a rapid correction rate. The median time from starting the insulin infusion to achieving a glucose < 300 mg/dL in the slow and rapid correction rate groups was 9.9 and 6.1 hours, respectively (p < 0.001). In the total population, 2 (1.5%) cerebral edema events occurred. Both patients were in the slow correction rate group and had radiographic evidence of cerebral edema on post-return of spontaneous circulation imaging. There were significantly larger decreases in glucose and osmolality levels in the rapid correction rate group at several time points during treatment. Conclusion and relevance: Rapid serum glucose correction rates were not associated with increased cerebral edema events. Our findings suggest glucose and osmolality levels can be corrected faster than what is currently recommended.

Background: Although guidelines recognize the utility of subcutaneous (SQ) insulin regimens in the management of mild to moderate diabetic ketoacidosis (DKA), the need to administer SQ insulin every 1-2 hours may discourage their use due to frequent lab testing and admission to higher level of care units. Objective: The purpose of this retrospective cohort study was to compare the proportion of patients whose mild to moderate DKA resolved within 12 hours after receiving the new SQ insulin order set and the institution’s intravenous (IV) insulin infusion order set. Methods: The SQ order set included single doses of glargine (0.2 units/kg) and lispro (0.2 units/kg) upon therapy initiation, followed by lispro (0.1-0.2 units/kg) given every 3 hours until DKA resolution. The IV order set included a nurse-managed titratable infusion. Glucose and labs were checked every 3 hours in the SQ group, whereas glucose was checked hourly and labs were checked every 2 hours in the IV group. Patients were managed on units with a RN to patient ratio of 1:4-5 and 1:2-3 in the SQ and IV groups, respectively. Results: The percentage of patients whose DKA resolved within 12 hours was 78% in the IV group and 90% in the SQ group ( P = 0.1). The time to DKA resolution and rates of hypoglycemia and hypokalemia were comparable between the groups. Conclusion and Relevance: Our study highlights the utility of combining rapid-acting and basal SQ insulin in the management of DKA and adds to the limited literature evaluating this approach.