The metaphor

Don’t take life too seriously – nobody gets out alive anyway…    

-many people, at varying points in time

 

I’m rather firmly of the opinion that there isn’t much to life other than surviving as long as you can, having kids if you want them, and spending as much of that time being as happy and kind as is humanly possible. As far as I can see, If you nail those things, you’re pretty much golden. You’re going to die at some point, *sniff* and the world is going to carry on as it was, drifting through the inky abyss, until everything explodes, collapses, and maybe starts again. (contentious)

 

 

Maybe you’ll come back as a duck or something.

 

I’m a complete sucker for the feel-good, motivational, ‘you-go-girl’ quotes that get banded around the internet. They’re often pretty quirky, and leave you with a quick, tingly feeling of motivation or sudden renewed faith in humanity.

Always do your best. What you plant now, you will harvest later – Og Mandino

Life is 10% what happens to you and 90% how you react to it – Charles R. Swindoll

Start where you are, do what you can, use what you have – Arthur Ashe

Other times they’re just crap.

I can’t see myself without pink lipstick. I can go without it for a couple days, but if there was no more pink lipstick in the world, I’d be useless. Seriously. – Nicki Minaj

 

 

Sometimes they have a really profound impact on me, and I actually try and learn something from them, such as – The Magical Bank metaphor…

It goes along the lines of:

  • Each morning you get £84000 thrown into your bank account
  • At the end of each day your account is wiped clean, and you start again the next day
  • The bank might crash at any point, and the game is over
  • Anything you don’t spend is lost, anything you buy you get to keep

Sounds awesome right?

Gives you a new perspective on the 84,000 seconds you wake up with each morning to spend how you please, knowing that any time you don’t use will be lost forever. If someone stole £300 from you, would you spend the remaining £83,700 trying to get them back for it? Probably not… So why spend the rest of the day fretting about something that can’t be changed, or someone that wasted your time? Surely you can’t afford it!

 

 

Don’t watch the clock. Do what it does, keep going – Sam Levenson

 

 

 

 

Why you should care about Magnesium

I never learned much about Magnesium in the first few years of med school, which was a mistake, because it’s awesome.

Here I’ve tried to outline why it’s important and when to think about it in a clinical setting.

1. There’s loads of it

Magnesium is the ninth most abundant element in the universe, and the eleventh (by mass if you’re being pedantic) in your body. It’s required by every single cell as it is crucial to the basic nucleic acid chemistry that makes life possible, over 300 enzymes need it as a co-factor, and even ATP likes to hang out as a chelate of magnesium ions.

2. It’s useful as medicine

Magnesium has been used for many medicinal uses. It is a common laxative, antacid and it can stabilise muscle spasm in eclampsia. It increases production of prostaglandins and reduces that of thromboxane and angiotensin II. It also, in low doses, makes mineral water taste tart apparently (that was just for interest).

3. You can get it from loads of places

Clearly the ninth most abundant element in the universe isn’t going to be difficult to find, and you can find buckets of it in foods such as:

  • Spices
  • Nuts
  • Cocoa
  • Vegetables (given it’s crucial to chlorophyll, green stuff’s your best bet)

4. It does a lot of stuff in the body

Magnesium’s pretty busy in the world of metabolism. Most of it (60%) just chills in the bones, and the rest is mostly intracellular (20% in skeletal muscle). About 1% sits in the extracellular space, so clearly measuring your blood levels of magnesium isn’t going to tell you much about how much there is in your body.

It interacts with three major ions and their conduction channels:

  • Sodium
  • Potassium
  • Calcium

Sodium

Magnesium is required for the NaKATPase to function correctly in myocytes. Thus low magnesium means the sodium isn’t being pumped out and potassium isn’t being brought back in. This leads to a tachycardia and a predisposition to arrhythmias.

Potassium

To begin with, magnesium inhibits potassium leaving the cell through its channels. This means that too little magnesium, and you’re going to start losing potassium from the kidneys, and develop hypokalaemia. So – if you have a patient who’s hypokalaemic, and they’re not responding to potassium supplementation, start thinking about magnesium! In addition, patients in DKA (diabetic ketoacidosis) should have their magnesium monitored, so that the hypokalaemia caused by insulin driving the potassium into the cells isn’t compounded by renal losses.

Calcium

Magnesium suppresses release of calcium from the sarcoplasmic reticulum. This has several effects

  • reduced muscle contraction
  • reduced neuronal excitation through two mechanisms:
    • blockage of NMDA glutamate receptors
    • inhibition of acetylcholine release
  • reduced production of parathyroid hormone
    • interestingly mild reduction of magnesium stimulates PTH release, however
    • severe drops in magnesium reduce PTH release
  • hypocalcaemia
  • reduces sensitivity of skeletal muscle to parathyroid hormone 

Clinically this is important, as magnesium sulphate can be used as a bronchodilator in severe asthma.

5. Too little is bad 

As explained in point 4, you can have a normal blood magnesium while still being significantly deficient, and there isn’t really a reliable biomarker to measure. The best way to test whether someone is deficient is to load them with magnesium (a magnesium loading test… weirdly) and see how much of it they retain. If they hold onto more than 20%, they were definitely deficient in the first place. You’ve also just fixed the problem, so win win!

Symptoms of magnesium deficiency include:

  • weakness
  • muscle cramps
  • abnormal heart rhythm
  • tremors and athetosis (fidgeting)
  • extensor plantar reflex
  • confusion
  • hallucinations
  • depression
  • seizures
  • tetany

It’s a scary list but it makes sense – the muscle cramps largely due to the increased calcium that results from low magnesium, and the potassium leakage from cells that occurs.

Reasons for low magnesium in the blood are put into three categories:

  1. not enough uptake
  2. redistribution into the cells
  3. too much loss

Not enough uptake

Magnesium is absorbed in the duodenum and secreted by the colon, so malabsorption or excessive throughput will prevent it being absorbed into the blood. Conditions such as Crohn’s or Ulcerative Colitis will cause hypomagnesaemia by causing diarrhoea.

Redistribution into the cells

Adrenaline and other catecholamines tend to shove magnesium ions into the cells. Thus after a heart attack, 80% of patients will have low serum magnesium. Drugs that cause intracellular shift of calcium will drag magnesium with it, so things like Digitalis are also a risk factor.

Too much loss

A huge cause of hypomagnesaemia is alcohol. 30% of alcoholics have low magnesium, as do 85% of those with delerium tremens. In terms of medications, anything that inhibits reabsorption in the Loop of Henle is going to result in shedding of magnesium into the urine. The most common are:

  • loop diuretics
  • antibiotics
  • proton pump inhibitors

6. Too much is equally bad

Equally, too much is rarely good for you, and magnesium toxicity can happen even if the serum levels are normal, so knowing what to look out for in a clinical setting can be life-saving for the patient. Usually this is rare because your kidneys are seriously good at shifting it from the blood, so you don’t tend to get it from dietary overdose. Typically it’s your renally-impaired patient who’s on magnesium supplementation who sees their blood levels gradually climbing, and as expected, there is usually concurrent hyperkalaemia and hypocalcaemia, which generate most of the symptomatology:

Symptoms of hypermagnesaemia:

  • arrhythmias
  • hypotension
  • respiratory depression
  • hypo or areflexia
  • dizziness and somnolence

Treatment of hypermagnesaemia is done by antagonising it with calcium. Calcium gluconate IV help to reduce the cardiac manifestations of hypermagnesaemia, while diuretics and dialysis can reduce the magnesium levels in the body to a more tolerable level.

So there you go, a brief intro into why you should care about magnesium. It’s a puppet-master, controlling potassium and calcium, and for the most part it’s your friend, as long as you don’t have too much of it!

The Red One

  • Banana                                 1
  • Greek yogurt                       3 tbsp
  • Frozen summer fruits     to taste (like, 1/3 of the blender)
  • Pine nuts                             2 tbsp
  • Flax seeds                            2 tbsp
  • Spinach                                1 frozen blob
  • Kale                                       1 frozen blob
  • Rice milk                             to volume/texture

Prevention, better than cure

If it ain’t broke, don’t fix it.

 

So why let your body get broke in the first place?

 

  • Exercise
  • Diet
  • Mental wellbeing