Infantile Colic: Recognition and Treatment.

Infantile colic is a benign process in which an infant has paroxysms of inconsolable crying for more than three hours per day, more than three days per week, for longer than three weeks. It affects approximately 10% to 40% of infants worldwide and peaks at around six weeks of age, with symptoms resolving by three to six months of age. The incidence is equal between sexes, and there is no correlation with type of feeding (breast vs. bottle), gestational age, or socioeconomic status. The cause of infantile colic is not known; proposed causes include alterations in fecal microflora, intolerance to cow's milk protein or lactose, gastrointestinal immaturity or inflammation, increased serotonin secretion, poor feeding technique, and maternal smoking or nicotine replacement therapy. Colic is a diagnosis of exclusion after a detailed history and physical examination have ruled out concerning causes. Parental support and reassurance are key components of the management of colic. Simethicone and proton pump inhibitors are ineffective for the treatment of colic, and dicyclomine is contraindicated. Treatment options for breastfed infants include the probiotic Lactobacillus reuteri (strain DSM 17938) and reducing maternal dietary allergen intake. Switching to a hydrolyzed formula is an option for formula-fed infants. Evidence does not support chiropractic or osteopathic manipulation, infant massage, swaddling, acupuncture, or herbal supplements.

On-road heavy-duty vehicle emissions monitoring system.

The introduction of particulate and oxides of nitrogen (NOx) after-treatment controls on heavy-duty vehicles has spurred the need for fleet emissions data to monitor their reliability and effectiveness. The University of Denver has developed a new method for rapidly measuring heavy-duty vehicles for gaseous and particulate fuel specific emissions. The method was recently used to collect 3088 measurements at a Port of Los Angeles location and a weigh station on I-5 in northern California. The weigh station NOx emissions for 2014 models are 73% lower than 2010 models (3.8 vs 13.9 gNOx/kg of fuel) and look to continue to decrease with newer models. The Port site has a heavy-duty fleet that has been entirely equipped with diesel particulate filters since 2010. Total particulate mass and black carbon measurements showed that only 3% of the Port vehicles measured exceed expected emission limits with mean gPM/kg of fuel emissions of 0.031 ± 0.007 and mean gBC/kg of fuel emissions of 0.020 ± 0.003. Mean particulate emissions were higher for the older weigh station fleet but 2011 and newer trucks gPM/kg of fuel emissions were nevertheless more than a factor of 30 lower than the means for pre-DPF (2007 and older) model years.

A stepwise approach to the interpretation of pulmonary function tests.

Office-based pulmonary function testing, also known as spirometry, is a powerful tool for primary care physicians to diagnose and manage respiratory problems. An obstructive defect is indicated by a low forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio, which is defined as less than 70% or below the fifth percentile based on data from the Third National Health and Nutrition Examination Survey (NHANES III) in adults, and less than 85% in patients five to 18 years of age. If an obstructive defect is present, the physician should determine if the disease is reversible based on the increase in FEV1 or FVC after bronchodilator treatment (i.e., increase of more than 12% in patients five to 18 years of age, or more than 12% and more than 200 mL in adults). Asthma is typically reversible, whereas chronic obstructive pulmonary disease is not. A restrictive pattern is indicated by an FVC below the fifth percentile based on NHANES III data in adults, or less than 80% in patients five to 18 years of age. If a restrictive pattern is present, full pulmonary function tests with diffusing capacity of the lung for carbon monoxide testing should be ordered to confirm restrictive lung disease and form a differential diagnosis. If both the FEV1/FVC ratio and the FVC are low, the patient has a mixed defect. The severity of the abnormality is determined by the FEV1 (percentage of predicted). If pulmonary function test results are normal, but the physician still suspects exercise- or allergen-induced asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing) should be considered.

Chest pain and costochondritis associated with vitamin d deficiency: a report of two cases.

Vitamin D is integral for bone health, and severe deficiency can cause rickets in children and osteomalacia in adults. Although osteomalacia can cause severe generalized bone pain, there are only a few case reports of chest pain associated with vitamin D deficiency. We describe 2 patients with chest pain that were initially worked up for cardiac etiologies but were eventually diagnosed with costochondritis and vitamin D deficiency. Vitamin D deficiency is known to cause hypertrophic costochondral junctions in children ("rachitic rosaries") and sternal pain with adults diagnosed with osteomalacia. We propose that vitamin D deficiency may be related to the chest pain associated with costochondritis. In patients diagnosed with costochondritis, physicians should consider testing and treating for vitamin D deficiency.

Cardiovascular risk factor screening and follow-up in a military population aged 40 years and older.

OBJECTIVE: This study analyzed a worksite-based cardiovascular risk assessment offered to soldiers aged 40 and older to identify unrecognized cardiovascular risk and evaluate compliance with instructions to follow up for further evaluation. METHODS: Participants had fasting blood tests, waist circumference and blood pressure measurement and a carotid artery duplex scan performed at their worksite. A healthcare professional discussed the participants' results with them and, if indicated, recommended follow up within the following one month. RESULTS: Seventy-six (46%) of the 163 eligible soldiers agreed to participate. Twenty-nine (38%) of the 76 participants were instructed to follow up for elevated blood pressure, glucose, or lipids. Only 7 of 29 (24%) complied with follow-up instructions. CONCLUSION: Voluntary worksite-based interventions can effectively identify soldiers with unmanaged cardiovascular risk factors, but a more aggressive follow-up strategy should be used to ensure these soldiers receive indicated medical intervention.

A pilot study of clinical agreement in cardiovascular preparticipation examinations: how good is the standard of care?

OBJECTIVE: To evaluate the interobserver agreement between physicians regarding a abnormal cardiovascular assessment on athletic preparticipation examinations. DESIGN: Cross-sectional clinical survey. SETTING: Outpatient Clinic, United States Military Academy, West Point, NY. PARTICIPANTS: We randomly selected 101 out of 539 cadet-athletes presenting for a preparticipation examination. Two primary care sports medicine fellows and a cardiologist examined the cadets. INTERVENTIONS: After obtaining informed consent from all participants, all 3 physicians separately evaluated all 101 cadets. The physicians recorded their clinical findings and whether they thought further cardiovascular evaluation (echocardiography) was indicated. MAIN OUTCOME MEASURES: Rate of referral for further cardiovascular evaluation, clinical agreement between sports medicine fellows, and clinical agreement between sports medicine fellows and the cardiologist. RESULTS: Each fellow referred 6 of the 101 evaluated cadets (5.9%). The cardiologist referred none. Although each fellow referred 6 cadets, only 1 cadet was referred by both. The kappa statistic for clinical agreement between fellows is 0.114 (95% CI, -0.182 to 0.411). There was no clinical agreement between the fellows and the cardiologist. CONCLUSIONS: This pilot study reveals a low level of agreement between physicians regarding which athletes with an abnormal examination deserved further testing. It challenges the standard of care and questions whether there is a need for improved technologies or improved training in cardiovascular clinical assessment.