Lead Poisoning in Children.

Asymptomatic lead poisoning has become more common in children. Blood lead levels of less than 5 µg per dL are associated with impairments in neurocognitive and behavioral development that are irreversible. Risk factors for lead poisoning include age younger than five years, low socioeconomic status, living in housing built before 1978, and use of imported food, medicines, and pottery. The U.S. Preventive Services Task Force released a recommendation in 2019 citing insufficient evidence to assess the balance of benefits and harms of universal screening for elevated blood lead levels in asymptomatic children and pregnant women. Local risk factors can be substantial, and the Centers for Disease Control and Prevention (CDC) recommends that states and cities formulate their own targeted screening guidelines. In the absence of local guidance, the CDC recommends screening all Medicaid-eligible children at 12 months and again at 24 months, or at least once between 36 and 72 months if not previously screened. The CDC also recommends universal screening in areas where more than 27% of the housing was built before 1950, or where at least 12% of children 12 to 36 months of age have blood lead levels greater than 10 µg per dL. Life-threatening lead levels are treated with chelation therapy, and lower levels should prompt case management and environmental investigations to identify and remove the source of exposure. Primary prevention strategies are essential to eliminate the harmful effects of lead on child development.

Nephrolithiasis.

Incidence of nephrolithiasis has increased dramatically over the past 30 years, likely due to environmental changes such as dietary habits. Nephrolithiasis presents as acute flank or abdominal pain with nausea and vomiting. Hematuria is present in 90% of cases, but its absence does not rule out nephrolithiasis. Most cases can be managed expectantly as an outpatient with hydration, analgesia, and possibly medications to aide in passage. A metabolic evaluation may be indicated after a second episode of nephrolithiasis in adults or after a first episode in children or those with a family history of nephrolithiasis.

Headache: Migraine.

Migraine is a primary headache disorder and a common, recurrent, disabling condition that affects an estimated 18% of women and 6% of men. Commonly reported triggers that induce migraine include stress, fatigue, various foods, alcohol, drugs, smoking, weather changes, and odors. Migraine is diagnosed clinically, with diagnostic testing indicated only in patients with red flag signs and symptoms. Research is providing new insights into the underlying pathophysiology and genetics of migraine as well as novel pharmacotherapies for management and prevention. Migraine is a complex and heterogeneous condition, which makes use of general treatment recommendations difficult. However, a variety of drugs has been proven to be effective for abortive treatment and migraine prophylaxis. This allows for treatment individualization for each patient's headache pattern. Integrative medicine therapies may have a role in management. Although migraine in children and adolescents is less well-studied, management recommendations for migraine in children and adolescents are similar to those for migraine in adults.

Acute Migraine Headache: Treatment Strategies.

Migraine is a primary headache disorder characterized by recurrent attacks. Acetaminophen, nonsteroidal anti-inflammatory drugs, triptans, antiemetics, ergot alkaloids, and combination analgesics have evidence supporting their effectiveness in the treatment of migraine. Acetaminophen and nonsteroidal anti-inflammatory drugs are first-line treatments for mild to moderate migraines, whereas triptans are first-line treatments for moderate to severe migraines. Although triptans are effective, they may be expensive. Other medications such as dihydroergotamine and antiemetics are recommended for use as second- or third-line therapy for select patients or for those with refractory migraine. The pharmacologic properties, potential adverse effects, cost, and routes of administration vary widely, allowing therapy to be individualized based on the pattern and severity of attacks. Several treatment principles, including taking medication early in an attack and using a stratified treatment approach, can help ensure that migraine treatment is cost-effective.

Emerging Topics in Gastroenterology.

The bacteria and fungi in the human gut make up a community of microorganisms that lives in symbiosis with humans, engaging in numerous diverse interactions that influence health. This article outlines the current knowledge on emerging topics in gastroenterology, including microbiome and probiotics, fecal microbiota transplantation, cyclic vomiting syndrome, eosinophilic esophagitis, and microscopic colitis.

Improving Interrater Reliability of Medical Student Assessment by Clinical Supervisors.

INTRODUCTION: Clinical clerkships that rely on community preceptors as faculty and assessors are challenged by the variability in their assessments of student performance. This workshop was designed to improve the interrater reliability of preceptors' assessment of student performance. METHODS: This workshop uses a series of videos showing standardized student interactions with standardized patients and a preceptor. The videos feature a borderline satisfactory student-patient encounter and a superior student encounter. For each case, there is a video of the student providing an oral presentation of the encounter to a preceptor. The concept of a plus/delta card is also presented. Participants are asked to note positive elements of the interactions and elements needing improvement on the plus/delta card while watching the videos. Next, participants share their assessment of the students with the group using an audience response system. Group discussion allows for consensus and leads to decreased variation in preceptor assessments of each student's performance. This workshop has been delivered to preceptors in our institution as a 1-hour workshop. Additionally, a version has been presented twice at national medical teaching conferences as a faculty development workshop, instructing faculty how to facilitate the workshop. RESULTS: Participant evaluations from the workshop show an increase in preceptors' awareness of specific student behaviors to observe as well as increased confidence with assessing more consistently across various student performances. DISCUSSION: Using videos with standardized patients, students, and preceptors demonstrating various qualities of performance is effective in improving precision in preceptors' assessment of students in clinical settings.

Metabolic Syndrome: Insulin Resistance and Prediabetes.

Metabolic syndrome is a cluster of conditions that synergistically increase the risk of cardiovascular disease, type 2 diabetes, and premature mortality. The components are abdominal obesity, impaired glucose metabolism, dyslipidemia, and hypertension. Prediabetes, which is a combination of excess body fat and insulin resistance, is considered an underlying etiology of metabolic syndrome. Prediabetes manifests as impaired fasting glucose and/or impaired glucose tolerance. Impaired fasting glucose is defined as a fasting blood glucose level of 100 to 125 mg/dL; impaired glucose tolerance requires a blood glucose level of 140 to 199 mg/dL 2 hours after a 75-g oral intake of glucose. In patients with prediabetes, the rate of progression to diabetes within 3 years can be decreased by approximately 58% with lifestyle modifications. These include weight loss through exercise (30 minutes or more of moderate physical activity on most, preferably all, days of the week) and dietary modifications. Recommended diets are high in fruits, vegetables, whole grains, and fish. Consumption of sweetened beverages, including diet soda, should be avoided. For patients who do not achieve goals with lifestyle modifications, metformin can be considered. Weight loss drugs and bariatric surgery are appropriate for select patients. Hypertension and dyslipidemia should be managed according to current guidelines.

Pro-anorexia websites: what a clinician should know.

OBJECTIVE: The purpose of this study was to conduct a content analysis of the "Tips and Tricks" section of pro-ana websites to better understand information shared on these sites, and aide clinicians in identification, treatment, and prevention of anorexia. METHOD: Nine pro-ana websites were evaluated to identify categories of information in "Tips and Tricks." A content analysis was performed using emergent coding methods and 16 categories were determined. Reliability was acceptable (Cohen's Kappa = 0.702). Discrepancies were corrected by consensus. Frequencies of individual categories were computed. RESULTS: Most "Tips and Tricks" are directed at dieting/restricting calories (28.6%) and distraction (14.0%). Most disturbing, 11% of comments were directed at lying and concealing symptoms. DISCUSSION: Clinicians aware of "Tips and Tricks" might be better equipped to recognize the symptoms of anorexia early in treatment. Knowledge of "Tips and Tricks" can also facilitate better education, making it difficult for clients to conceal their illness.