Expanding the Capacity of Primary Care to Treat Co-morbidities in Children with Autism Spectrum Disorder.

We examined barriers and facilitators to expanding primary care's capacity to manage conditions associated with autism spectrum disorder (ASD). We conducted semi-structured interviews with specialists, primary care providers (PCPs), primary care staff, and parents of children with ASD, discussing health/behavior problems encountered, co-management, and patient/family experience. Participants endorsed primary care as the right place for ASD-associated conditions. Specialists advising PCPs, in lieu of referrals, efficiently uses their expertise. PCPs' ability to manage ASD-associated conditions hinged on how behavioral aspects of ASD affected care delivery. Practices lacked ASD-specific policies but made individual-level accommodations and broader improvements benefitting children with ASD. Enhancing access to specialty expertise, particularly around ASD-associated behaviors, and building on current quality improvements appear important to expanding primary care.

Relation of heart rate with cardiovascular disease in normal-weight individuals: the Chicago Heart Association Detection Project in Industry.

The authors investigated the association of resting heart rate (RHR) with cardiovascular disease (CVD) risk factors and mortality among normal-weight individuals. Using data from our cohort (baseline examination in 1967-1973), individuals with a body mass index of 18.5 to 24.9 kg/m(2) (men [n=3724] and women [n=4929] aged 18-39; men [n=1959] and women [n=3735] aged 40-59), were grouped by RHR: <75, 75-84, and > or =85 beats per minute (bpm). A lower RHR was associated with lower mean blood pressure (BP) and cigarette use in each subgroup and total cholesterol (TC) and diabetes in men (P<.05). After a 32-year follow-up, hazard ratios (95% confidence intervals) for CVD mortality for an RHR <75 compared with > or =85 bpm adjusted for age, race, education level, BP, cigarette use, diabetes, and TC were 0.58 (0.34-0.84), 0.73(0.56-0.95), and 0.77 (0.61-0.98) for men aged 18 to 39 and men and women aged 40 to 59, respectively. In women aged 18 to 39, the relationship was not significant. In general, normal-weight individuals with lower RHRs have lower levels of CVD risk factors and mortality.

New-onset diabetes mellitus as a harbinger of pancreatic carcinoma. A case report and literature review.

We report the case of a middle-aged man with a 6-month history of diabetes treated with insulin. He was referred for diabetes control and education. Six weeks after we saw him, he was euglycemic (hemoglobin, Hgb A1C 5.9%), but returned because of weight loss, diarrhea, and abdominal cramps. Pancreatic adenocarcinoma was diagnosed. We review the literature on the relationship between diabetes mellitus and pancreatic carcinoma with particular emphasis on situations in which recent-onset diabetes may be a harbinger of pancreatic carcinoma. Several reports are cited in which the onset of diabetes mellitus in middle-aged patients antedated by a short time the onset of clinically recognizable pancreatic carcinoma. An otherwise silent pancreatic carcinoma may present as new-onset diabetes. Although rare, pancreatic carcinoma should be considered in a recently diagnosed middle-aged diabetic person with unusual manifestations, e.g., abdominal symptoms and continuous weight loss despite euglycemia.

Intestinal absorption in the mechanically obstructed rat intestine: protection by prostaglandins.

Intestinal obstruction inhibits amino acid absorption. The inhibition, being dependent on the pathological changes of the absorptive epithelium, was considered as an index of injury and measured after varying periods of obstruction and after pretreatment with clindamycin, indomethacin, 16,16-dimethyl-PGE2 or arachidonic acid. A reduction in amino acid uptake was apparent after 2h of obstruction and was increasingly evident after 4, 6 and 18 h. During the late phase (after 6 h), inhibition was partly prevented by pretreatment with clindamycin, but the antibiotic was ineffective during the early phase (within the first 2 h). Bacterial colony counts of luminal contents of rats obstructed for 2 h, were not different from counts obtained in controls, but significantly lower than counts in rats that have been obstructed for 6 h. Pretreatment of rats with 16,16-dimethyl-PGE2 or with arachidonic acid prevented the early inhibitory effects of the obstruction. The findings suggest that the early inhibition in amino acid uptake may be related to metabolic changes that are correctable by the administration of 16,16-dimethyl-PGE2 or of arachidonic acid. The inhibition, during the late phase, is mainly related to an overgrowth of the enteric bacteria.

Choledochoduodenal fistula and choledocholithiasis: treatment by endoscopic enlargement of the choledochoduodenal fistula.

Choledochoduodenal fistula is an uncommon complication of choledocholithiasis. Five patients with this entity were treated by endoscopic enlargement of the choledochoduodenal fistula without complication. Choledochoduodenal fistula complicating choledocholithiasis seem to arise either from stone erosion through the bile duct into the duodenum or as a complication of vigorous instrumentation at the time of common duct exploration. In patients in whom endoscopic sphincterotomy cannot be performed because of inability to cannulate the ampullary orifice, endoscopic enlargement of the choledochoduodenal fistula can be performed safely.