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The preferred method for revascularization of symptomatic infrapopliteal arterial occlusive disease (IPAD) has traditionally been open vascular bypass. Endovascular techniques have been increasingly applied to treat tibial disease with mixed results. We evaluated the short-term outcome of percutaneous infrapopliteal intervention and compared the different techniques used. A retrospective analysis of consecutive patients undergoing endovascular treatment for infrapopliteal arterial occlusive lesions between 2003 and 2007 in a tertiary teaching hospital was performed. Patient demographic data, indication for intervention, and periprocedural complications were recorded. Periprocedural and short-term outcomes were measured and compared. Forty-nine infrapopliteal arteries in 35 patients were treated. Twenty vessels (15 patients) underwent angioplasty and 29 vessels (20 patients) were treated with atherectomy. Demographic and angiographic characteristics were similar between the groups. Twenty-six patients had concurrent femoral and/or popliteal artery interventions. Overall, technical success was 90% and similar between angioplasty and atherectomy groups (85% versus 93%, p = NS). The vessel-specific complication rate was 10% and was similar between both groups (angioplasty 5% versus atherectomy 14%, p = NS). One dissection occurred in the angioplasty group; one perforation and three thromboembolic events occurred in the atherectomy group. Limb salvage and freedom from reintervention at 6 months were 81% and 68%, respectively, and were not significantly different between the angioplasty and atherectomy groups. Endovascular intervention for IPAD had acceptable periprocedural and short-term success rates in our high-risk patient population. Both atherectomy and angioplasty can be used successfully to treat symptomatic IPAD.

The Current Opioid Misuse Measure (COMM), a self-report assessment of past-month aberrant medication-related behaviors, has been validated in specialty pain management patients. The performance characteristics of the COMM were evaluated in primary care (PC) patients with chronic pain. It was hypothesized that the COMM could identify patients with prescription drug use disorder (PDD). English-speaking adults awaiting PC visits at an urban, safety-net hospital, who had chronic pain and had received any opioid analgesic prescription in the past year, were administered the COMM. The Composite International Diagnostic Interview served as the "gold standard," using DSM-IV criteria for PDD and other substance use disorders (SUDs). A receiver operating characteristic (ROC) curve demonstrated the COMM's diagnostic test characteristics. Of the 238 participants, 27 (11%) met DSM-IV PDD criteria, whereas 17 (7%) had other SUDs, and 194 (82%) had no disorder. The mean COMM score was higher in those with PDD than among all others (ie, those with other SUDs or no disorder, mean 20.4 [SD 10.8] vs 8.4 [SD 7.5], P<.0001). A COMM score of⩾13 had a sensitivity of 77% and a specificity of 77% for identifying patients with PDD. The area under the ROC curve was 0.84. For chronic pain patients prescribed opioids, the development of PDD is an undesirable complication. Among PC patients with chronic pain-prescribed prescription opioids, the COMM is a promising tool for identifying those with PDD. Among primary care patients with chronic pain-prescribed opioids, the validated Current Opioid Misuse Measure (COMM) is a promising tool for identifying patients with prescription opioid use disorder., (Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Objectives: We sought to test the effectiveness of expressive writing about irritable bowel syndrome (IBS) on disease severity, IBS-related cognition (perceived control over the illness or adaptive cognition), and IBS-specific quality of life., Methods: This was an exploratory pilot study, during which subjects with IBS were asked to write at an online portal for 30 min on 4 consecutive days about their deepest thoughts, emotions, and beliefs regarding the disease and their perception of its effects (writing group). The IBS severity scale (IBSSS), functional bowel disease-related cognition (CG-FBD), catastrophizing/coping (CT3), and IBS-specific quality of life (IBS-QOL) were measured at baseline and at 1 and 3 months' follow-up. Subjects who did not start writing for 3 weeks were asked to complete questionnaires without writing (non-writers group). Within-group comparisons pre- and post-assessment were compared. In addition, the writing and non-writers groups were compared. Linear mixed-effects models were used to assess the outcome measures over time (1 and 3 months)., Results: A total of 103 subjects were enrolled in the study (writing group, n=82; non-writers group, n=21). The mean age of all participants was 43 years (s.d. ±12), and the majority (91%) were female. The mean duration of IBS was 6.8 years (s.d. ±3.5); 102 subjects (99‰) had received physician-directed care for the disease. There were no significant differences between the writing and non-writers groups in baseline measurements. For the writing group at 1 and 3 months, the IBSSS improved significantly (+37.4 (±10.8), P=0.0012 and +53.8 (±13), P=0.0002, respectively) and this was not seen in the non-writers group. Similarly, the CG-FBD improved in the writing group by 0.58 (±0.2, P=0.006) at 3 months, although the changes in IBS-QOL did not reach clinical or statistical significance., Conclusions: In this exploratory study, expressive writing improved IBS disease severity and cognition in subjects with longer-term duration of the disease. A large, controlled study is warranted to evaluate the therapeutic potential of this novel modality for adjunctive management of IBS in the outpatient setting.

Objective: The American Academy of Pediatrics (AAP) strongly recommends the supine-only sleep position for infants and issued 2 more sudden infant death syndrome (SIDS) reduction recommendations: avoid bed sharing and use pacifiers during sleep. In this study, we investigated the following: 1) if mothers from at risk populations rate physicians as qualified to give advice about sleep practices and 2) if these ratings were associated with reports of recommended practice., Methods: A cross-sectional survey of mothers (N=2355) of infants aged <8 months was conducted at Women, Infants, and Children (WIC) Program centers in 6 cities from 2006 to 2008. The predictor measures were maternal rating of physician qualification to give advice about 3 recommended sleep practices and reported nature of physician advice. The dependent measures were maternal report of usage of recommended behavior: 1) "infant usually placed supine for sleep," 2) "infant usually does not share a bed with an adult during sleep," and 3) "infant usually uses a pacifier during sleep.", Results: Physician qualification ratings varied by topic: sleep position (80%), bed sharing (69%), and pacifier use (60%). High ratings of physician qualification were associated with maternal reports of recommended behavior: supine sleep (adjusted odds ratio [AOR] 2.1, 95% confidence interval [CI], 1.6-2.6); usually no bed sharing (AOR 1.5, 95% CI, 1.2-1.9), and usually use a pacifier during sleep (AOR 1.2, 95% CI, 1.0-1.5)., Conclusions: High maternal ratings of physician qualification to give advice on 2 of the 3 recommended sleep practices targeted to reduce the risk of SIDS were significantly associated with maternal report of using these behaviors. Lower ratings of physician qualification to give advice about these sleep practices may undermine physician effectiveness in promoting the recommended behavior., (Copyright © 2010 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Glucose levels 2 h after an oral glucose challenge are a clinical measure of glucose tolerance used in the diagnosis of type 2 diabetes. We report a meta-analysis of nine genome-wide association studies (n = 15,234 nondiabetic individuals) and a follow-up of 29 independent loci (n = 6,958-30,620). We identify variants at the GIPR locus associated with 2-h glucose level (rs10423928, beta (s.e.m.) = 0.09 (0.01) mmol/l per A allele, P = 2.0 x 10(-15)). The GIPR A-allele carriers also showed decreased insulin secretion (n = 22,492; insulinogenic index, P = 1.0 x 10(-17); ratio of insulin to glucose area under the curve, P = 1.3 x 10(-16)) and diminished incretin effect (n = 804; P = 4.3 x 10(-4)). We also identified variants at ADCY5 (rs2877716, P = 4.2 x 10(-16)), VPS13C (rs17271305, P = 4.1 x 10(-8)), GCKR (rs1260326, P = 7.1 x 10(-11)) and TCF7L2 (rs7903146, P = 4.2 x 10(-10)) associated with 2-h glucose. Of the three newly implicated loci (GIPR, ADCY5 and VPS13C), only ADCY5 was found to be associated with type 2 diabetes in collaborating studies (n = 35,869 cases, 89,798 controls, OR = 1.12, 95% CI 1.09-1.15, P = 4.8 x 10(-18)).

Purpose: Symptomatic atherosclerotic disease of the popliteal artery presents challenges for endovascular therapy. We evaluated the technical success, complications, and midterm outcomes of atherectomy and angioplasty involving the popliteal segment., Methods: We conducted a retrospective review of outcomes of popliteal artery intervention using atherectomy or angioplasty performed between 2003 and 2008., Results: A total of 56 patients (36% women, age 72.8 +/- 12.2 years, 77% critical limb ischemia) underwent popliteal atherectomy (n = 18) or angioplasty (n = 38). These patients had similar clinical characteristics, TransAtlantic Intersociety Consensus (TASC)/ TASC II classification, mean lesion length, and runoff scores. We observed a trend toward higher rates of technical success defined as <30% residual stenosis after atherectomy compared to angioplasty (94% vs 71%, P = .08). While angioplasty was associated with a higher frequency of arterial dissection (23% vs 0%, P = .003), atherectomy was associated with a higher rate of thromboembolic events (22% vs 0%, P = 0.01). Adjunctive stenting was used more frequently following angioplasty compared to atherectomy (45% vs 6%, P = .005). Thrombolysis was used to treat embolization in 4 patients in the atherectomy group. The improvement in the ankle-brachial index (ABI) was similar between the 2 treatment groups. Primary patency of the popliteal artery at 3, 6, and 12 months was 94%, 88%, and 75% in the atherectomy group and 89%, 82%, and 73% in the angioplasty group (P = not significant [NS]). There were no significant differences in limb salvage and freedom from reintervention at 1 year between the atherectomy and angioplasty groups., Conclusions: Our experience with popliteal artery endovascular therapy indicates a distinct pattern of procedural complications with atherectomy compared to angioplasty but similar midterm patency, limb salvage, and freedom from intervention.

In 1,079 infants monitored for >700,000 hr at home for apnea or bradycardia, we found an association between infants having multiple events exceeding conventional or a priori defined more extreme thresholds and less favorable developmental outcome at 1 year of age than infants with few or no events. If it is necessary to prevent such events to minimize risk for developmental morbidity, there is reason to determine whether there are disturbances in advance of the apnea or bradycardia that herald their onset. In the 85 infants with at least 1 extreme event and 1 conventional event, we hypothesized that apnea and bradycardia do not occur de novo but rather are preceded by cardiorespiratory and hemoglobin O2 saturation changes. We compared recorded time intervals preceding these events, and we analyzed three preceding time intervals for each conventional and extreme event, and each non-event recording: Time-2 hr: up to 2 hr before; Time-1 hr: up to 1 hr before; and Time-75 sec: the 75 sec immediately preceding each event. O2 saturation progressively decreased preceding both conventional and extreme events, and progressive increases occurred in heart and breathing rate variability. Duration of respiratory pauses and of periodic breathing progressively increased preceding conventional events, respiratory rate variability increased immediately preceding conventional events and at 1 hr preceding extreme events, and O2 saturation decreased immediately preceding both conventional and extreme events. Thus, conventional and extreme events do not occur de novo but rather are preceded by autonomic instability of the cardiorespiratory system., (Copyright (c) 2007 Wiley-Liss, Inc.)

Objectives: The risk for sudden infant death syndrome in black infants is twice that of white infants, and their parents are less likely to place them in the supine position for sleep. We previously identified barriers for parents to follow recommendations for sleep position. Our objective with this study was to quantify these barriers, particularly among low-income, primarily black mothers., Design/methods: We conducted face-to-face interviews with 671 mothers, 64% of whom were black, who attended Women, Infants, and Children Program centers in Boston, Massachusetts, Dallas, Texas, Los Angeles, California, and New Haven, Connecticut. We used univariate analyses to quantify factors that were associated with choice of sleeping position and multivariate logistic regression to calculate adjusted odds ratios for the 2 outcome variables: "ever" (meaning usually, sometimes, or last night) put infant in the prone position for sleep and "usually" put infant in the supine position to sleep., Results: Fifty-nine percent of mothers reported supine, 25% side, 15% prone, and 1% other as the usual position. Thirty-four percent reported that they ever placed infants in the prone position. Seventy-two percent said that a nurse, 53% a doctor, and 38% a female friend or relative provided source of advice. Only 42% reported that a nurse, only 36% a doctor, and only 15% a female friend or relative recommended the supine position for sleep. When a female friend or relative recommended the prone position, mothers were more likely ever to place their infants in the prone position and less likely usually to choose supine compared with those who received no advice from friends or relatives. When a doctor or a nurse recommended a nonsupine position, the mothers were less likely to choose supine compared with those who received no advice from a doctor or a nurse. Mothers who trusted the opinion of a doctor or a nurse about infant sleeping position were more likely to place their infants in the supine position. Half of the mothers believed that infants were more likely to choke when supine, and they were less likely to place their infants supine. Mothers who believed that infants are more comfortable in the prone position (36%) were more likely to place their infants prone. Twenty-nine percent believed that having their infants sleep with an adult helps prevent sudden infant death syndrome, and only 43% believed that sudden infant death syndrome is related to sleeping position., Conclusions: We identified specific barriers to placing infants in the supine position for sleep (lack of or wrong advice, lack of trust in providers, knowledge and concerns about safety and comfort) in low-income, primarily black mothers that should be considered when designing interventions to get more infants onto their back for sleep.