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Biomedical subjects

D R Gifford

Publications and source records attributed to D R Gifford.

At least 19 recordsLinked to original sources
PubMed1999

Improving adherence to dementia guidelines through education and opinion leaders. A randomized, controlled trial.

BACKGROUND: Educational methods that encourage physicians to adopt practice guidelines are needed. OBJECTIVE: To evaluate an educational strategy to increase neurologists' adherence to specialty society-endorsed practice recommendations. DESIGN: Randomized, controlled trial. SETTING: Six urban regions in New York State. PARTICIPANTS: 417 neurologists. INTERVENTION: The educational strategy promoted six recommendations for evaluation and management of dementia. It included a mailed American Academy of Neurology continuing medical education course, practice-based tools, an interactive evidence-based American Academy of Neurology-sponsored seminar led by local opinion leaders, and follow-up mailings. MEASUREMENTS: Neurologists' adherence to guidelines was measured by using detailed clinical scenarios mailed to a baseline group 3 months before the intervention and to intervention and control groups 6 months after the intervention. In one region, patients' medical records were reviewed to determine concordance between neurologists' scenario responses and their actual care. RESULTS: Compared with neurologists in the baseline and control groups, neurologists in the intervention group were more adherent to three of the six recommendations: neuroimaging for patients with dementia only when certain criteria are present (odds ratio, 4.1 [95% CI, 1.9 to 8.9]), referral of all patients with dementia and their families to the Alzheimer's Association (odds ratio, 2.8 [CI, 1.7 to 4.8]), and encouragement of all patients and their families to enroll in the Alzheimer's Association Safe Return Program (odds ratio, 10.8 [CI, 3.5 to 33.2]). For the other three recommendations, adherence did not differ between the intervention and the nonintervention groups. Agreement between scenario responses and actual care ranged from 27% to 99% for the six recommendations and was 95% or more for three of the recommendations. CONCLUSION: A multifaceted educational program can improve physician adoption of practice guidelines.

Dementia↗
PubMed1999

Tacrine use in nursing homes: implications for prescribing new cholinesterase inhibitors. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology.

OBJECTIVE: To describe the use of tacrine in nursing home residents using data from a clinically based resident assessment instrument used by all US nursing homes. METHODS: Data were from the Systematic Assessment of Geriatric Drug Use via Epidemiology (SAGE) database, a population-based data set with information on 329,520 patients admitted to all Medicare/Medicaid certified nursing homes in four US states (Maine, Mississippi, New York, and South Dakota) from 1992 through 1995. The SAGE database combines information from the Minimum Data Set (MDS) and the On-Line Survey and Certification Automated Record. We identified all residents receiving tacrine and up to five control residents per case matched on state, date of tacrine use, cognitive function, and dementia diagnosis. RESULTS: A total of 1,640 (0.5%) nursing home residents received tacrine at least once. Only 38% of these residents had a diagnosis of AD documented on the MDS; regardless of dementia diagnosis, 25% had severe cognitive impairment, 35% were severely dependent in activities of daily living (ADL), and 17% had both severe cognitive and ADL impairment. Only 8% achieved a therapeutic dose of at least 120 mg/d. After adjusting for confounding variables, wandering and being physically abusive were the strongest predictors of tacrine use. CONCLUSIONS: A minority of nursing home residents received tacrine. Of those who did, a significant proportion were unlikely to benefit from its use because of their level of cognitive and ADL impairment, or because low doses were used. As new medications become available for dementia, MDS data can be used by nursing homes to monitor the use of these therapies.

Aged↗
PubMed1999

A randomized trial to implement practice recommendations: design and methods of the Dementia Care Study.

The objective of the Dementia Care Study was to design, implement, and evaluate, in a randomized controlled trial a multi-faceted, specialty-society sponsored intervention to encourage neurologists' adoption of practice recommendations. Eligible participants were 417 neurologists in six regions in New York State (NYS) who were identified through the American Academy of Neurology (AAN) Membership Database and the NYS Physician Masterfile. An Advisory Panel of experts on dementia, neurologists who were local opinion leaders, and local representatives of the Alzheimer's Association guided the development of the intervention. The intervention included six components: (1) a mailing of six practice recommendations in a course of continuing medical education (CME) sponsored by the AAN; (2) a mailing of supplementary, practice-based tools; (3) follow-up mailings reinforcing the recommendations; (4) an invitation to an AAN-sponsored seminar; (5) endorsement by opinion leaders; and (6) specialty-society sponsorship and endorsement. The primary outcome measure was neurologists' decision-making, as assessed through a mailed survey that used detailed clinical scenarios. Intervention and control neurologists received the survey six months after the intervention, and a baseline group received it three months prior to the intervention. To evaluate the concordance of responses to scenarios with actual processes of care, we reviewed medical records in one study region. Secondary outcome measures included number of patient referrals received by the local Alzheimer's Associations and by the Association's National Safe Return Program. The specialty society, the opinion leaders, the dementia experts, local advocacy groups, and the study investigators achieved a high degree of collaboration. Specialty societies can integrate within their educational programs the capability to design and evaluate the impact of novel strategies to encourage the adoption of practice recommendations that are linked to improved quality of care.

Aged↗
PubMed1999

Survival after percutaneous endoscopic gastrostomy among older residents of Quebec.

CONTEXT: Percutaneous endoscopic gastrostomy has become a mainstay of nutritional support for individuals with swallowing dysfunction. There is little population-based data to guide the use of this intervention in older individuals. OBJECTIVE: To describe the use of percutaneous endoscopic gastrostomy among older residents of Quebec and to evaluate patient characteristics associated with subsequent survival and hospital discharge. DESIGN: A population-based cohort study. SETTING: Quebec, Canada. PATIENTS: 175 individuals with a billing claim for percutaneous endoscopic gastrostomy performed in 1993. MEASUREMENTS: Billing and hospitalization databases were used to collect patient characteristics, medical diagnoses, discharge destinations, and dates of death. The relationships between demographic and diagnostic variables before gastrostomy, and subsequent survival and discharge home, were evaluated using survival analysis. RESULTS: Median survival after gastrostomy was 210 days. Mortality at 30 days was 18.3%. Decreased survival was associated with a previous diagnosis of malignancy (risk ratio (RR) = 1.71; 95% CI, 1.09-2.68); mortality did not increase with increasing age. Of 163 individuals hospitalized at the time of gastrostomy, 42 (26%) were discharged home. Individuals with a previous diagnosis of stroke (RR = 2.80; 95% CI 1.01-7.77) were more likely to be discharged home than other individuals. CONCLUSIONS: Survival after percutaneous endoscopic gastrostomy is poor; the requirement for such a procedure appears to be a marker for severe underlying disease. The greater likelihood of return home after gastrostomy among individuals with stroke suggests that the use of this intervention as an adjunct to rehabilitation is appropriate in these individuals.

Aged↗
PubMed1998

Curbside consultation practices and attitudes among primary care physicians and medical subspecialists.

CONTEXT: Informal (curbside) consultations are an integral part of medical culture and may be of great value to patients and primary care physicians. However, little is known about physicians' behavior or attitudes toward curbside consultation. OBJECTIVE: To describe and compare curbside consultation practices and attitudes among primary care physicians and medical subspecialists. DESIGN: Survey mailed in June 1997. PARTICIPANTS: Of 286 primary care physicians and 252 subspecialists practicing in Rhode Island, 213 primary care physicians and 200 subspecialists responded (response rate, 76.8%). MAIN OUTCOME MEASURES: Self-reported practices of, reasons for, and attitudes about curbside consultation. RESULTS: Of primary care physicians, 70.4% (150/213) and 87.5% (175/200) of subspecialists reported participating in at least 1 curbside consultation during the previous week. In the previous week, primary care physicians obtained 3.2 curbside consultations, whereas subspecialists received 3.6 requests for curbside consultations. Subspecialties most frequently involved in curbside consultations were cardiology, gastroenterology, and infectious diseases; subspecialties that were requested to provide curbside consultations more often than they were formally consulted were endocrinology, infectious diseases, and rheumatology. Curbside consultations were most often used to select appropriate diagnostic tests and treatment plans and to determine the need for formal consultation. Subspecialists perceived more often than primary care physicians that information communicated in curbside consultations was insufficient (80.2% vs 49.8%; P<.001) and that important clinical detail was not described (77.6% vs 43.5%; P<.001). More subspecialists than primary care physicians felt that curbside consultations were essential for maintaining good relationships with other physicians (77.2% vs 38.6%; P<.001). CONCLUSIONS: Curbside consultation serves important functions in the practice of medicine. Despite the widespread use of curbside consultation, disagreement exists between primary care physicians and subspecialists as to the role of curbside consultation and the quality of the information exchanged.

Humans↗
PubMed1998

Practice styles of US compared to UK neurologists.

OBJECTIVE: This study assessed variation between neurologists in the United States and United Kingdom in their diagnostic and treatment decisions for commonly encountered neurologic presentations, and identified explanatory factors for any observed variation. METHODS: All 210 consultant neurologists in the United Kingdom and a nationally representative sample of 595 US neurologists received mailed surveys containing three detailed clinical scenarios depicting patients with (1) a single unprovoked seizure occurring 3 days previously, (2) early Parkinson's disease, and (3) dementia. The main study outcome measures were self-reported decisions regarding diagnostic test ordering and treatment, which were assessed after each scenario. Neurologists' practice characteristics, certainty about the diagnosis, and attitudes toward uncertainty were also measured. Survey response rates were 92% of US and 63% of UK neurologists. RESULTS: A higher proportion of US than UK neurologists indicated they would order additional diagnostic tests for all three scenarios (all p < 0.05); 77% of UK compared with 26% of US neurologists would manage a single unprovoked seizure without antiepileptic medication (p < 0.0001), but treatment of early Parkinson's disease was not different. Nearly all US and UK neurologists would obtain a neuroimaging study in the evaluation of dementia. International differences persisted after adjustment for differences in demographic and practice characteristics and for attitudes toward test use and clinical uncertainty. CONCLUSIONS: We identified large international variation in clinical decisions across three common neurologic conditions. Cross-country collaboration should explore these differences to develop consensus on standards of care.

Attitude of Health Personnel↗
PubMed1996

Can a specialty society educate its members to think differently about clinical decisions? Results of a randomized trial.

OBJECTIVE: Measure the effect of specialty society-developed continuing medical education (CME) on clinical decision making. DESIGN: Randomized controlled trial. SETTING: National sample of neurologists. PARTICIPANTS: Of 492 neurologists randomly selected from an ongoing American Academy of Neurology CME program, 248 were randomized to receive a mailed CME course, and 244 did not receive it. INTERVENTION: A mailed educational course on movement disorders, developed by the specialty society, containing information on diseases and practice recommendations with illustrative case presentations. MEASUREMENTS AND MAIN RESULTS: We assessed adherence to 16 practice recommendations on disease detection, diagnostic test use, and treatments by mailed survey sent to all subjects 4.5 months after the intervention group received the course (73% response rate). The survey contained detailed clinical scenarios to measure self-reported clinical decision making and short open-ended questions to measure factual knowledge. More intervention participants (up to 2.6 times more) than control subjects reported clinical decision making adherent to 9 of the 16 recommendations (p < .05). For 4 of the other 7 recommendations, adherence exceeded 85% in both groups. Within the intervention group, neurologists who read the educational course were 2 to 6 times more likely to be adherent than neurologists who did not. The intervention group had better factual knowledge than control subjects in six of seven areas (p < .01). CONCLUSIONS: This educational course improved neurologists' reported decision making. Specialty society-developed CME that utilizes a similar format may enhance the effectiveness of mailed CME information to improve physicians' approach to clinical decisions.

Decision Making↗
PubMed1996

Diagnostic reasoning in neurology.

Studies examining physicians' clinical decisions have demonstrated considerable variation in decisions and practices and identified numerous challenges to effective, efficient, and accurate decision making. Although use of the decision aids and tools described in this article may help overcome many of these challenges, greater self-awareness of the diagnostic reasoning process and the factors influencing decisions also should help improve clinical decisions and reduce variation, irrespective of the use of these tools. Continued research into the determinants and nature of the diagnostic reasoning process will provide additional insights that can be used to develop and apply improved decision aids and corrective procedures to overcome persistent problems.

Decision Support Techniques↗
PubMed1989

Pituitary and ovarian responses of post-partum acyclic beef cows to continuous long-term GnRH and GnRH agonist treatment.

Post-partum acyclic beef cows received continuous long-term treatment with GnRH (200 or 400 ng/kg body wt/h) or the GnRH agonist buserelin (5.5 or 11 ng/kg body wt/h) using s.c. osmotic minipumps which were designed to remain active for 28 days. All treatments increased circulating LH concentrations whereas FSH remained unchanged. Ovulation and corpus luteum (CL) formation as judged by progesterone concentrations greater than or equal to 1 ng/ml occurred in 0/5 control, 4/5 200 ng GnRH, 4/4 400 ng GnRH, 4/5 5.5 ng buserelin and 3/5 11 ng buserelin cows. The outstanding features of the progesterone profiles were the synchrony, both within and across groups, in values greater than or equal to 1 ng/ml around Day 6, and the fact that most CL were short-lived (4-6 days). Only 3 cows, one each from the 400 ng GnRH, 5.5 ng buserelin and 11 ng buserelin groups, showed evidence of extended CL function. Cows failed to show a second ovulation which was anticipated around Day 10 and this could have been due to insufficient FSH to stimulate early follicular development, or the absence of an endogenously driven LH surge. The highest LH concentrations for the respective groups were observed on Days 2 and 6 and by Day 10 LH was declining, although concentrations did remain higher than in controls up to Day 20.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1988

Gonadotrophin secretion and ovarian responses in prepubertal heifers actively immunized against androstenedione and oestradiol-17 beta.

Groups of heifer calves received a primary immunization against androstenedione (Group A; N = 11) or oestradiol-17 beta (Group E; N = 10) at 3 months of age and booster injections on 5 occasions at 2- to 3-month intervals. Controls (Group C, N = 11) were immunized against human serum albumin alone using the same protocol. Immunity was achieved against both steroids as judged by the secondary antisteroid antibody titres in Group A (1126 +/- 261; reciprocal of titre) and Group E (10,357 +/- 4067) heifers. In Groups A and E there was a general decline in the respective peak antibody titres after successive booster injections. From 3 to 9 months of age mean plasma concentrations of LH were higher (P less than 0.05) in Group E heifers (0.89 +/- 0.08 ng/ml) than in Group C (0.46 +/- 0.03 ng/ml) and Group A (0.59 +/- 0.05 ng/ml) heifers which did not differ from one another. There were no differences between groups in plasma FSH concentrations. At 10 months of age the LH response to exogenous LHRH was of higher (P less than 0.05) amplitude for heifers in Group E (2.59 +/- 0.56 ng/ml) than for those in Groups C (0.61 +/- 0.07 ng/ml) and A (1.04 +/- 0.22 ng/ml). Elevated plasma progesterone concentrations at 5 months of age were shown by 2 heifers in Group C, 10 in Group A, and 6 in Group E. From 8 to 14 months of age a consistently higher proportion of Group A heifers exhibited elevated progesterone compared with Group C and Group E heifers. After ovarian synchronization and booster injection at 15 months of age a corpus luteum was present in 2 heifers in Group C, 7 in Group A and none in Group E. The ovaries of Group A heifers were different from those of Groups C and E and were characterized by greater numbers of 2-4 mm follicles. It is concluded that active immunization against gonadal steroids influences both LH secretion and ovarian function in prepubertal heifers. Early increases in ovarian activity in androstenedione-immunized heifers are maintained after puberty and may therefore confer some lifetime reproductive advantages.

Androstenedione↗
PubMed1988

Immune complex acute necrotizing glomerulonephritis with progression to diffuse glomerulosclerosis. A murine model.

Male BALB/c mice given daily intraperitoneal injections of 4 mg of horse-spleen apoferritin develop, in the majority of cases, a proliferative and necrotizing glomerulonephritis with leukocytic infiltration and extensive intraglomerular thrombosis within 10 to 14 days, as previously reported. We now show that if injection of the antigen is discontinued, surviving animals develop extensive glomerulosclerosis (GS). Ten of 13 mice treated as indicated above and sacrificed 4 months after the last horse-spleen apoferritin injection developed segmental GS involving over 40% of their glomeruli. Tubulointerstitial damage of proportionate severity also developed. Ultrastructurally, pronounced mesangial expansion due to matrix deposition obliterated the glomerular architecture. We offer this as a reproducible model of immune complex-mediated GS particularly suited to the study of cellular interactions involved in the pathogenesis of GS.

Animals↗
PubMed1988

Cardiomyopathy associated with the acquired immune deficiency syndrome.

Three cases of congestive cardiomyopathy complicating the acquired immune deficiency syndrome (AIDS) are reported. In one case, acute cardiac decompensation resulted in prolonged but ultimately reversible cardiogenic shock. In the second case, clinical signs of cardiac disease were precipitated by acute renal failure and fluid overload. In the third, congestive heart failure developed spontaneously and responded promptly to administration of diuretics but the patient died suddenly, apparently due to an arrhythmia. The etiology of cardiomyopathy in AIDS is unclear and the manifestations of cardiomyopathy in this setting range from subclinical to life threatening.

Acquired Immunodeficiency Syndrome↗
PubMed1987

Reproductive hormone secretion and testicular growth in bull calves actively immunized against testosterone and oestradiol-17 beta.

Groups of bull calves received a primary immunization against testosterone (Group T; N = 7) or oestradiol-17 beta (Group E; N = 9) at 3 months of age and booster injections on four occasions at approximately 2 month intervals. Controls (Group C, N = 7) were immunized against human serum albumin alone using the same protocol. Immunity was achieved against both steroids as judged by the secondary antisteroid antibody titres in Group T (730 +/- 231; reciprocal of titre) and Group E (12,205 +/- 4366) bulls; however, peak antibody titres generally declined with successive booster injections. Mean plasma concentrations of LH, FSH and testosterone during the period from 3 to 10 months of age were higher (P less than 0.05) in Group T bulls than in Groups C and E. Group T bulls had larger testes compared with controls from 6 months of age onwards. At castration at 14 months of age, testes of Group T bulls were heavier (P less than 0.05) than those of Groups C and E (179 +/- 13, 145 +/- 8 and 147 +/- 6 g, respectively). At 10 months of age, there were no differences among treatment groups in LH responses to LHRH, but the testosterone responses were greater (P less than 0.05) in bulls in Group T (26.2 +/- 4.9 ng/ml) and Group E (16.6 +/- 1.8 ng/ml) compared with those in Group C (6.9 +/- 0.6 ng/ml). Testosterone responses to hCG determined at 13 months of age were also greater (P less than 0.05) in Groups T and E relative to controls. At 14 months of age daily sperm production rates per bull (X 10(-9)) were higher (P less than 0.10) in Group T bulls (2.2 +/- 0.1) than those in Groups C (1.6 +/- 0.2) and E (1.6 +/- 0.1). These results indicate that early immunity against testosterone is associated with increased gonadotrophin secretion and accelerated growth of the testes in prepubertal bulls. Also, chronic immunity against testosterone or oestradiol-17 beta enhances the steroidogenic response of bull testes to gonadotrophic stimulation. If the above responses observed in young bulls are shown to be sustained, then immunity against gonadal steroids early in life may confer some reproductive advantage in mature animals.

Animals↗