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Biomedical subjects

James M Gill

Publications and source records attributed to James M Gill.

At least 19 recordsLinked to original sources
PubMed2006

Antihypertensive prescribing practices: impact of the antihypertensive and lipid-lowering treatment to prevent heart attack trial.

This national study examines the impact of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) on the prescribing of thiazide-type diuretics and other antihypertensive medications for patients with newly diagnosed hypertension. A cross-sectional analysis was conducted using data from a national network of electronic health records for 2 groups with newly diagnosed hypertension and started on antihypertensive medications: one a year before and the other a year after the publication of ALLHAT. The percentage of new hypertensives started on thiazides increased from 29% pre-ALLHAT to 39% post-ALLHAT. An increase was also seen for angiotensin receptor blockers, while prescribing for angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-blockers declined. There was no significant change in prescriptions for alpha-blockers. Prescriptions for thiazides for patients with newly diagnosed hypertension increased after the publication of ALLHAT. Data from large national trials can have a considerable impact on prescribing practices.

Adrenergic alpha-Antagonists↗
PubMed2006

Diagnosis of Lyme disease.

The use of serologic testing and its value in the diagnosis of Lyme disease remain confusing and controversial for physicians, especially concerning persons who are at low risk for the disease. The approach to diagnosing Lyme disease varies depending on the probability of disease (based on endemicity and clinical findings) and the stage at which the disease may be. In patients from endemic areas, Lyme disease may be diagnosed on clinical grounds alone in the presence of erythema migrans. These patients do not require serologic testing, although it may be considered according to patient preference. When the pretest probability is moderate (e.g., in a patient from a highly or moderately endemic area who has advanced manifestations of Lyme disease), serologic testing should be performed with the complete two-step approach in which a positive or equivocal serology is followed by a more specific Western blot test. Samples drawn from patients within four weeks of disease onset are tested by Western blot technique for both immunoglobulin M and immunoglobulin G antibodies; samples drawn more than four weeks after disease onset are tested for immunoglobulin G only. Patients who show no objective signs of Lyme disease have a low probability of the disease, and serologic testing in this group should be kept to a minimum because of the high risk of false-positive results. When unexplained nonspecific systemic symptoms such as myalgia, fatigue, and paresthesias have persisted for a long time in a person from an endemic area, serologic testing should be performed with the complete two-step approach described above.

Adolescent↗
PubMed2006

New strategies for diagnosis and management of celiac disease.

Celiac disease is a gastrointestinal disorder characterized by inflammation, leading to injury to the mucosal lining of the small intestine. The inflammation occurs when gliadin, a protein found in such gluten-containing foods as wheat, rye, and barley, is ingested by genetically susceptible individuals. The mucosal damage and subsequent malabsorption of nutrients leads to various complications. Researchers estimate that more than 2 million people in the United States have celiac disease-a prevalence that is greater than was previously believed. Approximately 60,000 Americans are diagnosed annually with celiac disease. Until recently, diagnosis has been complicated by the fact that the indicators of celiac disease are nonspecific. However, because of the development of new, easy-to-administer serology tests, diagnosis has become much less complicated. After conducting a review of the literature, the authors recommend a serologic testing sequence for diagnosis of celiac disease and urge that adults and children with an assortment of symptoms be tested for this disease. Common signs and symptoms of celiac disease include anemia, arthralgia, fatigue, infertility, neuropathy, and weight loss, in addition to such gastrointestinal symptomatology as abdominal pain, anorexia, bloating, constipation, and diarrhea. The only treatment for patients with celiac disease remains a gluten-free diet.

Celiac Disease↗
PubMed2006

Use of antibiotics for adult upper respiratory infections in outpatient settings: a national ambulatory network study.

BACKGROUND AND OBJECTIVES: Studies have suggested that antibiotics are often inappropriately used in the treatment of acute upper respiratory tract infections (URIs). This study examined antibiotic use for adult URIs in a large national network of offices that use electronic health records (EHRs). METHODS: Using the Medical Quality Improvement Consortium (MQIC) database, URI episodes were identified for patients ages 18 to 65 years from January 1, 1998, to March 31, 2003. The percentage of episodes for which antibiotics were prescribed and the proportion of antibiotics that were broad spectrum were calculated. RESULTS: Of the 52,135 URI episodes identified, 65% received antibiotics. Antibiotics were prescribed for 78% of acute bronchitis episodes, 65% of acute pharyngitis episodes, 81% of acute sinusitis episodes, and 33% of nonspecific URI episodes. The proportion of antibiotics that were broad spectrum was 56% for all URI episodes, 68% for acute bronchitis, 55% for acute sinusitis and nonspecific URI, and 40% for pharyngitis. CONCLUSIONS: This study demonstrates overuse of antibiotics for adult URIs in a large national ambulatory care network, with particular overuse of broad-spectrum antibiotics. The study also illustrates the enormous potential of EHR data for conducting practice-based research across large national office networks.

Adolescent↗
PubMed2005

Diagnosis of lyme disease.

The use of serologic testing and its value in the diagnosis of Lyme disease remain confusing and controversial for physicians, especially concerning persons who are at low risk for the disease. The approach to diagnosing Lyme disease varies depending on the probability of disease (based on endemicity and clinical findings) and the stage at which the disease may be. In patients from endemic areas, Lyme disease may be diagnosed on clinical grounds alone in the presence of erythema migrans. These patients do not require serologic testing, although it may be considered according to patient preference. When the pretest probability is moderate (e.g., in a patient from a highly or moderately endemic area who has advanced manifestations of Lyme disease), serologic testing should be performed with the complete two-step approach in which a positive or equivocal serology is followed by a more specific Western blot test. Samples drawn from patients within four weeks of disease onset are tested by Western blot technique for both immunoglobulin M and immunoglobulin G antibodies; samples drawn more than four weeks after disease onset are tested for immunoglobulin G only. Patients who show no objective signs of Lyme disease have a low probability of the disease, and serologic testing in this group should be kept to a minimum because of the high risk of false-positive results. When unexplained non-specific systemic symptoms such as myalgia, fatigue, and paresthesias have persisted for a long time in a person from an endemic area, serologic testing should be performed with the complete two-step approach described above.

Adolescent↗
PubMed2005

Iron, lipids, and risk of cancer in the Framingham Offspring cohort.

Iron and lipids combine to create oxidative stress, and oxidative stress has a role in the development of cancer. The objective was to determine the risk of cancer among persons who had both elevated iron and lipids. The authors conducted an analysis of the cohort available in the Framingham Offspring Study. Adults aged 30 or more years at baseline had serum iron and high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol, and very low density lipoprotein cholesterol (VLDL-C) assessed in 1979-1982 and were followed for development of cancer until 1996-1997 (n = 3,278). Cox regression models were computed while controlling for age, gender, smoking status, and body mass index. In adjusted models, both elevated iron (hazard ratio (HR) = 1.66, 95% confidence interval (CI): 1.11, 2.46; 29 cases) and VLDL-C (HR = 1.54, 95% CI: 1.04, 2.28; 93 cases) had significant independent risks for development of cancer. When elevated iron was combined with elevated VLDL-C, the adjusted relative risk of cancer increased (HR = 2.68, 95% CI: 1.49, 4.83; 18 cases). Elevated iron and low HDL-C also had a significant adjusted relative risk of cancer (HR = 2.82, 95% CI: 1.50, 5.28; 14 cases). The results suggest that elevated serum iron levels coupled with either high VLDL-C or low HDL-C appear to interact to increase cancer risk in this cohort.

Adult↗
PubMed2005

Impact of providing a medical home to the uninsured: evaluation of a statewide program.

Lack of health insurance and a regular source of care (RSOC) are associated with suboptimal health care. This study examined the impact of a statewide program called the Community Healthcare Access Program (CHAP), which provided a RSOC for uninsured persons in Delaware. This cohort study used survey data to compare health care utilization from baseline to six months after enrollment in CHAP. The 795 eligible enrollees had significant increases in Pap tests, mammograms, breast exams, cholesterol tests, sigmoid/colonoscopy and influenza immunizations but not stool blood tests or pneumococcal immunizations. There was a significant decrease in the proportion with emergency department visits but not hospitalizations, and there was a significant improvement in satisfaction with care. Delaware's CHAP program is associated with significant improvements across many measures of health care utilization and represents a successful and financially feasible method for states to improve health care for their uninsured populations.

Adolescent↗
PubMed2005

Cholesterol, transferrin saturation, and the development of dementia and Alzheimer's disease: results from an 18-year population-based cohort.

BACKGROUND AND OBJECTIVES: Oxidative stress plays a role in Alzheimer's disease (AD), and iron and cholesterol together have been linked to oxidative stress. This study examined the relationship between transferrin saturation (TS) and cholesterol to see if both are necessary to increase the risk for the subsequent development of AD. METHODS: We analyzed data from US adults (ages 40-74 years at baseline) followed from baseline in 1971-1974 to 1992 (n=6,558) in the cohort study, the National Health and Nutrition Examination Survey I Epidemiologic Followup Study (NHEFS). RESULTS: The unadjusted relative risk of developing AD when both TS and cholesterol were at the 75th percentile was 3.19 (95% CI, 1.31-7.75). In adjusted models when only one marker was elevated, there was no significant increased risk for AD. The risk of AD increased as both markers increased. Even at the 85th percentile, individuals had no significant risk of AD when only having elevated cholesterol (>280 mg/dl) but not elevated TS (39.6%). Findings were similar for individuals with elevated TS but not elevated cholesterol. CONCLUSIONS: In this population-based cohort, the risk of developing AD when one has both elevated cholesterol and elevated TS is much larger than the risk associated with elevation of either of these factors alone.

Adult↗
PubMed2005

Complex regional pain syndrome underdiagnosed.

Complex regional pain syndrome (CRPS) type 1 may be diagnosed by history and physical exam with no further testing. Several different diagnostic criteria have undergone validity testing: the 1993 IASP criteria, Bruehl's criteria, and Veldman's criteria; there is no compelling reason to recommend 1 set of criteria over the others. Some cases of CRPS type 1 may be preventable. Some cases of CRPS type 1 in post-stroke upper extremity hemiplegia (also known as shoulder-hand syndrome) may be prevented by early inpatient rehabilitation and avoidance of shoulder trauma to the affected arm. Some cases of post-fracture CRPS type 1 may be prevented with 500 mg vitamin C daily started upon diagnosis of fracture and continued through healing.

Evidence-Based Medicine↗
PubMed2005

Complex regional pain syndrome: which treatments show promise?

Treatments for CRPS type 1 supported by evidence of efficacy and little likelihood for harm are: topical DMSO cream (B), IV bisphosphonates (A) and limited courses of oral corticosteroids (B). Despite some contradictory evidence, physical therapy and calcitonin (intranasal or intramuscular) are likely to benefit patients with CRPS type 1 (B). Due to modest benefits and the invasiveness of the therapies, epidural clonidine injection, intravenous regional sympathetic block with bretylium and spinal cord stimulation should be offered only after careful counseling (B). Therapies to avoid due to lack of efficacy, lack of evidence, or a high likelihood of adverse outcomes are IV regional sympathetic blocks with anything but bretylium, sympathetic ganglion blocks with local anesthetics, systemic IV sympathetic inhibition, acupuncture, and sympathectomy (B).

Calcitonin↗
PubMed2004

Association of ferritin and lipids with C-reactive protein.

C-reactive protein (CRP) and lipids (e.g., low-density lipoprotein [LDL]) are both markers of cardiovascular disease risk, yet they are not highly correlated. Oxidative stress of lipids induced by iron may play a role in vascular inflammation, as indicated by CRP. The purpose of this study was to examine, in a representative sample of United States adults, the relation between ferritin, lipids, and CRP. We analyzed data on adults (aged > or =25 years) in the National Health and Nutrition Examination Survey III, a national public-use data set collected between 1988 and 1994. Ferritin, total cholesterol, LDL, high-density lipoprotein, and ferritin-lipid combinations were analyzed in relation to CRP in age-, gender-, and race-adjusted models as well as models with other potential confounding variables. In adjusted models, neither elevated ferritin (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.94 to 1.32) nor elevated LDL was significantly associated with elevated CRP (OR 1.03, 95% CI 0.79 to 1.33). Patients with elevated ferritin and elevated LDL were more likely to have elevated CRP (OR 1.68; 95% CI 1.06 to 2.68). Patients with elevated ferritin and low high-density lipoprotein were also more likely to have elevated CRP (OR 1.71; 95% CI 1.28 to 2.27). These results suggest that both iron and lipids induce inflammation. Future research needs to focus on preventive medicine to decrease iron in patients with elevated lipids.

Adult↗
PubMed2004

Relationship between continuity of care and diabetes control: evidence from the Third National Health and Nutrition Examination Survey.

OBJECTIVES: We examined the relationship between continuity of care and diabetes control. METHODS: We analyzed data on 1400 adults with diabetes who took part in the Third National Health and Nutrition Examination Survey. We examined the relationship of continuity of care with glycemic, blood pressure, and lipid control. RESULTS: Continuity of care was associated with both acceptable and optimal levels of glycemic control. Continuity was not associated with blood pressure or lipid control. There was no difference between having a usual site but no usual provider and having a usual provider in any of the investigated outcomes. CONCLUSIONS: Continuity of care is associated with better glycemic control among people with diabetes. Our results do not support a benefit of having a usual provider above having a usual site of care.

Adolescent↗
PubMed2004

The Medical Society of Delaware's Uniform Clinical Guidelines for diabetes: did they have a positive impact on quality of diabetes care?

BACKGROUND: In 2001, the Diabetes Physician Committee of the Medical Society of Delaware developed Uniform Clinical Guidelines (UCGs) for diabetes mellitus. These guidelines were intended to provide a standard for the diabetes quality indicators that could be used by all providers and all major insurers in Delaware. The guidelines were sent to Delaware physicians in December 2001. This study examines whether implementation of the diabetes UCG had a positive impact on the quality of diabetes care in primary care offices. METHODS: A chart review was conducted for 258 diabetic patients of 28 primary care physicians in all three counties in Delaware. Quality of care was compared from the year prior to guideline implementation (2001) to the year after implementation (2002). Quality was determined by process measures, including receipt of recommended monitoring tests (glycosylated hemoglobin, blood pressure, lipids, microalbumin, foot exams, eye exams) and immunizations (influenza and pneumococcal), as well as by outcome measures, including adequate glycemic control, blood pressure control, and lipid control. RESULTS: There was no significant change in most quality indicators from the year before to the year after implementation of the UCG. The only improvements seen were in influenza immunizations and, to some extent, lipid and blood pressure control. However, none of these reached optimal levels, and for some process measures (microalbumin testing and eye exams) there was a decrease in adherence to guidelines. In a second analysis, physicians who used diabetes flow sheets had better quality of care for most measures, although these differences were relatively small and not consistent across all measures. CONCLUSIONS: The Medical Society of Delaware's Uniform Clinical Guidelines are intended to standardize care for diabetes and other conditions. While the guidelines may help to reduce unnecessary duplication and confusion caused by multiple guidelines, this study showed that they have not yet resulted in substantial improvements in quality of care for diabetes. Since the study does suggest that using flow sheets is associated with somewhat better care, it could be that quality will improve as more physicians incorporate these tools into their practices.

Adult↗
PubMed2004

The combined effect of transferrin saturation and low density lipoprotein on mortality.

BACKGROUND AND OBJECTIVES: Evidence suggests that cardiovascular disease (CVD) is accelerated by the oxidation of low-density lipoprotein (LDL) in the presence of iron. This study examined whether adults with elevated iron, as measured by transferrin saturation (TS), and elevated LDL are at an increased risk for mortality. METHODS: This is a cohort study of the adult US population using the National Health and Nutrition Examination Survey 1976-1980 (NHANES II) merged with the NHANES II Mortality Study in 1992. Multivariate Cox regression was performed to determine hazard ratios (HR) for CVD and all-cause mortality for high (>55%) or low (<55%) levels of TS and high (>160 mg/dl) or low (<160 mg/dl) levels of LDL. RESULTS: An elevated LDL alone did not significantly increase CVD mortality or all-cause mortality in the adjusted model. Individuals with elevated LDL and elevated TS had a statistically significant increase in both CVD mortality and all-cause mortality (HR=5.74 and 3.53, respectively) compared to the low LDL and low TS group. CONCLUSIONS: The results of this study indicate an increased risk associated with the combination of elevated LDL and elevated TS, which suggests that iron-mediated oxidation of LDL may be a significant factor in the progression of CVD.

Adult↗
PubMed2004

Do physicians in Delaware follow national guidelines for tobacco counseling?

BACKGROUND: Despite national guidelines, studies across the country have shown that many physicians do not regularly engage in tobacco cessation behaviors such as assisting their patients with quitting. This survey study examined tobacco cessation behaviors among physicians in Delaware as part of the state's tobacco control program called Plan for a Tobacco-Free Delaware. METHODS: A self-administered questionnaire was mailed to all Delaware physicians in primary care and specialties that manage tobacco-related illnesses (cardiology, pulmonology, and allergy) in May of 2002 (n=890). RESULTS: Of the 156 survey respondents, most physicians reported regularly asking their adolescent patients (57.3%) and their adult patients (65.4%) about smoking and advising their smoking patients to quit (84%). Most physicians do not regularly assist patients in quitting (17.6%) or arrange follow-up (28.1%). Also, most physicians do not regularly prescribe nicotine replacement (12.9%) or bupropion (10.7%), nor do they regularly give written materials to help in quitting (16.3%) or refer patients to smoking cessation programs (14.7%). CONCLUSIONS: While most physicians in Delaware ask their patients about smoking and advise them to quit, most physicians do not adequately assist their smoking patients in accordance with national guidelines. Reasons include lack of time, lack of quick and easy tools to help patients quit, and inadequate reimbursement for physicians' tobacco cessation activities and medications. This article suggests ways that the state can assist physicians with tobacco cessation that can be incorporated into the Plan for a Tobacco-Free Delaware. In particular, ensuring adequate and universal reimbursement for physician visits related to tobacco cessation, for tobacco cessation programs, and for tobacco cessation medications is essential to increasing physician involvement in tobacco cessation activities.

Adult↗