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Biomedical subjects

J M FitzGerald

Publications and source records attributed to J M FitzGerald.

At least 19 recordsLinked to original sources
PubMed2006

Asthma exacerbations . 4: Prevention.

Asthma exacerbations are common. They account for a significant morbidity and contribute a disproportionate amount to the cost of asthma management. The optimal strategies for the prevention of asthma exacerbations include the early introduction of anti-inflammatory treatment-most commonly, low dose inhaled corticosteroids. This should be coupled with a structured education programme which has a written action plan as an integral component. Where patients continue to be poorly controlled, the addition of a long acting beta agonist should be considered. The latter should not be used as monotherapy and should always be used with inhaled corticosteroids. Atopic patients with a history of repeated exacerbations, especially if they are steroid dependent and with a raised IgE, may be considered as potential candidates for omalizumab. In the early stages of an asthma exacerbation, doubling the dose of inhaled corticosteroids has been shown to be ineffective. The ideal strategy for the management of worsening asthma in patients on combination treatment, especially salmeterol and fluticasone, is uncertain. There is an emerging body of evidence for strategies on how to prevent progression to an exacerbation in patients taking a combination of budesonide and formoterol.

Administration, Inhalation↗
PubMed2006

A population-based study of risk factors for drug-resistant TB in British Columbia.

SETTING: Provincial tuberculosis (TB) services, British Columbia, Canada. OBJECTIVE: To investigate risk factors associated with resistance to anti-tuberculosis drugs in British Columbia and to determine if there are differences in risk factor characteristics among different resistance categories. DESIGN: Using population-based data from provincial TB services, all patients with positive culture for Mycobacterium tuberculosis from 1990 to 2001 were identified and included in the study. Logistic regression analyses were performed to assess risk factors for drug resistance. RESULTS: Among 3041 eligible TB cases, 295 (10%) were found to be drug-resistant. Significant risk factors for resistance were younger age, foreign birth, ethnicity, reactivated TB and place of initial diagnosis. Foreign-born subjects (OR 3.18, 95%CI 2.26-4.49) were three times more likely to present with resistance than Canadian-born subjects. Among ethnic groups, Chinese (OR 2.32, 95%CI 1.51-3.57), South-East Asian (OR 2.92, 95%CI 1.88-4.52) and Other Asian subjects (OR 4.40, 95%CI 2.77-7.01) were 2-4 times more likely to present with resistance than Caucasians. Reactivated cases (OR 2.69, 95%CI 1.91-3.77) were three times as likely to have resistance as new cases. CONCLUSION: These results document and quantify the risk of drug-resistant disease in a large population-based cohort, and highlight patient groups who should be identified as at risk for drug-resistant disease in the industrialised world.

Adolescent↗
PubMed2006

Impact of country of origin on drug-resistant tuberculosis among foreign-born persons in British Columbia.

SETTING: Provincial tuberculosis (TB) services, British Columbia, Canada. OBJECTIVES: To estimate the risk of drug resistance among foreign-born TB patients and to identify risk factors associated with drug resistance. DESIGN: Using the provincial TB database, we examined all culture-positive foreign-born TB patients for the years 1990-2001. The risk of having a drug-resistant isolate was estimated according to country and region of origin. RESULTS: Of 1940 foreign-born patients identified, 247 (12.7%, 95%CI 11.3-14.3) cases had isolates resistant to at least one of the first-line drugs, with 160 (8.3%) isolates showing monoresistance, 24 (1.2%) multidrug resistance (resistance to at least isoniazid and rifampin) and 63 (3.3%) polyresistance (resistance to two or more drugs, excluding MDR). Country-specific analysis showed that immigrants from Vietnam (adjusted OR 2.12, 95%CI 1.37-3.27) and the Philippines (adjusted OR 1.71, 95%CI 1.10-2.66) had a significantly higher risk of resistance than other immigrants. In addition, the risk was the highest for younger TB patients and patients with reactivated disease (adjusted OR 2.12, 95%CI 1.09-4.09). CONCLUSION: The risk of drug resistance was the highest among foreign-born patients from Vietnam and the Philippines. These findings should assist clinicians in prescribing and tailoring anti-tuberculosis regimens for immigrants more appropriately.

Adolescent↗
PubMed2005

Diagnostic accuracy of self collected vaginal specimens for human papillomavirus compared to clinician collected human papillomavirus specimens: a meta-analysis.

BACKGROUND/OBJECTIVES: Providing summary recommendations regarding self collection of vaginal specimens for human papillomavirus (HPV) testing is difficult owing to the wide range of published estimates for the diagnostic accuracy of this approach. To determine summary estimates from analyses of reported findings of the sensitivity, specificity and summary receiver operating characteristic curves (SROC) for self collected vaginal specimens for HPV testing compared to the reference standard, clinician collected HPV specimens. METHODS: Standard search criteria for a diagnostic systematic review were employed. Eligible studies were combined using a random effects model and summary ROC curves were derived for overall and for specific subgroups. RESULTS: Summary measures were determined from 12 studies. Six studies where patients used Dacron or cotton swabs or cytobrushes to obtain samples were pooled and had an overall sensitivity of 0.74 (95% CI 0.61 to 0.84) and specificity of 0.88 (95% CI 0.83 to 0.92), with diagnostic odds ratio of 22.3 and an area under the curve of 0.91. Self specimens using Dacron or cotton swabs or cytobrushes collected by women enrolled at referral clinics had an overall sensitivity of 0.81 (95% CI 0.65 to 0.91) and specificity of 0.90 (95% CI 0.80 to 0.95). Sensitivity and specificity of tampons ranged from 0.67-0.94 and 0.80-0.85 respectively. CONCLUSIONS: Our findings indicate that the combined sensitivity for HPV-DNA is more than 70% when patients use Dacron swabs, cotton swabs, or cytobrushes to obtain their own vaginal specimens for HPV-DNA evaluation. Self collected HPV-DNA swabs may be an appropriate alternative for low resource settings or in patients reluctant to undergo pelvic examinations.

Area Under Curve↗
PubMed2004

Transmission of tuberculosis from smear negative patients: a molecular epidemiology study.

BACKGROUND: While smear positive patients with tuberculosis (TB) are considered more infectious than smear negative patients, the latter can also transmit TB. METHODS: In a molecular epidemiology study of 791 patients in the Greater Vancouver regional district, the number of episodes of TB transmission from two groups of smear negative clustered patients by RFLP (assumed to be involved in recent transmission) was estimated after assessing for potential bias. Group 1 (n = 79) included patients with pulmonary TB or pulmonary + extrapulmonary disease (PTB or PTB+EPTB); group 2 (n = 129) included all patients in group 1 + extrapulmonary cases alone. RESULTS: In the total sample the mean (SD) age was 51 (21) years, 54.3% were male, and 17.0% of patients were clustered. Compared with smear negative patients, smear positive patients were more likely to be in a cluster (OR = 2.0, 95% CI 1.1 to 3.6) and to have had a history of ethanol abuse (OR = 2.7, 95% CI 1.0 to 6.7), diabetes mellitus (OR = 2.8, 95% CI 1.1 to 7.0), injection drug use (OR = 3.1, 95% CI 1.1 to 8.3), and to have had a previous hospital admission (OR = 8.5, 95% CI 5.1 to 14.0). The proportion of episodes of transmission from smear negative clustered patients ranged from 17.3% to 22.2% in group 1 and from 25% to 41% in group 2. CONCLUSION: In Greater Vancouver, smear negative cases appear responsible for at least one sixth of culture positive episodes of TB transmission.

Adolescent↗
PubMed2004

Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations.

BACKGROUND: Previous guidelines recommend doubling the daily dose of maintenance inhaled corticosteroid to treat or prevent progression of exacerbations of asthma. METHODS: Over a 6 month period a cohort of patients were evaluated prospectively and randomised in a double blind controlled trial to treatment with either a continued maintenance dose (MD) of inhaled corticosteroid or doubling the dose (DD) at the time of an exacerbation. RESULTS: A total of 290 patients were randomised (33% male) and 98 (DD, n = 46) experienced evaluable asthma exacerbations during the study period. Mean (SD) baseline characteristics at randomisation (age 33.5 (14.0) years; forced expiratory volume in 1 second (FEV(1)) 2.8 (0.7) l; peak expiratory flow (PEF) 422.9 (110.5) l/min) were similar in both groups. In the DD group 41% of patients were considered treatment failures because they either required systemic steroids (n = 12), had an unscheduled visit to a physician (n = 1), or their asthma did not return to baseline (n = 6). This did not differ from the MD group in which 40% were treatment failures (n = 9, 0, and 12, respectively; p = 0.94). CONCLUSIONS: In patients who regularly take an inhaled corticosteroid, doubling the maintenance dose may not affect the pattern of the exacerbation.

Adolescent↗
PubMed2004

Successful treatment of multidrug-resistant tuberculosis following drug-induced hepatic necrosis requiring liver transplant.

A 28-year-old female developed multidrug-resistant (MDR) tuberculous lymphadenitis following a trip to India. She was initially treated with a four-drug regimen of first-line anti-tuberculosis medications, but when sensitivities indicated resistance to isoniazid and rifampin, her regimen was altered to ciprofloxacin (CFX), pyrazinamide (PZA) and ethambutol. She subsequently developed a rash, flu-like symptoms and fever, which progressed to acute hepatic necrosis despite discontinuation of medication. The clinical presentation and subsequent investigations suggested a hypersensitivity reaction, possibly related to the quinolone. The patient subsequently had an orthoptic liver transplant; second-line anti-tuberculosis medications were restarted to which she responded clinically and radiologically. Our findings raise the possibility that the CFX and PZA combination was responsible for the hepatic necrosis. The patient also illustrates that active, even MDR tuberculosis is not a contraindication to hepatic transplant.

Adult↗
PubMed2003

The molecular epidemiology of tuberculosis in western Canada.

OBJECTIVE: To define the molecular epidemiology of TB in western Canada, and in particular the risk factors for clustering. MEASUREMENTS: We prospectively identified all positive cultures from newly diagnosed cases of TB diagnosed between February 1995 and January 1997 and carried out restriction fragment length polymorphism (RFLP) testing on all isolates. RESULTS: Of 956 cases identified, 944 fulfilled the entry criteria. The mean age was 49.65 years (+/- 22.33), and 508 (53.6%) were males. Three hundred and three (32.1%) subjects were clustered; this varied from 20.2% of the foreign born, 48.4% of Canadian non-Aboriginal and 61.1% of all Aboriginal persons. Younger persons (P = 0.0001), males (P = 0.015), those with pulmonary disease (P < 0.001), living in a shelter in the past year (P < 0.001), drug-susceptible disease (P < 0.036), predisposing factors (P < 0.001), prior contact (P < 0.001), and prior skin test (P < 0.002) were more likely to cluster. Among specific risk factors, HIV infection, injection drug use, alcohol excess, and weight loss were all significant. CONCLUSIONS: In this description of the molecular epidemiology of TB in Western Canada, previous results have been confirmed and extended. These results highlight the importance of identifying specific high risk groups, especially in the context of renewed efforts to target persons for treatment of latent TB infection.

Adult↗
PubMed2002

A meta-analysis of the effect of Bacille Calmette Guérin vaccination on tuberculin skin test measurements.

BACKGROUND: The accurate diagnosis of latent tuberculosis infection (LTBI) is an important component of any tuberculosis control programme and depends largely on tuberculin skin testing. The appropriate interpretation of skin test results requires knowledge of the possible confounding factors such as previous BCG vaccination. Uncertainty about the effect of BCG vaccination on tuberculin skin testing and the strength with which recommendations are made to individual patients regarding treatment of LTBI have identified a need to analyse the available data on the effect of BCG on skin testing. A meta-analysis of the evidence for the effect of BCG vaccination on tuberculin skin testing in subjects without active tuberculosis was therefore performed. METHODS: Medline was searched for English language articles published from 1966 to 1999 using the key words "BCG vaccine", "tuberculin test/PPD", and "skin testing". Bibliographies of relevant articles were reviewed for additional studies that may have been missed in the Medline search. Articles were considered for inclusion in the meta-analysis if they had recorded tuberculin skin test results in subjects who had received BCG vaccination more than 5 years previously and had a concurrent control group. Only prospective studies were considered. The geographical location, number of participants, type of BCG vaccine used, type of tuberculin skin test performed, and the results of the tuberculin skin test were extracted. RESULTS: The abstracts and titles of 980 articles were identified, 370 full text articles were reviewed, and 26 articles were included in the final analysis. Patients who had received BCG vaccination were more likely to have a positive skin test (5 TU PPD: relative risk (RR) 2.12 (95% confidence interval (CI)1.50 to 3.00); 2 TU RT23: 2.65 [corrected] (95% CI 1.83 to 3.85). The effect of BCG vaccination on PPD skin test results was less after 15 years. Positive skin tests with indurations of >15 mm are more likely to be the result of tuberculous infection than of BCG vaccination. CONCLUSIONS: In subjects without active tuberculosis, immunisation with BCG significantly increases the likelihood of a positive tuberculin skin test. The interpretation of the skin test therefore needs to be made in the individual clinical context and with evaluation of other risk factors for infection. The size of the induration should also be considered when making recommendations for treatment of latent infection.

BCG Vaccine↗
PubMed2000

Hospital ventilation and risk for tuberculous infection in canadian health care workers. Canadian Collaborative Group in Nosocomial Transmission of TB.

BACKGROUND: The risk for and determinants of transmission of tuberculosis in hospitals caring for moderate numbers of patients with tuberculosis remain uncertain. OBJECTIVE: To study the association of tuberculin conversion among health care workers with ventilation of patient care areas. DESIGN: Cross-sectional observational survey. SETTING: 17 acute-care community or university hospitals. PARTICIPANTS: All personnel who worked at least 2 days per week in the respiratory and physiotherapy departments or in selected nursing units. MEASUREMENTS: Participating workers underwent tuberculin skin testing and completed self-administered questionnaires. Previous tuberculin tests and bacille Calmette-Guérin vaccinations were verified. Records of patients with tuberculosis who were hospitalized in the 3 years preceding the study were reviewed. Air exchanges per hour in patient care areas were measured by using a tracer gas technique. Multivariate proportional hazards regression was used to estimate the effect of occupational factors on documented tuberculin conversion, after adjustment for nonoccupational factors, among participants with at least one previous negative result on tuberculin skin testing. RESULTS: Tuberculin conversion was associated with ventilation of general or nonisolation patient rooms of less than 2 air exchanges per hour (adjusted hazard ratio, 3.4 [95% CI, 2.1 to 5.8]); with work in moderate- to high-risk hospitals (adjusted hazard ratio, 2.2 [CI, 1.3 to 3.5]); and with work in the nursing (adjusted hazard ratio, 4.3 [CI, 2.7 to 6.9]), respiratory therapy (adjusted hazard ratio, 6.1 [CI, 3.1 to 12.0]), and physiotherapy (adjusted hazard ratio, 3.3 [CI, 1.5 to 7.2]) departments or housekeeping (adjusted hazard ratio, 4.2 [CI, 2.3 to 7.6]). Conversion was not associated with inadequate ventilation of respiratory isolation rooms (adjusted hazard ratio, 1.0 [CI, 0.8 to 1.3]). CONCLUSION: Tuberculin conversion among health care workers was strongly associated with inadequate ventilation in general patient rooms and with type and duration of work, but not with ventilation of respiratory isolation rooms.

Canada↗
PubMed2000

Management of adverse reactions to bacille Calmette-Guérin vaccine.

Published reports appear to underestimate the true rate of adverse reactions to bacille Calmette-Guérin (BCG) vaccine. At a recent national conference on tuberculosis control among aboriginal populations, lack of awareness of what constitutes an adverse reaction was considered a possible contributing factor to underreporting. The following review defines a normal BCG response and discusses the management of complications when they occur.

BCG Vaccine↗