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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
PubMed1998

Acceptance of amniocentesis by women in the state of Montana (USA) who are screen positive for Down's syndrome.

OBJECTIVE: To assess factors influencing uptake of amniocentesis after a positive Down's syndrome screening result. METHODS: Interviews of 53 Montana women with screening risks > or = 1 in 300 after delivery. RESULTS: Thirty had accepted amniocentesis ("yes" group) and 23 had declined ("no" group) (57% uptake). Age at delivery was significantly higher (p = 0.02) for the "no" than the "yes" group (mean 35.3 nu 31.7 years). The mean risk of Down's syndrome ascertained by screening was 1 in 190 for the "no" group and 1 in 115 for the "yes" group (p = 0.05). Statistically significant differences (p < or = 0.05) between opinions in the two groups included: (a) desire to know if the fetus had Down's syndrome; (b) perception of the burden of care for an affected child; (c) support of doctor, spouse, and relatives for choice about amniocentesis; (d) attitudes toward abortion; (e) importance of religion; and (f) concerns about the amniocentesis procedure. The most important factor for those choosing amniocentesis was knowing if the fetus had Down's syndrome, and for those not choosing amniocentesis, attitude about abortion. CONCLUSION: Our results show the need for prescreening education to enable pregnant women to make informed decisions about screening for Down's syndrome and diagnostic testing.

Adult↗
PubMed1998

Airway wall thickness in patients with near fatal asthma and control groups: assessment with high resolution computed tomographic scanning.

BACKGROUND: Airway wall thickening has been observed in post mortem studies of patients with asthma. Assessment of airway wall thickening by high resolution computed tomographic (HRCT) scanning has been reported in experimental studies. We have used HRCT scanning to measure airway wall thickness at the segmental and subsegmental levels in 40 patients with asthma and 14 normal controls. METHODS: The subjects were prospectively divided into four age and sex matched groups: 14 patients with a history of near fatal attack of asthma (NFA; group 1), 12 patients with moderate asthma (group 2), 13 patients with mild asthma (group 3), and 14 normal controls (group 4). All subjects were non-smokers. High resolution (1 mm collimation) CT scans of the chest were done at five different levels. RESULTS: The mean (SD) forced expiratory volume in one second (FEV1) was 68 (20)% of predicted for group 1, 73 (12)% for group 2, 102 (12)% for group 3, and 103 (12)% for group 4. The ratio of airway wall thickness to outer diameter (T/D) and the percentage wall area (WA%) defined as (wall area/total airway area) x 100 were used to compare airway wall thickness between the groups. The mean (SD) T/D and WA% were 0.27 (0.05) and 78.0 (9.2)% for group 1, 0.27 (0.05) and 78.8 (9.2)% for group 2, 0.25 (0.04) and 74.2 (7.5)% for group 3, and 0.23 (0.04) and 70.9 (8.2)% for group 4. T/D and WA% were not significantly different between groups 1 and 2. However, both groups 1 and 2 had higher T/D and WA% than either group 3 or 4 (p < 0.001) and group 3 had a higher T/D and WA% than group 4 (p < 0.03). The differences (95% CI) between the groups in WA% were 7.1% (0 to 14.4) for groups 1 and 4, 3.8% (-3.4 to 10) for groups 1 and 3, and 3.3% (-4.4 to 10) for groups 3 and 4. The differences between the groups in T/D and WA% were noted both for those with airways with a luminal diameter of > 2 mm and those with a luminal diameter of < or = 2 mm. CONCLUSIONS: All the patient groups had greater airway wall thickening than the normal subjects as assessed by HRCT scanning, but patients with more severe asthma had greater airway wall thickening than those with mild asthma. The methodology described in this study may be useful in assessing airway calibre in early intervention studies with anti-inflammatory therapy.

Adult↗
PubMed1998

Tuberculosis among health care workers in British Columbia.

OBJECTIVES: To compare the clinical features and prevalence of active TB in British Columbia (BC) health-care workers (HCWs) with those of the general population, between 1991 and 1996. METHODS: Comparison of 25 HCWs and 50 controls randomly selected from the Centres for Disease Control registry, with respect to demographics, prevention, diagnosis and management. RESULTS: HCWs had fewer related risk factors, but more had initiated prior chemoprophylaxis (16% vs. 0%, P < 0.01) and knew their bacille Calmette-Guerin (BCG) (68% vs. 24%, P < 0.001) and purified protein derivative (PPD) status (60% vs 32%, P < 0.05). There were no differences in symptom duration (3.3+/-3.6 vs. 3.0+/-3.4 months), mycobacteriology and diagnostic features, treatment duration (264.9+/-69.9 vs. 239.0+/-78.7 days) and completion rates (84% for both). All HCWs used self-administered treatment (100% vs. 70%, P < 0.01), and fewer were hospitalized (8% vs. 28%, P < 0.05). Disease rates in nurses (3.6+/-4.4 per 100 000) were lower than the general population rates (9.0+/-0.8), but did not differ among physiotherapists (8.96+/-21.95), general practitioners (7.60+/-11.78) and medical residents (30.75+/-75.32); CONCLUSIONS: Clinical features were similar in HCWs, but management strategies differed. BC HCWs are not at increased risk of tuberculosis, but the small sample size limited the power of our study to detect such an increase.

Adult↗
PubMed1998

Acceptance and safety of directly observed versus self-administered isoniazid preventive therapy in aboriginal peoples in British Columbia.

OBJECTIVE: To document experience with directly observed chemoprophylaxis (DOPT) compared to self-administered isoniazid (INH) among aboriginal persons in British Columbia. DESIGN: DOPT was compared to self-administered delivery (SAD) over a 3-year period. All aboriginal persons who received INH chemoprophylaxis in British Columbia between 1992 and 1994 were evaluated. Therapy completion rates and adverse outcomes associated with SAD were compared with DOPT. Treatment allocation was by patient choice. RESULTS: Of 608 people who received INH prophylaxis, 443 received SAD (mean age 31.6 years) and 165 received DOPT (mean age 23.9 years). Two hundred and seventy (60.9%) SAD compared to 124 (75.2%) in the DOPT group completed 6 months of INH (P = 0.0011). The 12-month completion rates were 162/443 (36.6%) for the SAD group and 84/165 (50.9%) for the DOPT group (P = 0.0014). Adverse reactions requiring discontinuation of medication occurred in 13.5% of the patients on SAD and 9.7% of those receiving DOPT (P = 0.202). The most common reason cited for failure to complete therapy was non-cooperation in both groups. There were three deaths in the SAD group, one of which was due to suicide by self-ingestion of INH. CONCLUSIONS: These data demonstrate that in aboriginal people compliance with preventive therapy can be improved by DOPT. Non random allocation to treatment groups might have influenced our findings, and further prospective randomized trials and cost-effectiveness analyses are required.

Adult↗
PubMed1998

Risk of tuberculosis in dialysis patients: a population-based study.

SETTING: Provincial tuberculosis (TB) and dialysis registries. OBJECTIVE: To document the risk of TB among patients on dialysis and to describe the clinical characteristics of these cases. METHODS: All cases of TB occurring among dialysis patients in British Columbia between January 1990 and December 1994 were reviewed, as were the age-specific rates for TB among the general population during the same period. RESULTS: During that period, a total of seven cases of TB occurred among 560 patients on hemo-dialysis and two cases among 326 patients on peritoneal dialysis. On an annual basis the rate of TB in the dialysis population was 253 per 100,000, compared to an age-matched rate of 10.1 per 100,000 in the general population, giving a relative risk of 25.3 (95% confidence interval 22.86-31.49, P = 0.0000001). CONCLUSIONS: The risk of TB in dialysis patients is significantly higher than previously reported from non population-based studies, indicating that dialysis patients should be considered a possible target population for systematic evaluation for the presence of TB infection and consideration for chemoprophylaxis.

Adult↗
PubMed1997

Delivering asthma education to special high risk groups.

Patients at high risk from their asthma and therefore worthy of more focused asthma education are those at risk of fatal and near fatal asthma(NFA). In recent years the characteristics of these patients have been better defined. The most important risk factor appears to be a prior history of NFA. Other important features include prior emergency room visits or hospitalization for asthma. Excess use of beta-agonists, especially in the absence of inhaled corticosteroids, also confers increased risk. High risk groups also share similar psychosocial barriers as well as economic deprivation. The benefits of asthma education in these groups have been assessed in a number of studies. In general, asthma education has been shown to have an impact on these patients. Greater effects have been achieved where there has been consistent follow-up by the same physician. Patients require frequent reinforcement of their asthma management, especially regarding their response to acute exacerbations. A sub-group of patients with more severe asthma appear to have a problem perceiving dyspnoea and may therefore benefit from peak flow monitoring but the problem of compliance with this intervention is significant. Behaviour modification plays an important role as does ensuring the patient has adequate resources to purchase medications especially the more expensive anti-inflammatory therapy. Future studies should focus on optimizing the potential benefits of educating high risk patients as they are not only those at greatest risk of death but also consume a disproportionate amount of health care resources.

Asthma↗
PubMed1997

Ganciclovir treatment of symptomatic congenital cytomegalovirus infection: results of a phase II study. National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group.

Congenital cytomegalovirus (CMV) infection occurs in approximately 1% of newborns in the United States. A phase II evaluation was done of ganciclovir for the treatment of symptomatic congenital CMV infection. Daily doses of 8 or 12 mg/kg were administered in divided doses at 12-h intervals for 6 weeks. Clinical and laboratory evaluations sought evidence of toxicity, quantitative virologic responses in urine, plasma drug concentrations, and clinical outcome. A total of 14 and 28 babies received 8 and 12 mg/kg/day, respectively. Five additional babies received ganciclovir on a compassionate plea basis. Significant laboratory abnormalities included thrombocytopenia (< or = 50,000/mm3) in 37 babies and absolute neutropenia (< or = 500 mm3) in 29 babies. Quantitative excretion of CMV in the urine decreased; however, after cessation of therapy, viruria returned to near pretreatment levels. Hearing improvement or stabilization occurred in 5 (16%) of 30 babies at 6 months or later, indicating efficacy.

Alanine Transaminase↗
PubMed1997

The clinical efficacy of combination nebulized anticholinergic and adrenergic bronchodilators vs nebulized adrenergic bronchodilator alone in acute asthma. Canadian Combivent Study Group.

The role of ipratropium bromide as adjunct therapy to beta-agonists in acute asthma is uncertain. We therefore decided to compare the use of 3 mg of salbutamol sulfate alone vs 3 mg salbutamol sulfate with 0.5 mg ipratropium bromide in patients with acute asthma. Patients presenting with acute asthma and an FEV1 less than 70% predicted were randomized to a single combination treatment vs salbutamol alone. All patients received supplemental oxygen and methylpred-nisolone, 125 mg, IV. Baseline measurements were repeated at 45 and 90 min and these included spirometry, oximetry, and vital signs. A total of 952 patients were screened of whom 342 patients were deemed eligible and were randomized in two groups of 171 patients. The mean (SE) age was 30 years (0.9) vs 29 years (0.7), women, 103 (60.2%) vs 110 (64%), 81 (47.4%) never-smoked vs 83 (48.5%), and duration of asthma in years 16.0 (0.8) vs 16.6 (0.8) were no different in the combination vs salbutamol alone group, respectively. Likewise, there was no significant difference in asthma therapy received in the 24 h prior to presentation; most notably, 151 (88.3%) vs 153 (89.5%) received inhaled beta-agonists in that period. Baseline FEV1 was 1.62 L (0.05 L) vs 1.53 L (0.03 L), and median time to treatment being received was no different between both groups. Both treatment arms improved significantly. The increase in FEV1 in the combination group was 0.6I L (0.04 L) and in the salbutamol alone group was 0.52 L (0.04 L) at 90 min. There was a trend toward greater bronchodilation in the combination group, but this did not reach statistical significance. Fewer hospitalizations, 5.9% vs 11.2%, occurred in the combination group, but this did not reach statistical significance. In conclusion, this large multicenter study failed to show a significantly better response to a combination of salbutamol and ipratropium bromide vs salbutamol alone.

Adrenergic beta-Agonists↗
PubMed1996

A review and economic evaluation of bronchodilator delivery methods in hospitalized patients.

BACKGROUND: Bronchodilator delivery by metered dose inhaler (MDI) to treat airflow obstruction is considered to be less expensive and as effective as nebulized therapy. OBJECTIVES: To document the utilization of bronchodilator delivery methods in a tertiary care Canadian university teaching hospital and to perform an economic evaluation. METHODS: A prospective 6-week audit of 4 preselected hospital wards (respiratory, thoracic surgery, general surgery, and a general internal medicine clinical teaching unit) and a cost-minimization economic evaluation were performed. Bronchodilator (salbutamol and ipratropium bromide) doses, frequency, and delivery methods, either MDI or wet nebulizer (WN), were recorded for 95 patients treated with aerosolized bronchodilators. Direct costs for medications and hourly wages including benefits and equipment were obtained. Time and motion studies identified time allocated to MDI and WN delivery. We used sensitivity analyses to test assumptions that could significantly affect treatment costs, especially assumptions about medications, labor, and spacer devices. Costs are expressed in Canadian dollars (Can$1 = US$0.75). RESULTS: Sixty-seven patients (70.5%) were treated with WN, 6 (6.3%) with MDI, and 22 (23.2%) with both WN and MDI. Self-administration of salbutamol by MDI was the least expensive: $1.27 for 200-microgram doses and $1.73 for 400-microgram doses compared with $2.62 for a 2.5-mg dose delivered by WN. The difference in cost between equivalent treatments (400-microgram MDI vs 2.5-mg WN) is only $0.89. Sensitivity analyses showed that MDI was the least expensive therapy when self-administration was possible and for all levels of supervision if more than 4 minutes was needed to administer a WN treatment. CONCLUSIONS: Bronchodilator delivery by WN is commonly prescribed for hospitalized patients despite evidence for equivalency of effect using MDI and in the absence of substitution protocols. Previous studies have estimated a far greater cost differential based on unrealistic labor estimates. We found that supervision of patients using MDIs minimized the differential cost between WN and MDI therapy and that cost savings are maximal in patients who can self-administer MDI therapy. Methodologically sound economic evaluations can better identify true cost savings and variables that need further study.

Adolescent↗
PubMed1996

Comparison of males and females presenting with acute asthma to the emergency department.

OBJECTIVES: To determine the female:male ratio and compare the severity of asthma between female and male patients presenting with acute asthma to the authors' emergency department (ED). PATIENTS: Patients aged 15-50 years presenting with acute asthma. SETTING: Emergency department of a university-affiliated hospital. METHODS: Retrospective analysis of asthma surveillance data and medical records of all asthma-related visits to ED over 6 months (January 1992-June 1992). RESULTS: One hundred and thirty-seven patients aged 15-50 years made 196 consecutive visits to the authors' ED over 6 months. The ratio of female:male patients was 1.9 and the ratio of the number of visits made by female vs. male patients was 2.6. Initial peak expiratory flow rate (PEFR) and forced expiratory volume in 1 s (FEV1) were recorded in 94% and 49% of the visits, respectively. There was no statistically significant difference between the male and female patients in heart rate, respiratory rate or percentage of patients admitted to hospital. The mean (SD) initial FEV1 as a percentage of predicted was significantly higher in females compared to males (49% +/- 20% vs. 33% +/- 15%; P < 0.001). CONCLUSION: In the authors' institution there is a high female:male ratio among patients presenting with acute asthma, and males tend to present later or with more severe disease. These findings need to be confirmed by a prospective study looking at all the factors that may contribute to asthma patients presenting to the ED.

Acute Disease↗
PubMed1996

Fatal asthma.

This brief review highlights the rise in asthma mortality witnessed in many countries. It outlines the multifactorial character of this phenomenon, which in most instances is a complex interplay between physician, patient, and environment. The pathophysiology of airflow obstruction and in particular the role of hyperinflation are outlined. These data may allow better prediction of who is at risk of fatal asthma (FA). Finally, potential approaches to the prevention of FA are outlined.

Airway Obstruction↗
PubMed1996

Miliary tuberculosis. Diagnostic accuracy of chest radiography.

STUDY OBJECTIVE: To assess the efficacy of the chest radiograph in identifying patients with miliary tuberculosis. DESIGN: Retrospective case-controlled review by three independent blinded chest radiologists. SETTING: Provincial tuberculosis control center. PATIENTS: Population-based sample, including all proved cases of miliary tuberculosis diagnosed in the Province of British Columbia, Canada, between November 1982 and November 1992. One hundred cases of miliary tuberculosis were identified, of which 71 had chest radiographs available for review. Forty-four normal chest radiographs and 20 chest radiographs of patients with localized pulmonary tuberculosis were also included as controls. MAIN OUTCOME MEASURES: The primary outcome of measurements was the sensitivity and interobserver variability of the chest radiograph in the diagnosis of miliary tuberculosis. The observers were also asked to describe the pattern and extent of pulmonary abnormalities based on the International Labor Organization (ILO) classification of pneumoconioses. RESULTS: The three independent observers identified 42, 44, and 49 of the 71 cases of miliary tuberculosis, respectively (sensitivity, 59 to 69%). The three observers incorrectly diagnosed miliary tuberculosis in 2, 0, and 2 of the 64 controls, respectively (specificity, 97 to 100%). There was good interobserver agreement (90%, kappa = 0.77). The nodules measured less than 3 mm in diameter in 90% of cases in which miliary tuberculosis was correctly identified. In 10% of cases, the nodules measured greater than 3 mm in diameter. The ILO profusion scores ranged from mild (profusion score 1) in 45% of cases, through moderate (profusion score 2) in 27%, and severe (profusion score 3) in 28%. CONCLUSIONS: The chest radiograph allowed identification of 59 to 69% of cases of miliary tuberculosis with a high specificity and good interobserver agreement.

Adolescent↗
PubMed1996

HIV-related tuberculosis in British Columbia: indications of a rise in prevalence and a change in risk groups.

OBJECTIVES: To identify patients with coexisting HIV infection and tuberculosis (TB) and recent trends in prevalence and factors associated with coinfection. DESIGN: Case review. PARTICIPANTS: All known patients with TB and HIV infection in British Columbia, in whom TB was diagnosed between 1990 and 1994. This group was compared with those in whom TB was diagnosed between 1984 and 1990. OUTCOME MEASURES: Patients' demographic characteristics and risk factors for HIV infection, site of TB, occurrence of drug-resistant TB, treatment and outcome. RESULTS: Forty-four patients with HIV infection and TB were identified, of whom 16% were women, whereas non of those diagnosed from 1984 to 1990 were women, and 14 (32%) were aboriginal Canadians, compared with only 3 (8%) of those diagnosed from 1984 to 1990 (p < 0.01 for both). Forty patients had identifiable risk factors for HIV infection. A smaller proportion of the recent group than of the previous group were homosexual men (excluding those for whom risk factors were not known, 17/33 men [52%] in 1990 to 1994 v. 36/39 [92%] in 1984 to 1990), and a larger proportion were intravenous drug users (22/40 [55%] in 1990 to 1994 v. 8/39 [21%] in 1984 to 1990, p < 0.01 for both). Since 1984 an increasing proportion of patients with TB diagnosed each year have also had HIV infection (linear trend p < 0.001). Drug resistance was not found in any cultures taken at the time of diagnosis; however, rifampin resistance developed 7 months after therapy was initiated in one patient. Of the 40 patients who started therapy, 24 had directly observed therapy. Nine patients died while receiving therapy, and four died without receiving any antituberculous therapy. TB was the cause of death, or a contributing factor to death, in five cases. CONCLUSIONS: Significantly more intravenous drug users, aboriginal Canadians and women are now presenting with HIV-related TB in British Columbia. All HIV-positive patients need to be evaluated for TB, and HIV infection must be considered in assessing all newly diagnosed TB cases and in screening contacts of active cases, especially if patients have risk factors for HIV infection.

AIDS-Related Opportunistic Infections↗