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J M FitzGerald

Publications and source records attributed to J M FitzGerald.

70 records · Page 4Linked to original sources
PubMed1987

The Montana Fetal Genetic Pathology Program and a review of prenatal death in humans.

Western medicine is being sensitized to the enormous extent of prenatal death in humans at a time when such deaths, occurring after the first missed period, involve to an ever increasing degree wanted pregnancies conceived by women with rising mean maternal age, decreasing mean fertility, and ever greater desire and intention to assure a good pregnancy outcome. Available data suggest that about two-thirds of human ova, embryos, and fetuses fail to reach birth or the end of the first year of life, with infant mortality of 1.06%, stillbirth rate of 8/1,000, abortion rate of about 15%, and death rate around the time of implantation estimated at 34%. Based on limited data on sperm, ova aspirated from Graafian follicles in infertile women, direct observation of a few implanting ova, the low rate of human fecundity, and the high failure rate of in vitro fertilization, it seems reasonable to suppose that about 30% of human ova perish at the time of fertilization and before implantation. Most of this prenatal death is attributable to chromosome abnormalities (aneuploidy and polyploidy), estimated to be present at the beginning of development in about half of all human ova or embryos. Parent's anguish about prenatal death and their desire to understand its causes and to prevent recurrence is putting the medical profession under severe pressure to provide diagnostic and counseling services and make available prenatal diagnosis and preventive approaches; this comes at a low point in the ability of Western medicine to respond adequately, especially in the fields of embryology and developmental genetics, clinical teratology, anatomical pathology, and genetic pathology. Unless drastic ameliorative measures are taken, the situation is likely to get much worse, since health insurance pays for only a minute fraction of costs involved and the number of pediatric pathologists devoting major effort to this work in North America has dwindled to a small number without great hope for replacement from younger ranks, primarily as a result of the lack of incentive by the tertiary centers to make fetal genetic pathology ("morphology") an attractive field to work in. Here we report an effort by a secondary care center to provide such a service--presently more on demand than as systematic effort to reach all at need--in a huge, underpopulated state with birthrate of less than 13,000 and lacking any specially trained pathologist with a strong interest in the field.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1986

Two sporadic cases of amelia/phocomelia with similar phenotype: rare and unusually symmetrical form of FFU dysostosis or separate entity?

We report on two infants born at term with amelia/phocomelia and a striking appearance with facial hemangiomas and micrognathia. The upper limbs were absent and the lower limbs were extremely short, containing only a tibia; the phocomelic feet lacked one to four lateral rays. There was no known teratogen exposure and the infants were born in different regions of the USA. This may be considered an unusually symmetrical and rare form of FFU dysostosis, or a separate entity.

Ectromelia↗
PubMed1985

NOR activity and centromere suppression related in a de novo fusion tdic(9;13)(p22;p13) chromosome in a child with del(9p) syndrome.

A female infant with del(9p) syndrome was found to have the karyotype 45,XX,tdic(9;13)(p22;p13) de novo. In the translocation chromosome, various combinations of AgNOR activity and inactivity were found with suppression of either the 9 or neither centromere. These phenomena of discontinuous centromeric suppression and variation in NOR activity in the one chromosome were scored on AgNOR, GTG, and a combination of AgNOR- and GTG-banded preparations. With AgNOR staining, 15.8% tdic chromosomes were AgNOR-positive, and this coincided (in preparations with GTG banding only) with 16% tdic chromosomes with a nonstaining gap present at the NOR site. This suggested that when the NOR-nonstaining gap was present the AgNOR staining would be positive; this was confirmed by the absence of gaps in combination AgNOR-GTG-banded preparations. In cells with tdic-NOR-negative chromosomes, equal proportions of cells with the 13 or both centromeres constricted were observed, but in cells with tdic-AgNOR-positive chromosomes there was only half the proportion of tdic chromosomes with both centromeres constricted; ie, there was a (significant) tendency towards inactivity of the NOR when both centromeres were constricted in the tdic chromosome. Therefore, the 2 phenomena, variation in NOR activity and centromeric suppression, are interrelated in this case.

Centromere↗
PubMedDate not supplied

Management of acute asthma in Canada: an assessment of emergency physician behaviour.

The study objective was to assess Canadian emergency physicians for their management preferences and their compliance with recently developed guidelines for treatment of acute asthma in adults. The design was a cross-sectional survey sent to members of the Canadian Association of Emergency Physicians (CAEP) and to the emergency department (ED) directors of all Canadian hospitals with more than 25 beds in November 1992. ED directors who had not responded were sent a second survey in January 1993. The response rates for the survey were 60.1% (362/602) for ED directors and 53.4% (302/586) for CAEP members. Respondents were more likely to be from larger hospitals and to have completed some training beyond general practice level (CCFP, CCFP-EM, ABEM, FRCPC). There were wide variations among respondents in the use of objective measurements of asthma severity (forced expiratory volume in 1 s [FEV1] and peak expiratory flow rates [PEFR]), dosing of bronchodilators, and utilization of systemic corticosteroids. Forty-six percent of respondents used the FEV1 "occasionally" (22.3%) or "never" (23.8%), and 26.7% used PEFR "occasionally" (15.8%) or "never" (10.9%) in asthma management. Ninety-seven percent used nebulized beta agonist "always" (71.3%) or "often" (25.6%), but only 48.5% used the metered dose inhaler (MDI) "always" (11%) or "often" (37.5%). More than a quarter of respondents (27.2%) used doses of beta agonists that were less than those recommended (> every 30-60 min). Oral corticosteroids were prescribed at discharge only "occasionally" (51.1%), "seldom" (18.9%), or "never" (6.5%) in 76.6% of physicians. Physicians with more training were more likely to assess and treat patients according to current asthma treatment guidelines. The survey shows that many Canadian emergency physicians did not follow published recommendations for the care of patients with acute asthma. This finding was especially so with regard to objective evaluation of airflow, aggressive use of beta-agonists, the use of corticosteroids, and in making appropriate arrangements for patient discharge and follow-up.

Acute Disease↗
PubMedDate not supplied

Health care costs associated with acute asthma: a prospective economic analysis.

OBJECTIVE: To determine the direct and indirect costs associated with the care of acute asthma in an adult teaching hospital. DESIGN: A prospective, cost identification study. PATIENTS AND METHODS: Patients aged 15 to 55 years presenting with acute asthma. Consecutive emergency department visits for asthma at Vancouver Hospital and Health Sciences Centre over six months were prospectively monitored. The duration of hospital stay, physician's care, laboratory procedures and medication given were recorded. Time lost from work or school was determined by follow-up telephone calls. The costs were calculated in 1997 Canadian dollars. RESULTS: One hundred and forty-nine patients made 195 emergency department visits over the six-month study. Twenty-eight (14%) of these visits led to hospital admissions. The total cost associated with the care of these patients was $250,570. The median (standard deviation in brackets) direct medical costs associated with each emergency department visit and hospital day were $324.00 (+/-52.00) per visit, and $677.00 (+/-76.00) per day, respectively. CONCLUSION: The present study provides a more accurate estimation of the operational cost of managing asthma in a teaching hospital setting than previous studies. The data presented in this study can be used in future cost effectiveness and cost-benefit studies in acute asthma, particularly where these studies involve specific intervention such as asthma education. More studies, which include children with asthma and patients treated outside of the hospital setting, are needed.

Acute Disease↗
PubMedDate not supplied

A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation.

OBJECTIVE: Prednisone (PRED) is recommended at discharge to reduce the relapse rate following emergency treatment for an asthmatic attack. However, PRED has systemic side effects. Inhaled anti-inflammatory medications, such as budesonide (BUD), are well tolerated. This study was designed to compare the effectiveness of PRED and BUD on relapse rate. DESIGN: A prospective, randomized, double-blind, double dummy, parallel group design. SETTING: Tertiary referral emergency departments. POPULATION STUDIED: One hundred and eighty-five patients with acute asthma who received standard treatment with bronchodilators and systemic glucocorticosteroids in the emergency department, had a forced expiration volume in 1 s (FEV1) greater than 50% predicted and who were deemed well enough to be discharged from the emergency department. INTERVENTION: Patients were randomized to receive either BUD Turbuhaler 600 microg qid or PRED 40 mg in the morning for seven to 10 days. At discharge and final visit, symptoms, medication use, FEV1, peak expiratory flow (PEF) and quality of life (QoL) were assessed. Relapse rate to the emergency department during the follow-up was determined by a yes and/or no questionnaire. MAIN RESULTS: The PRED (n=85) and BUD (n=90) treatment groups were comparable at baseline (emergency department discharge) for age (mean +/- SD; 27.6+/-8.5 years and 29. 2+/-8.7 years) and prebronchodilator FEV1 (1.77+/-0.79 L and 1. 75+/-0.78 L), respectively. BUD was at least as effective as PRED in preventing a relapse to the hospital; relapse rate was 10 (11.8%) during PRED treatment and nine (10.0%) for BUD treatment (95% CI PRED-BUD, -7.5% to 11.0%). Improvements in FEV1, asthma symptoms, PEF and QoL were not significantly different between treatments. CONCLUSIONS: In patients whose acute asthma has been stabilized in the emergency department, high dose BUD may be an alternate to PRED as a follow-up treatment.

Acute Disease↗
PubMedDate not supplied

Tuberculosis among aboriginal and nonaboriginal persons in British Columbia.

OBJECTIVE: To compare cases of tuberculosis (TB) diagnosed among aboriginal persons with a random sample of nonaboriginal persons diagnosed with TB, and evaluate the trends in rates of disease between both groups during the same period. DESIGN: A case-control study. SETTING: A provincial TB control program. PATIENTS AND METHODS: All patients with TB diagnosed among aboriginal persons in British Columbia between 1992 and 1996 were compared with control patients diagnosed during the same period. For each patient a control patient was identified. INTERVENTION: The demographic details, type of disease, bacteriology, risk factors for TB, therapy received as well as mode of administration were documented. The number of contacts identified for each patient as well as the number of patients completing chemoprophylaxis were identified. The rates of disease during the same period were also documented. RESULTS: During the study, 202 patients with TB were diagnosed among aboriginal persons and 201 controls were chosen. Apart from age at diagnosis (35.1+/-20 years versus 45.7+/-19.7), differences in the prevalence of lymphadenopathy (5.9% versus 16.4%, P=0.0008) and pleural disease (21.3% versus 16.4%, P=0.00008), there were no differences in presentation between aboriginal and nonaboriginal people. Aboriginal people were more likely to have a history of contact with a patient with TB (53% versus 17.9%, P<0.05), to have received directly observed therapy (55% versus 33.8%, P=0.00002) and to have contacts who were purified protein derivative (PPD) positive (4+/-9 versus 2+/-3, P=0.002). These contacts were more likely to start isoniazid (2+/-3 versus 1+/-1, P=0.002). Overall, there was a significant decline in rates of TB among aboriginal persons compared with the general population, but there was a small increase in rates among all subjects in the final year of the study. CONCLUSIONS: In the present study, significant variations in rates of TB among different population groups in British Columbia were found. During the study period, there was a greater decline in the rates of TB among aboriginal persons. A greater use of directly observed therapy and greater use of chemoprophylaxis occurred among aboriginal persons, which may have contributed to this decline, or alternatively, it simply reflects the natural evolution of the TB epidemic.

Adolescent↗
PubMedDate not supplied

What is new since the last (1999) Canadian Asthma Consensus Guidelines?

The objective of the present document is to review the impact of new information on the recommendations made in the last (1999) Canadian Asthma Consensus Guidelines. It includes relevant published studies and observations or comments regarding what are considered to be the main issues in asthma management in children and adults in office, emergency department, hospital and clinical settings. Asthma is still insufficiently controlled in a large number of patients, and practice guidelines need to be integrated better with current care. This report re-emphasises the need for the following: objective measures of airflow obstruction to confirm the diagnosis of asthma suggested by the clinical evaluation; identification of contributing factors; and the establishment of a treatment plan to rapidly obtain and maintain optimal asthma control according to specific criteria. Recent publications support the essential role of asthma education and environmental control in asthma management. They further support the role of inhaled corticosteroids as the mainstay of anti-inflammatory therapy of asthma, and of both long acting beta2-agonists and leukotriene antagonists as effective means to improve asthma control when inhaled corticosteroids are insufficient. New developments, such as combination therapy, and recent major trials, such as the Children's Asthma Management Project (CAMP) study, are discussed.

Adrenergic beta-Agonists↗
PubMedDate not supplied

Comparison of a weight-based heparin nomogram with traditional heparin dosing to achieve therapeutic anticoagulation.

Optimum anticoagulation with heparin within the first 24 hours of a thrombotic event is critical in preventing a recurrence. We believed that traditional nonweight-based heparin dosing at our institution resulted in delayed anticoagulation. A weight-based heparin nomogram was therefore created and compared to traditional heparin dosing in patients with a diagnosis of acute deep vein thrombosis or pulmonary embolism. Fifty historical control patients were compared to 50 consecutive patients treated prospectively using the weight-based nomogram. The primary outcome assessed was time to achieve therapeutic anticoagulation, defined as an activated partial thromboplastin time (aPTT) of 46-70 seconds (1.5-2.5 times the control aPTT). The weight-based nomogram achieved an aPTT above the therapeutic threshold more rapidly than the control group (10.7 hrs nomogram vs 33.3 hrs control group, p < 0.004). Similarly, the proportion of patients who exceeded the therapeutic threshold at the first aPTT measurement, at 24 hours, and at 48 hours was significantly higher in the nomogram group. There was no difference in the frequency of bleeding complications or recurrent thrombotic events between the two groups. The initial nomogram was revised for patients weighing more than 80 kg owing to a greater frequency of excessive anticoagulation in these patients. Subsequent analysis of 29 patients using the modified nomogram revealed sustained efficacy and a reduced number of supratherapeutic aPTTs. We concluded that a weight-based heparin nomogram is superior to traditional therapy in achieving rapid therapeutic anticoagulation without an increase in adverse outcomes.

Anticoagulants↗
PubMedDate not supplied

Bronchodilator delivery in acute airflow obstruction. A meta-analysis.

OBJECTIVE: To compare the effect of bronchodilator delivery by use of a metered-dose inhaler (MDI) or wet nebulizer on objective measurements of acute airflow obstruction in adult patients. METHODS: Published and unpublished research was identified by MEDLINE searches for articles published from 1966 to 1994, review of scientific citations, review of article bibliographies, communication with experts in the area of asthma therapy and aerosol delivery, primary investigators, and a manufacturer of spacer devices. Eighteen studies were selected from 159 potentially relevant articles by independent review in triplicate. Selection criteria included randomized trials that compared bronchodilator delivery by use of an MDI and wet nebulizer in adults with acute exacerbations of asthma or chronic obstructive pulmonary disease who were treated in an emergency department or a hospital. Data for patient characteristics, study setting, bronchodilator doses, outcomes, and methodological quality were independently extracted. RESULTS: Twelve studies with a total of 507 patients had sufficient data to calculate an effect size (in SD units) for improvement in airflow obstruction after bronchodilator delivery. All but 2 studies used spacer devices with the MDI. The overall treatment effect size was -0.02 (95% confidence interval [CI], -0.20 to 0.16) that favored the MDI, but the magnitude of the effect size was not clinically or statistically significant. No significant effect was observed in the subgroup analyses that compared the diagnosis: asthma, -0.17 (CI, -0.41 to 0.07) compared with chronic obstructive pulmonary disease, 0.23 (CI, -0.35 to 0.81); bronchodilator dose; or methodological quality. The results of a sensitivity analysis that included 5 of 6 excluded studies supported the findings from the primary analysis: 0.05 (CI, -0.11 to 0.20). CONCLUSIONS: Bronchodilator delivery by means of an MDI or wet nebulizer is equivalent in the acute treatment of adults with airflow obstruction. Spacer devices were used for bronchodilator delivery with an MDI in most studies and are recommended for the treatment of acute airflow obstruction. The choice of the delivery method will depend on the need for expedient treatment, availability of staff, consideration of costs, and findings from studies designed to evaluate treatment effects from larger than standard doses of bronchodilators delivered by use of an MDI.

Acute Disease↗
PubMedDate not supplied

Development and implementation of asthma guidelines.

In recent years there has been concern regarding asthma management, with a number of studies identifying poor management. In addition, prevalence, and until relatively recently mortality, have been increasing in patients with asthma. In parallel with these developments has been the publication of a large number of asthma guidelines. Many deficiencies identified in earlier guidelines have been corrected in more recent publications - especially those using an evidence-based format. The critical problem of disseminating and implementing the guidelines remains. It appears that traditional continuing medical education will not lead to a change in clinical practice. The challenge remains to create a framework for implementing methodologically sound guidelines locally.

Anti-Asthmatic Agents↗