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Biomedical subjects

M J Carella

Publications and source records attributed to M J Carella.

At least 19 recordsLinked to original sources
PubMed1999

The effects of a low-dose regimen of fosinopril on elevated urinary albumin excretion in normotensive type 1 diabetic patients.

Normotensive type 1 diabetics with persistent albuminuria were randomized between 12 months' treatment with low-dose fosinopril (10 mg/d) and placebo in a 24-month, double-blind, crossover trial. Metabolic and cardiovascular variables were measured every three months and two-dimensional and M-mode echocardiography was performed before and after each treatment phase. Low-dose fosinopril led to 70% reduction in urinary albumin excretion (UAE) (220 +/- 199 vs 82 +/- 67 mg/24-h, p < 0.05), but UAE did not change during placebo treatment; the maximal change became apparent after 3 months and was reversible once treatment was stopped. Even though blood pressure (BP) did not change during fosinopril treatment, there was a significant correlation between baseline UAE and diastolic BP (r = 0.77, p = 0.027) and between change in UAE and change in systolic BP (r = 0.84, p = 0.01). The change in UAE approached borderline significance in correlation with the change in triglyceride concentration (r = 0.66, p = 0.07). Low-dose fosinopril favorably affects the "cardiorenal syndrome" seen in type 1 diabetics with persistent microalbuminuria.

Adult↗
PubMed1999

Bone mineral density (BMD) in obesity effect of weight loss.

It is generally believed that bone mineral density (BMD) is increased in obese subjects, but the effect of weight loss on BMD has not been well studied. Therefore, we evaluated BMD among 11 obese women (mean age 45.5 +/- 14.2 years) before and after weight loss achieved by ingesting an 800 calorie diet for 12 weeks. BMD measurements were made at baseline, 6 months and 1 year intervals. Urinary hydroxyproline:creatinine (H:Cr), calcium:creatinine (Ca:Cr) ratios were measured as indices of bone turnover. Mean weight at baseline was 103.8 +/- 15.8 kg and decreased to 83.2 +/- 12.2 at six months and was 85.8 +/- 14.2 kg at one year. Total body, hip and lumbar spine BMD were 1.12 +/- 0.07, .87 +/- 0.11, and 1.02 +/- 0.12 gm/cm2, respectively. Total body BMD was significantly lower at 12 months compared to baseline. No significant change was observed in BMD of the lumbar spine. There was also a significant decrease in hip BMD at six months and 12 months compared to baseline. H:Cr and Ca:Cr ratios did not change over time. We conclude that weight loss achieved by VLCD is accompanied by a statistically significant change in BMD, but the BMD remained in the normal range.

Body Weight↗
PubMed1998

Evaluation of "solitary" thyroid nodules in a community practice: a managed care approach.

Evaluation of thyroid nodules remains a challenge for primary care physicians. To include or exclude the presence of malignancy in a thyroid nodule, radioisotope scan, ultrasound, and fine-needle aspiration biopsy of the thyroid generally are used. The objectives of this study were to determine the utility and cost effectiveness of fine-needle aspiration biopsy of solitary thyroid nodules in a community setting; to compare the cost of fine-needle aspiration biopsy with that of radioisotope scan and ultrasound; and to determine whether the practice of obtaining radioisotope scans and ultrasound has changed in the 1990s compared with the 1980s. Patients were referred by community physicians to university-based endocrinologists for evaluation of thyroid nodules. Many of the patients had previously undergone radioisotope scans and ultrasound scans at the discretion of their primary care physicians. All patients underwent fine-needle aspiration biopsy. The biopsy results were evaluated prospectively, and the practice of community physicians' obtaining radioisotope scans and ultrasound scans was compared for the 1980s and 1990s. Eighty-three patients underwent 104 biopsies. In 20 biopsies the specimens were inadequate; the others showed 70 benign, 9 suspicious, and 4 malignant lesions. All four patients with biopsy findings read as malignant were found to have malignant growth at surgical procedures. Two benign biopsy findings were false-negative results. Malignant growth was correctly diagnosed later for one patient at a second biopsy and for the other because of growth of the nodule. The cost of 104 biopsies was $20,800. The cost of radioisotope scans was $22,400, and the cost of ultrasound scans was $10,640. The frequency of obtaining radioisotope scans (84.5% vs 77%) and ultrasound scans (65% vs 45%) was slightly higher in the 1990s compared with the 1980s. Fine-needle aspiration biopsy is a safe and cost effective initial evaluation modality for smaller community-based centers, as it is at large tertiary centers. The cost incurred ($33,040) in obtaining the radioisotope scans and ultrasound scans could have been saved if fine-needle aspiration biopsy had been used as the initial diagnostic procedure for evaluation of these nodules. Although radioisotope scan and ultrasound scan are of little diagnostic help in the evaluation of thyroid nodules, they continued to be obtained at a high frequency during the last decade.

Adolescent↗
PubMed1997

Serial measurements of body composition in obese subjects during a very-low-energy diet (VLED) comparing bioelectrical impedance with hydrodensitometry.

Bioelectrical impedance analysis (BIA) is a convenient, inexpensive, and noninvasive technique for measuring body composition. BIA has been strongly correlated with total body water (TBW) and also has been validated against hydrodensitometry (HD). The accuracy and clinical utility of BIA and HD during periods of substantial weight loss remain controversial. We measured body composition in moderately and severely obese patients serially using both methods during a very-low-energy diet (VLED). Mean initial weight in these patients was 116 (+/-30) kg (range, 74-196 kg). Mean weight loss was 24 (+/-13) kg with a decrease in fat mass (FM) by HD of kg (p < 0.001) and a decrease in fat-free mass (FFM) of 3.6 kg (p < 0.05). Loss of FFM is best predicted by the rate (kg/wk) of weight loss (r2 = 0.86, p < 0.0001). FFM, as predicted from BIA equations, was highly correlated with FFM as estimated by HD during all testing sessions (r = 0.92-0.98). Although highly correlated, BIA overestimated FFM relative to HD and this difference appeared to be more pronounced for taller patients with greater truncal obesity. Although the discrepancy was no greater during weight-loss treatment, the level of disagreement was considerable. Therefore, the two methods cannot be used interchangeably to monitor relative changes in body composition in patients with obesity during treatment with VLED. The discrepancy between BIA and HD may be caused by body mass distribution considerations and by perturbations in TBW which affect the hydration quotient for FFM (BIA) and/or which affect the density constants for FFM and FM (HD).

Adult↗
PubMed1997

Apolipoproteins in obesity: effect of weight loss.

We evaluated serum concentrations of apoprotein (APO) A1, B, total cholesterol, triglycerides, high density cholesterol (HDL-C), and low density cholesterol (LDL-C) in twelve obese subjects whose body mass index (BMI) was > or = 30 before and after a clinically significant weight loss was obtained utilizing a very-low calorie diet (VLCD) consisting of liquid protein (Optifast) providing 800 calories a day. At baseline, the mean weight +/- SD was 119.77 Kg and decreased significantly to 89.29 +/- 13.46 Kg by 24 weeks. Statistically significant reductions of APO-A1, APO-B, total cholesterol, and triglyceride concentrations were also observed along with the weight loss. LDL-C decreased from 156.0 +/- 55.9 mg/dL to 122.5 +/- 42.2 mg/dL (4.03 +/- 1.4 to 3.16 +/- 1.1 mmol/L), but this difference was not statistically significant. There was no significant change in the HDL-C and the ratios of APO-A1 to APO-B. We conclude that the use of VLCD is associated with changes in the lipid pattern that lower the cardiovascular risk profile in addition to the beneficial effects of weight loss itself.

Adult↗
PubMed1996

Utility of micral test strips in screening for microalbuminuria.

OBJECTIVE: To evaluate the clinical utility of Micral strips for detection of microalbuminuria. DESIGN: One hundred three urine samples were tested by Micral strips for the presence of microalbuminuria, and the results were compared with the immunonephelometric method. SETTING: Endocrine diabetes clinic in a university-affiliated outpatient facility and the associated clinical laboratory. PATIENTS: Sixty-seven, 24-hour urine samples were obtained from 64 patients with diabetes. Thirty-six urine samples were obtained from normal controls; 22 of these were 24-hour samples and 14 were overnight samples. MAIN OUTCOME MEASURE: Concordance of results obtained by the two methods for the presence or absence of microalbuminuria. RESULTS: All 36 control subjects and 44 urine samples from diabetic patients had normal albumin excretion (<15 mg/24 h) by the immunonephelometric method. Seventy-eight of these were correctly identified as negative by Micral strips, giving a specificity of 97.5%. There were 23 samples with albumin excretion of more than 16 mg/24 h. Sixteen of these were correctly identified, giving a sensitivity of 69.5%. There were 16 samples with albumin excretion of 30 mg/24 h or more; 14 of these were correctly identified by Micral strips, and two were false negatives, giving a sensitivity of 87.7%. However, when urine samples with albumin concentrations of less than 11 mg/L were excluded, the Micral strips correctly read 21 out of 23 samples, giving a sensitivity of 91.3%. CONCLUSIONS: The specificity of Micral strips for detection of albuminuria in 24-hour urine samples is high (97.5%), but the sensitivity is low, ranging from 69.5% to 87.7%. The sensitivity was greatly improved when urine samples with albumin concentrations of less than 11 mg/L were excluded.

Albuminuria↗
PubMed1996

Obesity, adiposity, and lengthening of the QT interval: improvement after weight loss.

OBJECTIVES: To determine the prevalence of QT interval prolongation in patients referred to an outpatient clinic for treatment of obesity; and to describe the change in the QT interval during rapid weight loss with a very-low-calorie diet. DESIGN: Retrospective and prospective review of charts and electrocardiograms. SUBJECTS: Five hundred twenty-two obese patients (411 female, 112 males) with a mean age 44 (18-78 y) and a mean initial weight of 116 kg (63-285 kg) completing 26 weeks of treatment between September, 1989 through to December, 1993. MEASUREMENTS: We reviewed the EKGs of all patients and serially monitored the QTc if greater than 0.44 s or if more than 23 kg was lost during treatment. The QTc interval was calculated with Bazzett's formula using both a manual method and an automated software program. In some patients, body composition was measured by hydrodensitometry. RESULTS: The QTc interval before treatment was 0.42 +/- 0.026 s by manual measurement and 0.41 +/- 0.021 s by automated measurement. Forty-one to 53% of patients showed a QTc interval of greater than 0.42 s and 10-24% demonstrated moderate prolongation (> 0.44 s). In those patients for whom repeat EKG were performed, QTc showed shortening with weight loss by both methods (mean +/- s.e. of 0.42 +/- 0.003 to 0.41 +/- 0.003 s, P < 0.01 manually and 0.41 +/- 0.003 to 0.40 +/- 0.003 s, p < 0.005 by automated program). Analyses were repeated excluding 179 patients with a cardiovascular-related diagnosis or intraventricular block and the results were similar. By regression analysis, gender and fat mass (FM) percentage above normal predicted the QTc. CONCLUSIONS: QT Interval prolongation is common in obesity. For each 50% increase in FM% above normal, there is a 5 ms increase in the QTc above a 'normal' upper limit of 0.40 and 0.38 s in women and men, respectively. Moreover, the QT interval shortens with weight loss. This change may represent an additional benefit of weight loss along with the improvement in other cardiovascular risk factors.

Adipose Tissue↗
PubMed1994

Early diabetic nephropathy. Emerging treatment options.

Diabetic nephropathy affects approximately 35% of patients with insulin-dependent diabetes mellitus and about 5% to 10% of patients with non-insulin-dependent diabetes mellitus. Diabetic kidney disease can be detected early by special methods that measure microalbuminuria in the range of 15 to 140 micrograms/min or 0.02 to 0.20 g/d. Specific strategies have been proved beneficial in patients with this early diabetic kidney disease, also called "incipient nephropathy." Protein restriction, tight control of blood sugar and blood pressure, and specific therapy with angiotensin-converting enzyme inhibitors have been shown independently to reduce microalbuminuria and preserve renal function in these patients. We review the pathogenesis of diabetic kidney disease and discuss the effects of these treatment strategies on the renal, cardiovascular, metabolic, and other abnormalities found in early (incipient) and overt diabetic nephropathy.

Albuminuria↗
PubMed1994

Adrenal effects of low-dose aminoglutethimide when used alone in postmenopausal women with advanced breast cancer.

Aminoglutethimide (Ag) is a potent aromatase-enzyme inhibitor used in the treatment of patients with breast cancer. In the past, it has been administered in doses of 1,000 mg/d (usually with 40 mg hydrocortisone). At these dose levels, the drug also affects multiple cytochrome P-450 enzymes, including enzymes for adrenal steroid biosynthesis. Recently, lower-dose regimens (500 mg/d) of Ag have been found to be just as effective for breast cancer therapy, but less toxic than the higher conventional dose. There is limited information on the adrenal effects at the lower dosages, and it is not known whether these effects are clinically significant. We measured basal and synthetic corticotropin (Cortrosyn)-stimulated levels of adrenal steroids in postmenopausal breast cancer patients before and during treatment with low-dose Ag (500 mg/d) administered without a glucocorticoid preparation. Basal levels of progesterone, 17-OH progesterone, and 11-deoxycortisol were higher after 2 months' treatment (P < .01). After ACTH injection, peak levels of progesterone and 17-OH progesterone were higher (P < .01), but in contrast, peak levels of 18-OH corticosterone were lower during treatment (P < .02). Basal and peak levels of cortisol, aldosterone, and all other adrenal steroids were unchanged during treatment. We conclude that low-dose Ag treatment leads to partial inhibition of the 21-hydroxylase, 11-hydroxylase, and 18-hydroxylase adrenal enzymes. Since cortisol and aldosterone secretion remained normal with minimal shunting to or accumulation of adrenal androgen compounds, we believe that the mild inhibition was compensated for by further endogenous ACTH stimulation.

17-alpha-Hydroxyprogesterone↗
PubMed1994

Management of diabetes in the elderly: a clinical perspective.

Glucose tolerance deteriorates with advancing age. According to the currently accepted National Diabetes Data Group criteria, the prevalence of diabetes increases from 2% in the 20- to 44-year-old age-group to nearly 18% in those aged 65 to 74 years. Although the principles of management of diabetes in the elderly are similar to those applied to young adults, they must be modified according to the coexisting conditions unique to the elderly. Treatment modalities include diet, exercise, oral hypoglycemic agents (sulfonylureas, metformin in the near future), and insulin. A dietary and exercise prescription should be given to all patients, but must be carefully individualized. If nonpharmacologic measures do not succeed, oral hypoglycemic agents or insulin may be used. It should not be assumed that long-term vascular complications of diabetes will not occur in elderly diabetics. An attempt should therefore be made to control hyperglycemia. The Diabetes Control and Complications Trial demonstrated that tight blood glucose control effectively delays the onset and progression of complications in young patients with insulin-dependent diabetes; however, tight control is associated with an increased risk of hypoglycemia. Hypoglycemia in older adults may have serious consequences, such as precipitating a myocardial infarction or stroke. Treatment should thus aim for a reasonable degree of blood glucose control without producing hypoglycemia or seriously interfering with the enjoyment of life. Coexisting renal or hepatic dysfunction or other factors also make the elderly more prone to developing hypoglycemia, which must be carefully avoided. If complications are present, their treatment and efforts to prevent their worsening are important objectives of the therapeutic plan.

Adult↗
PubMed1993

Hypothalamic-pituitary-adrenal function one week after a short burst of steroid therapy.

"Steroid burst therapy" is commonly used for various acute medical conditions, but its suppressive effect on hypothalamic-pituitary-adrenocortical (HPA) function and the time period for recovery of HPA function is not fully known. We therefore evaluated the HPA function in 10 normal adults before and after a short burst of Prednisone (40 mg/three times daily for 3 days, then tapered over the next 4 days). HPA function was evaluated by iv administration of 100 micrograms of ovine CRH (oCRH) and blood samples for ACTH and cortisol assay were obtained at -30,0,10,15,30,60,90, and 120 min. On another day, 250 micrograms synthetic ACTH (Cosyntropin) were given iv and blood samples for cortisol were obtained at 0,30,60, and 90 min. Basal and peak levels of ACTH and cortisol before and 1,2, and 3 weeks after discontinuation of prednisone in response to oCRH iv are shown below (see Table 1). All values are mean (SEM). Peak levels of cortisol after iv administration of Cosyntropin at week 0 were 922(56.8), week 1 899(63.7), week 2 861(70.9), and week 3 855(53.0). There was no significant difference noted in the levels of ACTH and cortisol in response to oCRH before and after prednisone treatment. Pre- and posttreatment responses of cortisol to Cosyntropin administration were also similar. In addition, cumulative responses (area under the curve) and the change from baseline (delta) before and after administration of prednisone were similar for ACTH and cortisol. We conclude that HPA function is normal 1 week after discontinuation of a short burst of prednisone. These findings suggest that administration of additional steroids may not be required during periods of "stress" for those patients who have previously received similar steroid burst therapy, if at least 1 week has elapsed after such treatment was given.

Adrenocorticotropic Hormone↗
PubMed1993

Pregnancy in a patient with premature ovarian failure.

Spontaneous pregnancy in patients with premature ovarian failure, although previously reported, remains quite rare. We report a patient with premature ovarian failure who spontaneously conceived and carried the pregnancy to full term. A 26 year old, white female with primary hypothyroidism (diagnosed in 1979) was first seen by us in January 1984 for secondary amenorrhea of six months duration. Menarche occurred at age 13 and menstrual periods were regular until May 1983. She experienced hot flashes in the summer of 1983, and also complained of dryness in her vagina. Serum estrogens were low, and serum gonadotropins were elevated. Physical exam was within normal limits except for a slight, diffuse enlargement of the thyroid gland. Antithyroglobulin and anti-microsomal antibodies were positive. She was clinically and bio-chemically euthyroid while taking exogenous L-thyroxine. A diagnosis of premature ovarian failure was, therefore, made. Therapy was initiated with Premarin and Provera, and she began to have regular withdrawal bleeding. In February 1991, she presented to her obstetrician stating that she was pregnant. The course of the pregnancy was uncomplicated. A cesarean section was performed at 40.5 weeks gestation and she delivered a live female infant. This case confirms that, although rare, patients with premature ovarian failure may spontaneously ovulate and conceive. The course of pregnancy in patients with ovarian failure appears to be normal.

Adult↗
PubMed1990

Diffuse pulmonary tumor microemboli from prostatic carcinoma with an associated fibrous histiocytic sarcoma.

Diffuse tumor microemboli to the lungs from prostatic carcinoma are extremely rare, with only six reported cases in the literature published in English. Here a seventh case is reported. The patient resembled the previously reported cases in the following ways: (1) There were minimal chest x-ray findings; (2) there was no other evidence of significant parenchymal or lymphangitic tumor involvement; and (3) pulmonary hypertension developed, but without signs of cor pulmonale. The case was even more unusual because of the presence of an apparent second neoplasm, ie, a malignant fibrous histiocytic sarcoma primary in the chest wall. There were wide-spread "collisional metastases" (metastases from each malignancy at the same site).

Adenocarcinoma↗
PubMedDate not supplied

Hyperparathyroidism and pregnancy: case report and review.

In pregnant women with symptomatic hyperparathyroidism, parathyroidectomy should be undertaken during the second trimester. We feel that the woman who is initially diagnosed well into the third trimester should be treated medically unless the hypercalcemia worsens or other complications occur. Since the treatment of asymptomatic hyperparathyroidism itself is controversial, it is even more difficult to define the treatment plan for an asymptomatic pregnant patient who has primary hyperparathyroidism. However, a recent consensus panel recommended that young patients with asymptomatic hyperparathyroidism be treated surgically. Accordingly, we believe that the asymptomatic pregnant patient should also be treated surgically, preferably in the second trimester. Whether a patient is treated medically or surgically in these situations, the pregnancy should be considered high-risk. The neonate should be monitored carefully for signs of hypocalcemia or impending tetany. If the mother is treated medically to term (or if spontaneous or elective abortion occurs), the mother should be monitored for hyperparathyroid crisis postpartum. Sudden worsening of hypercalcemia can result from the loss of the placenta (active placental calcium transport may be somewhat protective) and dehydration. Finally, every effort should be made to make the definitive diagnosis early in pregnancy in order to initiate optimal management. The diagnosis should be suspected during pregnancy if the following conditions exist: appropriate clinical signs or symptoms (especially nephrolithiasis or pancreatitis), hyperemesis beyond the first trimester, history of recurrent spontaneous abortions/stillbirths or neonatal deaths, neonatal hypocalcemia or tetany, or a total serum calcium concentration greater than 10.1 mg/dL (2.52 mmol/L) or 8.8 mg/dL (2.2 mmol/L) during the second or third trimester, respectively.

Abortion, Spontaneous↗