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Biomedical subjects

R H Caplan

Publications and source records attributed to R H Caplan.

At least 19 recordsLinked to original sources
PubMed2000

Efficient evaluation of thyroid nodules by primary care providers and thyroid specialists.

OBJECTIVE: To determine whether primary care providers and thyroid specialists at Gundersen Lutheran Medical Center are evaluating thyroid nodules efficiently by following recently published clinical guidelines. STUDY DESIGN: One-year retrospective chart review. PATIENTS AND METHODS: We reviewed patient records from 1996 and tabulated the use of fine-needle aspiration cytology, radionuclide scanning, and thyroid ultrasonography by 49 primary care physicians evaluating 81 thyroid nodules and by 5 thyroid specialists evaluating 29 thyroid nodules. The results were compared with our previous findings and those recently reported by others. RESULTS: Fine-needle aspiration cytology was widely used by both groups of Gundersen Lutheran healthcare providers. Primary care physicians used imaging studies modestly and generated $106 per patient in unnecessary costs. Thyroid specialists occasionally used radionuclide scanning but did not use thyroid ultrasonography; they generated $41 per patient in unnecessary costs. Overall, the introduction of fine-needle aspiration cytology at our institution has reduced the use of radionuclide scanning from 90% to 12% and the use of thyroid ultrasonography from 30% to 10%. We also found that the frequency of surgery in patients with thyroid nodules fell substantially, yet detection of thyroid cancer in the operative specimens increased from 16% to 43% while the cost of removing a thyroid carcinoma decreased from $64,000 to $25,000. CONCLUSIONS: Fine-needle aspiration cytology, adopted as the initial test for diagnosing thyroid nodules by most of our healthcare providers, has reduced the use of imaging studies far below the frequency reported by others and has substantially decreased the cost of thyroid nodule management.

Adolescent↗
PubMed1999

The rapid low-dose (1 microgram) cosyntropin test in the immediate postoperative period: results in elderly subjects after major abdominal surgery.

BACKGROUND: Recently the rapid low-dose (1 microgram) cosyntropin test has been found to be superior to the standard (250 micrograms) rapid cosyntropin test for evaluating the hypothalamic-pituitary-adrenal axis. Because the 1-microgram test has not been studied in postoperative patients, we evaluated the test after major abdominal surgery. METHODS: We performed rapid 1-microgram cosyntropin tests in 20 patients aged 65 years or older immediately and 24 hours after uncomplicated elective abdominal surgery (group A) and in 10 patients who were suspected of having adrenal insufficiency after abdominal surgery (group B). Subsequently, 250 micrograms of cosyntropin was infused over 8 hours on 2 successive days in group B patients. RESULTS: Ninety-five percent of group A patients had normal rapid 1-microgram cosyntropin test results immediately after surgery and 90% had normal test results 24 hours postoperatively. Six group B patients had abnormal rapid 1-microgram cosyntropin test results. Additional testing indicated primary adrenal insufficiency in 2 patients and central adrenal insufficiency in 1 patient; another patient probably had primary adrenal insufficiency and 2 patients appeared to be euadrenal. Four group B patients had normal rapid 1-microgram cosyntropin test results. After additional testing, 3 of these patients appeared to have normal adrenal function; 1 probably had primary adrenal insufficiency. CONCLUSION: The rapid 1-microgram cosyntropin test accurately evaluated adrenal gland function in selected patients after uncomplicated surgery. The test, however, was difficult to interpret in unselected seriously ill postoperative patients. Therefore we recommend that postoperative patients with unexplained hypotension or other features suggestive of adrenal insufficiency who have random plasma cortisol levels less than 20 micrograms/dL be treated with glucocorticoids and the hypothalamic-pituitary-adrenal axis be studied by standard tests after recovery.

Abdominal Neoplasms↗
PubMed1998

Treatment of established postmenopausal osteoporosis with raloxifene: a randomized trial.

Raloxifene is a selective estrogen receptor modulator that in experimental animals acts as an estrogen receptor antagonist in breast and endometrium but as an estrogen receptor agonist in the skeletal and cardiovascular systems. We conducted a 1-year prospective, randomized, double-blind trial in 143 postmenopausal osteoporotic women (mean +/- SD age, 68.4+/-5.0 years) with at least one prevalent vertebral fractures and low bone mineral density (BMD), comparing groups receiving raloxifene at 60 mg/day (RLX60) or 120 mg/day (RLX120) and a control group receiving supplements of 750 mg/day of calcium and 400 IU/day of vitamin D. There were no differences among groups in the occurrence of uterine bleeding, thrombophlebitis, breast abnormalities, or increased endometrial thickness (assessed by ultrasonography). As compared with controls, the changes in values over 1 year for RLX60 and RLX120, respectively, were significant for serum bone alkaline phosphatase (-14.9%, -8.87%), serum osteocalcin (-20.7%, -17.0%), and urinary C-telopeptide fragment of type I collagen/creatinine (-24.9%, -30.8%), markers of bone turnover; for serum total cholesterol (-7.0% for RLX60) and low density lipoprotein cholesterol (LDL) (-11.4% for RLX60) and for the LDL/HDL cholesterol ratio (-13.2%, -8.3%). BMD increased significantly in the total hip (1.66% for RLX60) and ultradistal radius (2.92%, 2.50%). There were nonsignificant trends toward increases over controls in BMD for lumbar spine, total body, and total hip (for RLX120). Using a >15% cutoff definition, raloxifene had no effect on incident fractures, but using a >30% cutoff, there was a dose-related reduction (p = 0.047). We conclude that raloxifene therapy is well tolerated, reduces serum lipids, and does not stimulate the uterus or breasts. It has beneficial effects on bone, although, under the conditions of this study, these appear to be of a smaller magnitude than have been reported with estrogen therapy.

Aged↗
PubMed1997

Management of thyroid cancer of follicular cell origin: Gundersen/Lutheran Medical Center, 1969-1995.

BACKGROUND: Most reports regarding the treatment of thyroid cancer originate from university referral centers. In this article, we report our experience in managing thyroid cancer of follicular cell origin at a non-university institution over a 26-year period. STUDY DESIGN: We reviewed the medical records of all patients treated for thyroid cancer at the Gundersen/Lutheran Medical Center from 1969 to 1995. Histologic types, demographic and clinical characteristics, laboratory results, treatment, complications, and followup observations were tabulated. Risk was assigned according to the age, presence of distant metastasis, extent of the primary tumor, and site of the primary tumor (AMES) staging system. RESULTS: The histologic classification was as follows: papillary, 139; follicular, 24; Hürthle cell, 14; and anaplastic, 11. Low-risk lesions were identified in 96%, 79%, and 71% of the patients with papillary, follicular, and Hürthle cell (collectively designated differentiated) carcinoma, respectively. We treated 60% of our patients with differentiated thyroid cancer with near-total or total thyroidectomy. Clinically involved cervical lymph nodes were removed singly or by modified neck dissection. We frequently ablated thyroid remnants after operation with 29.9 mCi (1,110 MBq) of 131I, after which we treated the patient with suppressive doses of levothyroxine. Patients were evaluated yearly with thyroglobulin measurements and, in some high-risk patients, with total-body 131I scans. Cancer recurred in 13%, 8%, and 7% of our patients with papillary, follicular, and Hürthle cell carcinoma, respectively. Only three patients died of differentiated thyroid cancer; eight are alive with malignancy. In anaplastic thyroid cancer, cervical lymph node metastases, local invasion, and distant metastases were present in 18%, 64%, and 45% of patients at the time of initial evaluation. Total or near-total thyroidectomy was possible in only four of nine patients treated surgically. External radiation (11 patients) and chemotherapy (two patients) were used. Additional metastases developed in 45% of the patients, and nine patients died within a year. Permanent hypoparathyroidism or hoarseness complicated 2.7% of the thyroid operations. CONCLUSIONS: Although our followup was relatively short, the results of treating thyroid cancer by general surgeons at a nonuniversity hospital compare favorably with results obtained from university referral centers.

Adenocarcinoma↗
PubMed1996

A quality improvement project to increase the use of postmenopausal hormonal replacement therapy (HRT)

Many medical institutions are initiating quality improvement and disease prevention programs. In this paper, we report the results of a program designed to increase the rate of hormonal replacement therapy (HRT) in a postmenopausal population. After initially assessing the rate of HRT use, we instituted an educational program directed at both physicians and patients. Reassessment two years later indicated the rate of HRT had increased from 31% to 48.4%. Further educational efforts were followed by a reassessment three years later that showed a further improvement in prescription rate to 64%. We conclude that our educational program directed at physicians and patients dramatically increased the rate of HRT prescription of postmenopausal women.

Education, Medical, Continuing↗
PubMed1995

Serum parathyroid hormone-related protein levels during lactation.

We measured parathyroid hormone-related protein (PTHrP) in the serum of 15 healthy women within three days of beginning breast-feeding and within one hour of completing nursing. A sensitive immunoradiometric assay that measures N-terminal PTHrP containing at least the first 74 amino acids was used. We found normal PTHrP values in all patients. Values one day before and two days after delivery in a hypoparathyroid woman who chose not to breast-feed were also normal. Since N-terminal PTHrP fragments of 1-36 amino acids or more are biologically active, we believe additional studies using sensitive PTHrP assays that measure smaller fragments and investigations performed under other conditions of breast-feeding are necessary before concluding that PTHrP does not have a role in calcium homeostasis in nursing mothers. Furthermore, additional studies in hypoparathyroid nursing mothers should be performed.

Calcium↗
PubMed1995

A simplified method for treating Graves' disease with radioactive 131I.

We reviewed the medical records of 53 patients treated in 1986 for Graves' disease with moderate doses of 131I. The cumulative incidence of hypothyroidism at 3 and 12 months after therapy was 38 and 80%, respectively. The hyperthyroidism, however, was rapidly cured and only 4(7.5%) patients required a second dose of 131I. In a separate study of 21 patients with Graves' disease, we determined that the 4-hour 123I uptake measurement was as reliable as the standard 24-hour test for supporting the diagnosis of hyperthyroidism. We also demonstrated that the 4-hour uptake accurately predicted the 24-hour uptake. Based on these findings and a review of the literature, we believe that either a 4 or 24-hour 123I uptake study followed by the administration of a fixed dose of 131I (10 or 15 mCi) provides a convenient and cost-effective method for treating Graves' disease.

Adolescent↗
PubMed1994

Subclinical hormone secretion by incidentally discovered adrenal masses.

OBJECTIVE: To determine the frequency of subclinical hormone secretion in incidentally discovered adrenal masses. DESIGN: We reviewed the radiologic reports of 1779 consecutive computed tomographic scans of the chest, abdomen, and pelvis. SETTING: Regional referral medical center. PATIENTS: Eighty-nine patients with abnormalities of one or both adrenal glands were identified. Patients with nonadrenal gland malignant neoplasms, primary aldosteronism, adrenal hemorrhage, and death or severe illness were not investigated. The final study group consisted of 26 patients with incidentally discovered adrenal masses. MAIN OUTCOME MEASURES: Aldosterone secretion was assessed by measuring plasma renin activity and the plasma aldosterone concentration in patients with unexplained hypokalemia. We evaluated cortisol secretion by performing a 1-mg overnight dexamethasone suppression test and by measuring the corticotropin concentration at 8 AM by a sensitive method. In patients with low corticotropin values, we also measured the 24-hour urinary excretion of free cortisol and 17-ketosteroids and assessed diurnal variation by measuring plasma cortisol concentrations at 8 AM and 4 PM. Adrenal medullary function was studied by measuring urinary free catecholamines. RESULTS: One patient had unrecognized primary aldosteronism, two patients had elevated free catecholamine excretion, and three patients (12%) had subclinical Cushing's syndrome. CONCLUSION: Based on our observations and a review of the literature, we conclude that subclinical hormone secretion, especially cortisol secretion, is more common in patients with incidentally discovered adrenal masses than previously appreciated. Surgeons and anesthesiologists must be alert to the possibility that adrenal insufficiency or a hypertensive crisis may develop in the perioperative period in patients with incidentally discovered adrenal masses.

17-Ketosteroids↗
PubMed1994

Hürthle cell neoplasms of the thyroid gland: reassessment of functional capacity.

We treated a hyperthyroid man and a euthyroid woman who had autonomously functioning Hürthle cell adenomas and demonstrated uptake of radioactive 131I in a woman with recurrent Hürthle cell carcinoma. Since these tumors are thought to be inactive, we reassessed the functional capacity of Hürthle cell neoplasms by reviewing the medical records of all patients operated upon for these tumors at our medical center from 1950 through November, 1993. We also reviewed series of Hürthle cell neoplasms identified from a MEDLINE search of papers published from 1960 to November, 1993. We identified 92 patients with Hürthle cell neoplasms. Thyroid scintigraphy was performed in 28 of 72 patients with benign adenomas and six of 20 patients with Hürthle cell carcinomas. In addition to the two index cases, four euthyroid patients had hot nodules that partially suppressed the extranodular tissue; seven patients had warm nodules. Thyroid scans performed in patients with Hürthle cell carcinomas revealed five cold nodules and one warm nodule. Our index patient with carcinoma displayed elevated serum thyroglobulin levels when the cancer recurred. This patient and another had uptake of 131I by recurrent or metastatic cancer that allowed for treatment with this nuclide. Of 539 patients identified in a literature survey, 489 had benign Hürthle cell adenomas and 50 had Hürthle cell carcinoma. Thyroid scans performed in 282 patients revealed 247 cold nodules, 20 warm nodules, and 8 hot nodules. Our results, added to those published in case series of Hürthle cell neoplasms, indicated that 4.4% of thyroid scans were hot and 8.9% were warm.(ABSTRACT TRUNCATED AT 250 WORDS)

Adenocarcinoma↗
PubMed1994

Postoperative acute adrenal failure caused by transient corticotropin deficiency.

BACKGROUND: Acute adrenal insufficiency after a surgical procedure or trauma is rarely reported. In recent years, however, we have treated seven patients with acute primary adrenal insufficiency and three patients with secondary adrenal insufficiency who presented with shock after a surgical procedure or trauma. The standard cosyntropin test was misleading for the diagnosis of corticotropin deficiency. METHODS: In this study we measured serum cortisol in patients older than 65 years who had unexplained hypotension after an abdominal surgical procedure. If the serum cortisol was less than 15 micrograms/dl, we performed 1 microgram and standard (250 micrograms) cosyntropin tests and measured thyroxine, thyrotropin, leutinizing hormone in all patients, and free testosterone in men. RESULTS: We identified five (5%) of 105 patients after an operation who displayed evidence of corticotropin deficiency (i.e., serum cortisol < 15 micrograms/dl during hypotension, prompt hemodynamic improvement with glucocorticoid therapy, and normal response to standard dose cosyntropin). In these patients 1 microgram cosyntropin produced abnormal peak cortisol levels. These patients also had thyrotropin or leutinizing hormone deficiency. After recovery the low hormone levels improved or became normal. CONCLUSIONS: Postoperative adrenal insufficiency, particularly that caused by transient corticotropin deficiency, is more common in patients than currently recognized. The 1 microgram cosyntropin test may be more sensitive than the standard test for identifying secondary adrenal insufficiency.

Acute Disease↗
PubMed1993

Transient corticotropin deficiency in critical illness.

We describe three critically ill patients who displayed indirect evidence of transient corticotropin deficiency. All these patients were elderly, were poorly nourished, and had unexplained hypotension intraoperatively or immediately postoperatively. During the hypotensive episodes, they had inappropriately low plasma cortisol levels (10, 12, and 6 micrograms/dl) and responded dramatically to the administration of glucocorticoids. A normal response to infusion of synthetic corticotropin excluded primary adrenal insufficiency. Two patients tested had low thyroxine levels without increased thyrotropin concentrations and depressed levels of gonadotropins. In all three patients, the dose of glucocorticoids was successfully tapered and then discontinued. After recovery, serum thyroxine levels increased, gonadotropins reverted to normal concentrations, and the administration of metyrapone to two patients demonstrated normal hypothalamic-pituitary-adrenal function. Cortisol levels of less than 15 micrograms/dl in critically ill patients suggest the presence of adrenal insufficiency. The infusion of synthetic corticotropin may not exclude adrenal insufficiency attributable to corticotropin deficiency. If direct tests of corticotropin reserve are impractical, treatment with glucocorticoids is warranted.

Adrenocorticotropic Hormone↗
PubMed1993

Reduced calcitriol requirements for treating hypoparathyroidism during lactation. A case report.

We reduced the dose of calcitriol from 0.75 to 0.25 microgram/d to maintain low normal serum calcium levels in a hypoparathyroid woman during lactation. Calcitriol requirements quickly returned to 0.75 microgram/d when she discontinued breast-feeding. In her previous pregnancy, failure to reduce the dose of calcitriol resulted in serious hypercalcemia 11 days after she began breast-feeding. The changing requirement for calcitriol in our patient related directly to the falling level of estradiol. Although the cause or causes of diminished calcitriol requirements in hypoparathyroid women during lactation remains unclear, increased bone resorption promoted by low plasma estrogen levels may be an important mechanism. We conclude that the dose of calcitriol should be reduced during lactation and that both the hypoparathyroid mother and her infant should be carefully monitored to detect abnormal serum calcium levels.

Adult↗
PubMed1992

Treatment of postmenopausal osteoporosis with transdermal estrogen.

OBJECTIVE: To evaluate the tolerance and effectiveness of transdermal estrogen for women with established postmenopausal osteoporosis and vertebral fractures. DESIGN: Double-blind, randomized, placebo-controlled clinical trial lasting 1 year. SETTING: Referral-based outpatient clinic. PATIENTS: Seventy-five postmenopausal women, 47 to 75 years of age, with one or more vertebral fractures due to osteoporosis. INTERVENTIONS: Thirty-nine women received dermal patches delivering 0.1 mg of 17 beta-estradiol for days 1 to 21 and oral medroxyprogesterone acetate for days 11 to 21 of a 28-day cycle. Another 39 women received placebo. MEASUREMENTS: Bone turnover assessed by biochemical markers and iliac bone histomorphometry; bone loss assessed by serial measurement of bone density; and vertebral fracture rate. RESULTS: Compared with the placebo group, the median annual percentage change in bone mineral density in the estrogen group reflected increased or steady-state bone mineral density at the lumbar spine (5.3 compared with 0.2; P = 0.007), femoral trochanter (7.6 compared with 2.1; P = 0.03), and midradius (1.0 compared with -2.6, P less than 0.001) but showed no significant difference at the femoral neck (2.6 compared with 1.4; P = 0.17). Estrogen treatment uniformly decreased bone turnover as assessed by several methods including serum osteocalcin concentration (median change, -0.35 compared with 0.02 nmol/L; P less than 0.001). Histomorphometric evaluation of iliac biopsy samples confirmed the effect of estrogen on bone formation rate per bone volume (median change, -12.9 compared with -6.2% per year; P = 0.004). Also, 8 new fractures occurred in 7 women in the estrogen group, whereas 20 occurred in 12 women in the placebo group, yielding a lower vertebral fracture rate in the estrogen group (relative risk, 0.39; 95% CI, 0.16 to 0.95). CONCLUSIONS: Transdermal estradiol treatment is effective in postmenopausal women with established osteoporosis.

Administration, Cutaneous↗
PubMed1991

Fine-needle aspiration biopsy of thyroid nodules. A cost-effective diagnostic plan.

Fine-needle aspiration biopsy is a safe and accurate method for diagnosing thyroid nodules. Personnel who have experience with the aspiration technique and with the cytologic classification of specimens are crucial to accurate results. One important advantage of using fine-needle biopsy to initially screen patients with nodules is that it can save substantially on healthcare resources.

Biopsy, Needle↗
PubMed1991

Fine needle aspiration biopsy of thyroid nodules.

Between April 1982 and December 1988, we performed 611 fine needle aspiration (FNA) biopsies in 502 patients with solitary thyroid nodules. The biopsy results were classified as follows: unsatisfactory, 19%; benign, 53%; suspicious, 23%; and malignant, 5%. Malignant lesions were found at surgery in 24 of 25 patients with malignant cytology and 31 of 68 patients with suspicious cytology. Autonomous nodules, obviating the need for surgery, were detected in 5 of 36 (14%) patients with cytology suspicious for follicular neoplasm. We conclude that FNA biopsy of the thyroid nodule is a safe and accurate diagnostic test. Thyroid scintigraphy remains useful in patients with cytologic results suspicious for follicular neoplasm. A cost-effective strategy for managing thyroid nodules is presented.

Adenocarcinoma↗
PubMed1991

Incidentally discovered adrenal masses.

This report describes a retrospective study of 23 patients with incidentally discovered adrenal masses. Two patients with subclinical cortisol secretion developed adrenal insufficiency after removal of benign adenomas. Another patient, who probably harbors an asymptomatic pheochromocytoma, developed a hypertensive crisis when a mass was palpated during aortic vascular surgery. Twelve patients underwent surgery. Seven benign adenomas, an angiomyolipoma, and a cyst were removed. Three patients had malignant masses that include an angiosarcoma, an adrenal adenocarcinoma, and a congenital neuroblastoma. We conclude that hormones, especially cortisol, may be secreted in subclinical amounts by incidentally discovered masses. We recommend a concise laboratory evaluation that includes an overnight dexamethasone suppression test. Based on our interpretation of the literature, we believe masses greater than 3 cm in size should be removed. Patients who do not undergo surgery should have computed tomographic scans repeated for one year and should be reassessed periodically for the development of hormone secretion.

Adenoma↗