Osteopenia in women with hypothalamic amenorrhea: a prospective study

Hypothalamic amenorrhea, a common disorder associated with abnormalities in gonadotropin pulsatility and subsequent estrogen deficiency, is usually transient, and treatment indications are unclear unless fertility is desired. To determine whether this disorder is associated with progressive bone loss, we studied 24 women with primary or secondary amenorrhea related to stress or simple weight loss, compared with 31 normal women of the same age. Amenorrheic women had significantly lower (P = .01) body fat (26.4 +/- 7.3 versus 30.6 +/- 4.7%) and higher (P = .0001) urine free cortisol levels (250 +/- 100 versus 140 +/- 50 nmol/day) than normals. Trabecular bone density in women with hypothalamic amenorrhea as assessed by spinal computed tomography was significantly (P = .001) lower than in normals (140.2 +/- 27.3 versus 175.1 +/- 24.6 mg K2HPO4/mL, respectively). Twenty of the 24 amenorrheic women had initial spinal bone density below the mean in normals, and in eight it was 2 standard deviations or more below the normal mean. Initial bone density correlated negatively with duration of amenorrhea (r = -0.489, P = .02) and positively with serum free testosterone levels (r = 0.517, P = .02). Prospective evaluation showed a decline in spinal bone density in those who were amenorrheic for fewer than 5 years. The slope of change in bone density correlated with initial weight, percent ideal body weight, and percent body fat (R2 = 0.597, P = .0003; R2 = 0.549, P = .0007; and R2 = 0.618, P = .0002, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)     

Geometry of the vascular pedicle in free tissue transfers to the head and neck

Traditionally, the most important parameters for success in free tissue transfer have been expertise in performing small vessel anastomoses, meticulous donor site dissection, and careful recipient vessel preparation. It has been our experience, in free flap transfers for head and neck reconstruction, that a very crucial, often unrecognized, parameter is the geometry of the vascular pedicle. This term encompasses the three-dimensional positioning of the nutrient vascular pedicle as well as vessel tension and redundancy. The ideal axis for the lie of the vascular pedicle in the neck is in the longitudinal direction. This configuration helps to eliminate the kinking of the pedicle that is observed with side-to-side movements of the head. The primary objectives in recipient vessel selection are to use a healthy artery and vein and to perform the anastomoses in a location that provides easy access for the surgeon and assistant. Recipient vessel selection is also a major determining factor in the achievement of the desired pedicle geometry. We believe that the transverse cervical artery and the external jugular vein are the best recipient vessels for free tissue transfer. The reasons for this selection, as well as technical details to improve pedicle geometry, are discussed in depth. Representative cases that demonstrate pitfalls in vascular pedicle geometry are presented.     

The internal oblique-iliac crest osseomyocutaneous free flap in oromandibular reconstruction. Report of 20 cases

Microvascular free tissue transfer techniques using composite flaps are the most reliable method for the combined bone and soft-tissue reconstitution of oromandibular defects. Functional oromandibular reconstruction requires that maximum tongue mobility be achieved along with dental prosthetic rehabilitation. The internal oblique-iliac crest osseomyocutaneous microvascular free flap was used in 20 patients for oromandibular reconstruction. The internal oblique muscle, based on the ascending branches of the deep circumflex iliac artery and vein, was used to resurface mucosal defects of the oral cavity and pharynx. The iliac bone, because of its length, width, and natural contour, is the best source of vascularized bone for mandibular reconstruction. The improved soft-tissue component of this composite flap markedly improved the functional results. Reconstruction failed in one patient. Eleven patients underwent dental rehabilitation with either a tissue-borne or osseointegrated implant-borne denture. Follow-up of longer than one year showed minimal donor site morbidity.     

The superior trapezius myocutaneous flap in head and neck reconstruction.

The superior trapezius myocutaneous flap, based on the paraspinous perforating branches of the intercostal vessels, is generally not a first-line choice for reconstruction of head and neck defects. However, after wound breakdown following radical neck dissection and radiation therapy, the superior trapezius flap is extremely reliable for coverage of exposed major neck vessels. The flap was used in 30 patients undergoing lateral neck reconstruction. All 30 patients had undergone prior neck dissection and all but two had undergone prior radiation therapy. There were no flap failures. The superior trapezius flap is unique among other regional myocutaneous flaps presently in use in that it has a superiorly based pedicle, which reduces the problem of gravitational pull on the suture lines of severely unfavorable recipient beds. Another advantage of using the denervated muscle of this flap is that it imposes no additional functional loss. The deficiencies of this flap are primarily related to its limited arc of rotation, thereby precluding its use when resurfacing defects that extend beyond the midline of the neck. The reliability of the superior trapezius flap after neck dissection can be explained by the angiosome concept. Based on that concept, previous ligation of the transverse cervical vessels during a neck dissection serves to simultaneously stage this flap, thereby improving its reliability and potential surface area available.     

Response to oral β-carotene supplementation in patients with cystic fibrosis: a 16-month follow-up study

The aim of this study was to determine the efficacy of long-term oral β -carotene supplementation for correcting impaired β -carotene status in cystic fibrosis patients. Thirty-five patients (2.3-30.5 years of age) with coefficients of fat absorption of 46-96% (median 88%) received β -carotene 0.5 mg/kg daily and were followed over a 16-month treatment period. Baseline plasma β -carotene concentrations in patients (meanSD, 0.090.06 μ mol/1) were significantly lower than those of age-matched controls (0.860.56 μ mol/1) ( p < 0.0001). Concentrations increased rapidly and reached a plateau at or before 3 weeks that was maintained throughout the study period. Values obtained at 3 weeks (0.890.64 μ mol/1) were significantly higher ( p < 0.0001) than those at baseline and did not differ from controls. Plasma retinol and α -tocopherol concentrations increased during the observation period, but remained within normal ranges. Plasma retinyl palmitate, which was below the detection limit in all but one patient at baseline, did not increase. Thus oral β -carotene supplementation is effective and normalizes β -carotene status of cystic fibrosis patients without evidence of significant side effects. β -Carotene, cystic fibrosis, LDL-cholesterol, oral supplementation, retinol, α-tocopherol     

Antiplatelet prescribing patterns for TIA and ischemic stroke: the Indiana University experience

This study assessed the effect of muscle unloading on the neuromuscular system. Sixteen male Fischer 344 rats were randomly assigned to either a hindlimb suspension (unloaded) or control group (N=8/group) for 16 days. Following this intervention period, pre- and postsynaptic features of the neuromuscular junctions (NMJs) of soleus muscles were stained with cytofluorescent techniques, and myofibers were histochemically stained for ATPase activity. The data indicate that 16 days of muscle unloading resulted in significant (P<0.05) atrophy among myofibers (>50%) that was evident among all three major fiber types (I, IIA and IIX), but failed to significantly alter any aspect of NMJ morphology quantified. These results demonstrate an impressive degree of NMJ resilience despite dramatic remodeling of associated myofibers. This may be of benefit during post-unloading rehabilitative measures where effective neuromuscular communication is essential.     

Contrasting the neurologic complications of cardiac transplantation in adults and children

The objective of this study was to evaluate neurologic complications associated with cardiac transplantation and compare the neurologic complications seen in adults and children. As advances in immunology have led to longer survival times for cardiac transplant recipients (1- and 5-year survival rates have improved to 86% and 65%, respectively), a number of neurologic complications have emerged. We performed a 14-year retrospective review of all adults and children (<18 years old) who had orthotopic cardiac transplantation at either Indiana University Hospital or James Whitcomb Riley Hospital for Children. The rates of neurologic complications involving the central and peripheral nervous systems in adults and children were assessed for differences using the chi-square test and Fisher's exact test where appropriate. A total of 191 orthotopic cardiac transplants were performed from 1986 to 2000, with follow-up available for 184, including 107 adults and 77 children. Thirty-two of 107 (30%) adults experienced a total of 47 complications, with peripheral neuropathies being the most frequent complication. Eighteen of 77 (23%) children experienced a total of 22 complications, with seizures being the most frequent complication. Other complications occurring in both groups were cerebrovascular, infectious, encephalopathies, neoplasms, and "other." Neurologic complications in children and adults after orthotopic cardiac transplantation are similar in both incidence and type. However, peripheral neuropathies tend to occur more frequently in adults than in children (P = .04), and the types of complications in the immediate post-transplant period seem to differ.     

Outcome of extracranial cervicocephalic arterial dissections: a follow-up study

Cervicocephalic arterial dissections (CCAD) are an increasingly recognized cause of ischemic stroke in young adults. Various treatments have been suggested but no controlled trial has ever been performed. Medical treatment has included anticoagulant or platelet antiaggregant therapy. Surgical correction has been proposed for selected patients who have failed medical therapy. Percutaneous balloon angioplasty and stenting have been increasingly used in some patients, although long-term results are unknown. The objective of the study was to review our recent experience with the management and outcome of extracranial CCAD. We identified 27 patients with extracranial CCAD who were evaluated, treated and/or followed by our Stroke Service from September 1995 to August 2001. Clinical presentation, diagnostic evaluation, management, and outcome were reviewed. There were 15 men (56%) and 12 women (44%) with mean ages of 38 and 43 years respectively. Diagnosis was made by cerebral angiography in 15 (56%) patients and by MRI/MRA only in 12 (44%) patients. Twenty-two patients had spontaneous and five had traumatic extracranial CCAD. Most common associated disorders were arterial hypertension (37%) and migraine (26%). One patient presented only with a painful post-ganglionic Horner syndrome, another patient with neck pain and post-ganglionic Horner syndrome, another patient solely with protracted unilateral headaches, three with transient ischemic attacks (TIA), and 21 with ischemic strokes. The internal carotid artery (ICA) was the most frequently involved vessel (63%), followed by the vertebral artery (30%, and multivessel involvement in two patients (7%). Eighteen patients received anticoagulant therapy and nine platelet anti-aggregants. Follow-up extended from 2 to 115 months, with a mean of 58 months. At the end of follow-up, 23 (85%) patients had either no disability or only minor sequelae (modified Rankin score: 0 to 1), and four (15%) patients had moderate limitations (modified Rankin score: 2 to 3). Two patients had a recurrent ischemic stroke, one unrelated to recurrent CCAD, and the other following percutaneous balloon angioplasty/stenting for treatment of a persistent vertebral artery pseudoaneurysm. Most CCAD involved the extracranial ICA. The clinical presentation is variable, most patients having an ischemic stroke or TIAs. The short- and long-term outcome are usually favorable with either anticoagulant or platelet antiaggregant therapy. A medical initial approach to the management of extracranial CCAD is recommended for most patients.     

Moyamoya: Indiana University Medical Center experience

BACKGROUND: Moyamoya usually presents with cerebral ischemia in children and intracranial hemorrhage in adults. Treatment remains controversial. DESIGN AND OBJECTIVE: We reviewed our experience from June 1995 to August 1999 of 20 adult and pediatric angiographically diagnosed patients with moyamoya to report their clinical presentation, radiological findings, management, and clinical outcomes. RESULTS: The mean age of patients at symptom onset was 17 years (range, 2-54 years). Patients were divided into 2 age groups (group 1, <18 years; group 2, > or =18 years). There were 13 patients in group 1 and 7 patients in group 2. Ischemic strokes or transient ischemic attacks were the predominant initial presentations in both groups. One patient in group 2 had an intraparenchymal brain hemorrhage. Five patients received medical treatment, and 15 had surgical revascularization. The mean time from symptom onset to surgical procedure was significantly longer for patients in group 1 than for those in group 2 (P =.03). The mean follow-up time was 36 months. One patient in group 1 had an ischemic stroke. There was no difference in stroke recurrence, mortality, or modified Rankin scale score among medically or surgically treated patients. CONCLUSIONS: Moyamoya disease may have a different presentation and more benign natural history in our population than in Asian populations. Our findings emphasize the need to better understand the natural history of patients with moyamoya as well as the clinical benefit of different treatment modalities. Structured multicenter randomized clinical trials are needed to further assess the best treatment modalities for patients with moyamoya in the United States.     

Elevated Serum Alpha Fetoprotein and Normal Liquor Alpha Fetoprotein Values in Association with an Abdominal Pregnancy

Summary: A case report is described in which abdominal pregnancy was misdiagnosed by ultrasound scanning as a pregnancy within a horn of a bicornuate uterus. Two serum alpha fetoprotein (SAFP) results were greatly elevated and an amniocentesis was performed, the liquor alpha fetoprotein (LAFP) and karyotype were normal. Elective Caesarean section was performed at 38 weeks for a persistent transverse lie and an abdominal pregnancy was found. The outcome was excellent for both the mother and child.
This is the first reported case of amniocentesis and measurement of LAFP in an abdominal pregnancy and confirms abdominal pregnancy as a rare cause of an elevated SAFP.