Albert C. Hergenroeder

Bone mineral changes in young women with hypothalamic amenorrhea treated with oral contraceptives, medroxyprogesterone, or placebo over 12 months

OBJECTIVES The objectives of this study were to assess (1) whether treatment with oral contraceptives, in comparison with medroxyprogesterone and placebo, improved bone mineral in women with hypothalamic amenorrhea and (2) whether treatment with medroxyprogesterone, in comparison with placebo, improved bone mineral in women with hypothalamic oligomenorrhea. STUDY DESIGN The study was a randomized, controlled clinical trial. Twenty-four white women, aged 14 to 28 years, with hypothalamic amenorrhea or oligomenorrhea were prospectively enrolled for a 12-month intervention period. Amenorrheic subjects were randomized to receive oral contraceptives, medroxyprogesterone, or placebo. Oligomenorrheic subjects were randomized to receive medroxyprogesterone or placebo. Bone mineral was measured by dual-energy x-ray absorptiometry at baseline and at 6 and 12 months. RESULTS In amenorrheic subjects spine and total body bone mineral measurements at 12 months were greater in the oral contraceptive group than in the medroxyprogesterone and placebo groups when baseline bone mineral measurements, body weight, and age were controlled for (p < or = 0.05). There were no differences in hip bone mineral calcium and bone mineral density measurements at 12 months among the three groups. In oligomenorrheic subjects there was no detectable improvement in bone mineral associated with medroxyprogesterone use. CONCLUSIONS This study supports the hypothesis that oral contraceptive use in women with hypothalamic amenorrhea will improve lumbar spine and total body bone mineral.

Bone mineralization, hypothalamic amenorrhea, and sex steroid therapy in female adolescents and young adults☆☆☆★★★♢

1. The vast majority of bone mineralization in girls occurs by the middle of the second decade. 2. Premature bone demineralization occurs in women with hypothalamic dysfunction manifest as amenorrhea and oligomenorrhea, associated with athletics, dancing, and eating disorders. 3. In young women with amenorrhea associated with weight loss, BMD loss will be occurring soon after the amenorrhea develops. Treatment to prevent BMD loss or promote BMD accretion should begin soon, probably within 6 months after amenorrhea occurs. 4. Women who recover from anorexia nervosa at a young age (< 15 years of age) can have normal total body BMD, but regional (lumbar spine and femoral neck) BMD may remain low. The longer the anorexia nervosa persists, the less likely it is that the BMD will return to normal. Girls and women with anorexia nervosa need to be rehabilitated early in the disease to maximize BMD accretion. 5. Conjugated estrogen, in doses that improve bone mineralization in postmenopausal women and in combination with medroxyprogesterone, has not been shown to improve BMD in young women with hypothalamic amenorrhea. The role of orally administered medroxyprogesterone at a dose of 10 mg per day, 10 days per month, in improving BMD in teenage girls with hypothalamic amenorrhea or oligomenorrhea remains to be established. 6. Treatment with OCP may have a beneficial effect on BMD in young women with hypothalamic amenorrhea, but this has not been established in a double-masked, randomized, controlled trial. Doing a double-masked trial using OCP will be difficult because estrogen-deficient subjects treated with OCP will be likely to have menstrual bleeding, whereas those treated with placebo will not. In addition, the risk of pregnancy in a sexually active subject, who does not know whether she is receiving OCP, is too great for some subjects. 7. Osteoporosis is a major cause of morbidity and death. Peak bone mass is a major determinant of the risk of osteoporosis, and the second decade is the critical period of peak bone mass acquisition; thus providers of health care for adolescents need to understand the factors that affect bone mineralization during this period, and advise patients accordingly.

Prophylactic Ankle Bracing

Many choices are available to athletes seeking an ankle support. The time-honored tradition of ankle taping with adhesive tape does offer protection against ankle sprains during activity. Laced stabilizers offer an equal or possibly greater amount of support, are less costly and easier to apply, and can be retightened frequently during activity. The physician should become familiar with one of these two methods and choose one based on availability and feasibility in the community. The air stirrup may be indicated for patients with a history of ankle injury who are undergoing a graduated rehabilitation program. Nevertheless, the air stirrup has not been shown to provide significantly greater inversion restriction than taping or lace-on braces and is not recommended as a first-line method of support for individuals with no history of recent ankle sprain. High-top shoes are better when the ankle is taped, although low-top shoes are better when a laced stabilizer is worn. Elastic guards help reduce ankle edema but do not provide ankle stability.

Predictors of Outcome at 1 Year in Adolescents With DSM-5 Restrictive Eating Disorders: Report of the National Eating Disorders Quality Improvement Collaborative

PURPOSE The National Eating Disorders Quality Improvement Collaborative evaluated data of patients with restrictive eating disorders to analyze demographics of diagnostic categories and predictors of weight restoration at 1 year. METHODS Fourteen Adolescent Medicine eating disorder programs participated in a retrospective review of 700 adolescents aged 9-21 years with three visits, with DSM-5 categories of restrictive eating disorders including anorexia nervosa (AN), atypical AN, and avoidant/restrictive food intake disorder (ARFID). Data including demographics, weight and height at intake and follow-up, treatment before intake, and treatment during the year of follow-up were analyzed. RESULTS At intake, 53.6% met criteria for AN, 33.9% for atypical AN, and 12.4% for ARFID. Adolescents with ARFID were more likely to be male, younger, and had a longer duration of illness before presentation. All sites had a positive change in mean percentage median body mass index (%MBMI) for their population at 1-year follow-up. Controlling for age, gender, duration of illness, diagnosis, and prior higher level of care, only %MBMI at intake was a significant predictor of weight recovery. In the model, there was a 12.7% change in %MBMI (interquartile range, 6.5-19.3). Type of treatment was not predictive, and there were no significant differences between programs in terms of weight restoration. CONCLUSIONS The National Eating Disorders Quality Improvement Collaborative provides a description of the patient population presenting to a national cross-section of 14 Adolescent Medicine eating disorder programs and categorized by DSM-5. Treatment modalities need to be further evaluated to assess for more global aspects of recovery.

Serum concentrations of insulin, insulin-like growth factor-I and insulin-like growth factor binding proteins are different between white and African American girls.

OBJECTIVES To determine whether serum insulin-like growth factor (IGF)-I and IGF binding protein (IGFBP) concentrations are different between African American and white girls. STUDY DESIGN Serum glucose and hormone concentrations were measured in blood samples collected after a 12-hour fast from 79 white and 57 African American healthy girls between 9 and 17 years of age. Tanner stages of pubic hair development were evaluated by physical examination, and body composition by dual energy x-ray absorptiometry. RESULTS The African American girls were older and sexually more mature and had higher fat mass, higher serum insulin and free IGF-I concentrations, higher serum free IGF-I to total IGF-I ratio, but lower serum IGFBP-1 concentrations than the white girls. After controlling for sexual maturation and fat mass, the serum concentrations of total IGF-I, bound IGF-I, and IGFBP-3 in the white girls became significantly higher than those in the African American girls. The higher concentrations of total IGF-I in the white girls were due to a proportional increase in the concentrations of bound IGF-I that coincided with a similar increase in serum IGFBP-3 concentrations. CONCLUSIONS Higher serum insulin concentrations in the African American girls are associated with lower serum IGFBP-1 concentrations and increased bioavailability of free IGF-I, which may contribute to their accelerated growth compared with their white counterparts.

Increasing physical activity and decreasing sedentary activity in adolescent girls – The Incorporating More Physical Activity and Calcium in Teens (IMPACT) study

BackgroundLack of regular physical activity and consequent sub-optimal bone mass acquisition in youth has been implicated as a primary cause of adult-onset osteoporosis. IMPACT was a behavioral theory-based 1 1/2 year randomized controlled field study aimed at increasing bone accretion in middle school girls. The objective of this study was to determine the intervention effects of the IMPACT program upon key physical and sedentary activity endpoints among schools that participated in the IMPACT study. Endpoints examined included weight bearing physical activity (WBPA); moderate to vigorous physical activity (MVPA); vigorous physical activity (VPA); MET (metabolic equivalent) – weighted WBPA and MVPA; sedentary activity; before/after-school physical activity; and weekend physical activity.MethodsPrimary data analysis using a pretest-posttest control group design was conducted utilizing mixed model analysis of covariance. Data gathered from the IMPACT cohort from 2000–2002 were analyzed to determine baseline versus follow-up differences in activity endpoints. Confounders investigated included ethnicity, body mass index, menarcheal status, participation in 7th grade PE/athletics, friend/familial support and neighborhood safety.ResultsFollow-up means were higher for participating intervention schools relative to control schools for all physical activity variables but were statistically significant only for the following variables: daily minutes of vigorous physical activity (mean difference between Intervention (I) and Control (C) = 6.00↑ minutes, 95% CI = 5.82–6.18, p = 0.05), daily after school activity minutes (mean difference between I and C = 8.95↑ minutes, 95% CI = 8.69–9.21, p = 0.04), and daily weekend activity minutes (mean difference between I and C = 19.00↑ minutes, 95% CI = 18.40–19.60, p = 0.05). The intervention significantly reduced duration of student daily TV/Video watching (mean difference between I and C = 12.11↓ minutes, 95% CI = 11.74–12.48, p = 0.05) and total daily sedentary activity minutes (mean difference between I and C = 16.99↓ minutes, 95% CI = 16.49–17.50, p = 0.04).ConclusionA well designed and implemented school based health and physical activity intervention can result in a positive influence upon increasing physical activity levels and decreasing sedentary activity. Future interventions should consider a more structured intervention component to obtain significant changes in WBPA.

Anterior Knee Pain in Adolescents

The purpose of this study was to determine historical and physical factors associated with anterior knee pain in a cross section of athletic and nonathletic adolescents. We studied 142 high-school students, each of whom answered a questionnaire addressing athletic involvement and a history of knee pain. All subjects underwent a complete knee examination, and measurements of quadriceps girth, Q angle, lower extremity flexibility, and limb length. Forty-five percent of the subjects had a diagnosis of anterior knee pain including patellofemoral pain, patellar tendinitis, or tibial tuberosity pain. Significant correlations were found between anterior knee pain and several historical variables: current pain, pain with exercise, pain with stair climbing, the theater sign, and pain with routine activity. Painful quadriceps “setting” was significantly related to the diagnosis of anterior knee pain. Multiple regression analysis showed that a history of current pain and painful quadriceps setting accounted for 34% of the variance of the diagnosis of anterior knee pain. No other measurement variable, including Q angle, was related to the current diagnosis. We conclude that traditional historical variables associated with anterior knee pain contributed to its diagnosis in a cross section of adolescents. Anterior knee pain could not be predicted from structural measurements of lower extremities.

Body Composition in Adolescent Athletes

This article has set out to provide basic knowledge about body composition in athletic and nonathletic adolescents and young adults and to provide the practicing physician with methods of making body composition assessment. We suggest the physician approach the adolescent athlete who requests information about body composition in the following way: 1. Calculate the ideal body weight. 2. Estimate the percentage of body fat, realizing the errors associated with each method. If a body composition laboratory is available, use that equipment. In the absence of this equipment, we recommend the equations of Slaughter et al, given earlier. 3. The athlete should be given a range of percentage of body fat values measured in other athletes of the same gender and sport. Health and performance should be monitored as the athlete attempts to achieve or maintain body composition in this range. 4. If the athlete has an interest in altering body composition, then recommend the athlete seek the advice of a professional who has expertise in nutrition and physiology.

Waist circumference predicts increased cardiometabolic risk in normal weight adolescent males

OBJECTIVE The aims of the study were to establish waist circumference (WC) cut-off points that identify clustering of obesity-related conditions and determine if the cut-off points identified an increased risk of disease when used within BMI categories. METHODS This is a secondary analysis of the Centers for Disease Control NHANES III complex, multistage probability weighted data set collected between 1988 and 1994 from multiple locations in the United States. There were 2003 adolescents ages 12-19 years. Main outcome measures were low (<2 risk factors) or high (≥2 risk factors) risk for cardiometabolic disease based on the number of abnormal serum measurements for fasting glucose, high-density lipoprotein (HDL), triglycerides, and blood pressure. Receiver-operating characteristic curve analysis created the WC cut-off points and logistic regression determined if cut-off points predicted of within BMI categories. RESULTS Analysis identified cut-off points of ≥80.5 cm for males and ≥81 cm for females. Cut-off points predicted abnormal values for all outcome variables except fasting serum glucose in females, p < 0.05. Males with a normal BMI and elevated waist circumference were more likely to be high risk (OR = 5.23, CI = 1.79, 15.24, p < 0.013) and have increased odds of abnormal serum triglycerides, HDL and blood pressure. Overweight females (BMI ≥ 85-94%) with elevated waist circumference were more likely to have elevated blood pressure (OR = 9.05, 95% CI: 1.44, 56.83). CONCLUSION WC within BMI categories may identify those who have cardiometabolic disease risk factors despite having normal or overweight BMI.

MANAGEMENT OF ANKLE SPRAINS

This article reviewed the basics of ankle diagnosis and rehabilitation. It is hoped that after reading this, pediatricians will have more confidence in caring for these injuries.