Heidi Splete

WASHINGTON – Parents whose autistic children turn their lives upside down might turn to a movement therapist for help.

Understanding children's nonverbal expressions can be a springboard for managing their tantrums and improving their socialization, Suzi Tortora, Ed.D., explained at a press conference on Parkinson's disease sponsored by the Laban/Bartenieff Institute of Movement Studies.

Dr. Tortora, who is a certified movement analyst and dance therapist with a private practice in New York City, works with a variety of children, including those with autism and pervasive development disorder, attention-deficit hyperactivity disorder, and unspecified developmental delays.

Dr. Tortora's intervention strategies are based on harnessing the child's own unique ways of coping and responding to the environment and using the child's nonverbal actions as communication tools. She observes and interacts with her child clients and their parents and uses principles of movement analysis to interpret a child's particular movement expressions and determine how the child is responding to his or her environment.

When working with autistic children, Dr. Tortora tries to help them transition from the experience of physical dysregulation to regulation.

“The key is that children with autistic spectrum disorder have a difficult time relating,” she said. “They are idiosyncratic in their movements. They are sensorially over- or understimulated, and they can quickly escalate to a place of total body dysregulation.”

Her therapy includes riding out a tantrum with the child by using movement and dance as a way to stay connected nonverbally. She mirrors the type and emotional quality of the child's movements to keep the child relating to her instead of disappearing into his or her own world.

The goal is to help the child learn to communicate and stay connected during a tantrum in order to regain control.

For more information about Dr. Tortora and the use of movement therapy in children, visit www.suzitortora.org

WASHINGTON – Parents whose autistic children turn their lives upside down might turn to a movement therapist for help.

Understanding children's nonverbal expressions can be a springboard for managing their tantrums and improving their socialization, Suzi Tortora, Ed.D., explained at a press conference on Parkinson's disease sponsored by the Laban/Bartenieff Institute of Movement Studies.

Dr. Tortora, who is a certified movement analyst and dance therapist with a private practice in New York City, works with a variety of children, including those with autism and pervasive development disorder, attention-deficit hyperactivity disorder, and unspecified developmental delays.

Dr. Tortora's intervention strategies are based on harnessing the child's own unique ways of coping and responding to the environment and using the child's nonverbal actions as communication tools. She observes and interacts with her child clients and their parents and uses principles of movement analysis to interpret a child's particular movement expressions and determine how the child is responding to his or her environment.

When working with autistic children, Dr. Tortora tries to help them transition from the experience of physical dysregulation to regulation.

“The key is that children with autistic spectrum disorder have a difficult time relating,” she said. “They are idiosyncratic in their movements. They are sensorially over- or understimulated, and they can quickly escalate to a place of total body dysregulation.”

Her therapy includes riding out a tantrum with the child by using movement and dance as a way to stay connected nonverbally. She mirrors the type and emotional quality of the child's movements to keep the child relating to her instead of disappearing into his or her own world.

The goal is to help the child learn to communicate and stay connected during a tantrum in order to regain control.

For more information about Dr. Tortora and the use of movement therapy in children, visit www.suzitortora.org

WASHINGTON – Parents whose autistic children turn their lives upside down might turn to a movement therapist for help.

Understanding children's nonverbal expressions can be a springboard for managing their tantrums and improving their socialization, Suzi Tortora, Ed.D., explained at a press conference on Parkinson's disease sponsored by the Laban/Bartenieff Institute of Movement Studies.

Dr. Tortora, who is a certified movement analyst and dance therapist with a private practice in New York City, works with a variety of children, including those with autism and pervasive development disorder, attention-deficit hyperactivity disorder, and unspecified developmental delays.

Dr. Tortora's intervention strategies are based on harnessing the child's own unique ways of coping and responding to the environment and using the child's nonverbal actions as communication tools. She observes and interacts with her child clients and their parents and uses principles of movement analysis to interpret a child's particular movement expressions and determine how the child is responding to his or her environment.

When working with autistic children, Dr. Tortora tries to help them transition from the experience of physical dysregulation to regulation.

“The key is that children with autistic spectrum disorder have a difficult time relating,” she said. “They are idiosyncratic in their movements. They are sensorially over- or understimulated, and they can quickly escalate to a place of total body dysregulation.”

Her therapy includes riding out a tantrum with the child by using movement and dance as a way to stay connected nonverbally. She mirrors the type and emotional quality of the child's movements to keep the child relating to her instead of disappearing into his or her own world.

The goal is to help the child learn to communicate and stay connected during a tantrum in order to regain control.

For more information about Dr. Tortora and the use of movement therapy in children, visit www.suzitortora.org

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance in the listener, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.”

The physician states that there is a discrepancy between the behavior and what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement reiterating that the problematic behavior, and the patient's reaction to it, is the patient's responsibility.

For example, you might say, “What you do about your drinking is up to you.”

▸ Advice. Doctors who avoid the use of the words “should” and “need,” when offering advice are less likely to generate resistance in patients.

“I encourage you to consider reducing your drinking” is better than telling the patient she should cut back; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. However, Dr. Weir said that he avoids saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors.

For example: “Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

Dr. Weir also explained what motivational interviewing is not. “It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance,” he said.

“[Lack of] knowledge is not as much of a deficit as ambivalence,” he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value as a doctor was negatively affected if a patient continued to engage in an unhealthy behavior.

When using the FRAMES technique, Dr. Weir said he prefers to sit on the small stool found in most exam rooms, with the patient sitting on the table, so the patient's position is higher than his. This arrangement makes him seem less of an expert and more of a collaborator in a patient's decision to change an unhealthy behavior.

If Not FRAMES, What About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., is another way to get the most from motivational interviewing:

▸ Open-ended questions. Motivational interviewing is the strategic use of open-ended questions, which can be the keys to a patient's decision to change a behavior. The goal is to encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Listen without interrupting and without judgment, and use body language to acknowledge the speaker. Body language includes nodding, facing the patient, and making eye contact.

▸ Summarizing. Recap to make sure the patient has made the point. For example, “Let me see if I understand what you've said so far. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Presented by Betsey LaForge of Blue Cross/Blue Shield of North Carolina at the annual meeting of the American College of Preventive Medicine.

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance in the listener, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.”

The physician states that there is a discrepancy between the behavior and what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement reiterating that the problematic behavior, and the patient's reaction to it, is the patient's responsibility.

For example, you might say, “What you do about your drinking is up to you.”

▸ Advice. Doctors who avoid the use of the words “should” and “need,” when offering advice are less likely to generate resistance in patients.

“I encourage you to consider reducing your drinking” is better than telling the patient she should cut back; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. However, Dr. Weir said that he avoids saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors.

For example: “Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

Dr. Weir also explained what motivational interviewing is not. “It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance,” he said.

“[Lack of] knowledge is not as much of a deficit as ambivalence,” he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value as a doctor was negatively affected if a patient continued to engage in an unhealthy behavior.

When using the FRAMES technique, Dr. Weir said he prefers to sit on the small stool found in most exam rooms, with the patient sitting on the table, so the patient's position is higher than his. This arrangement makes him seem less of an expert and more of a collaborator in a patient's decision to change an unhealthy behavior.

If Not FRAMES, What About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., is another way to get the most from motivational interviewing:

▸ Open-ended questions. Motivational interviewing is the strategic use of open-ended questions, which can be the keys to a patient's decision to change a behavior. The goal is to encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Listen without interrupting and without judgment, and use body language to acknowledge the speaker. Body language includes nodding, facing the patient, and making eye contact.

▸ Summarizing. Recap to make sure the patient has made the point. For example, “Let me see if I understand what you've said so far. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Presented by Betsey LaForge of Blue Cross/Blue Shield of North Carolina at the annual meeting of the American College of Preventive Medicine.

WASHINGTON — The key to motivational interviewing is raising a subject without generating resistance in the listener, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.”

The physician states that there is a discrepancy between the behavior and what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Make a statement reiterating that the problematic behavior, and the patient's reaction to it, is the patient's responsibility.

For example, you might say, “What you do about your drinking is up to you.”

▸ Advice. Doctors who avoid the use of the words “should” and “need,” when offering advice are less likely to generate resistance in patients.

“I encourage you to consider reducing your drinking” is better than telling the patient she should cut back; the doctor communicates respect for the patient by the way he or she phrases the advice.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. However, Dr. Weir said that he avoids saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients, but the doctor believes in their ability to change and will support their efforts when they are ready.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors.

For example: “Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

Dr. Weir also explained what motivational interviewing is not. “It is not arguing that a person has a problem and needs to change, it is not giving a solution without the patient's permission, and it is not taking an 'expert' stance,” he said.

“[Lack of] knowledge is not as much of a deficit as ambivalence,” he added. Patients usually have feelings about their behavior, and it can be important to let them hear themselves talk about these feelings and have the opportunity to reflect on them.

Dr. Weir recalled that as a younger physician, he sometimes felt that his own value as a doctor was negatively affected if a patient continued to engage in an unhealthy behavior.

When using the FRAMES technique, Dr. Weir said he prefers to sit on the small stool found in most exam rooms, with the patient sitting on the table, so the patient's position is higher than his. This arrangement makes him seem less of an expert and more of a collaborator in a patient's decision to change an unhealthy behavior.

If Not FRAMES, What About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., is another way to get the most from motivational interviewing:

▸ Open-ended questions. Motivational interviewing is the strategic use of open-ended questions, which can be the keys to a patient's decision to change a behavior. The goal is to encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Listen without interrupting and without judgment, and use body language to acknowledge the speaker. Body language includes nodding, facing the patient, and making eye contact.

▸ Summarizing. Recap to make sure the patient has made the point. For example, “Let me see if I understand what you've said so far. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Presented by Betsey LaForge of Blue Cross/Blue Shield of North Carolina at the annual meeting of the American College of Preventive Medicine.

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they will adhere to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presentation at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

“We assume that there is a relationship between actually taking the drug and having a positive outcome, but it has not been previously demonstrated for bisphosphonate therapy,” she said in her oral presentation.

In a retrospective study of 6,285 women, 48% of the participants were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women, compared with noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women, compared with nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women in the study were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% of them received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, the drugs' effectiveness depends on compliance over an extended period of time.

And compliance with bisphosphonate treatment is notoriously poor, doctors say. The currently approved daily dose must be taken while the patient is sitting or standing, immediately after waking in the morning. In addition, the patient must allow one hour before eating or drinking anything except water.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and could actually improve compliance.

The need to improve adherence is obvious, given that the U.S. population as a whole averages 1.5 million osteoporotic fractures each year, Dr. Siris noted in her poster.

Dr. Siris serves as a consultant for and has received honoraria from drug manufacturers Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they will adhere to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presentation at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

“We assume that there is a relationship between actually taking the drug and having a positive outcome, but it has not been previously demonstrated for bisphosphonate therapy,” she said in her oral presentation.

In a retrospective study of 6,285 women, 48% of the participants were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women, compared with noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women, compared with nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women in the study were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% of them received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, the drugs' effectiveness depends on compliance over an extended period of time.

And compliance with bisphosphonate treatment is notoriously poor, doctors say. The currently approved daily dose must be taken while the patient is sitting or standing, immediately after waking in the morning. In addition, the patient must allow one hour before eating or drinking anything except water.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and could actually improve compliance.

The need to improve adherence is obvious, given that the U.S. population as a whole averages 1.5 million osteoporotic fractures each year, Dr. Siris noted in her poster.

Dr. Siris serves as a consultant for and has received honoraria from drug manufacturers Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they will adhere to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presentation at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

“We assume that there is a relationship between actually taking the drug and having a positive outcome, but it has not been previously demonstrated for bisphosphonate therapy,” she said in her oral presentation.

In a retrospective study of 6,285 women, 48% of the participants were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women, compared with noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women, compared with nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women in the study were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% of them received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, the drugs' effectiveness depends on compliance over an extended period of time.

And compliance with bisphosphonate treatment is notoriously poor, doctors say. The currently approved daily dose must be taken while the patient is sitting or standing, immediately after waking in the morning. In addition, the patient must allow one hour before eating or drinking anything except water.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and could actually improve compliance.

The need to improve adherence is obvious, given that the U.S. population as a whole averages 1.5 million osteoporotic fractures each year, Dr. Siris noted in her poster.

Dr. Siris serves as a consultant for and has received honoraria from drug manufacturers Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter and Gamble Pharmaceuticals, and Novartis.

The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.” The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Reassert that problematic behavior and remind the patient of her responsibility in the matter—for example, “What you do about your drinking is up to you.”

▸ Advice. Avoid the use of the words “should” and “need,” when offering advice. “I encourage you to consider reducing your drinking” is better; this communicates your respect for the patient.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. But avoid saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

“Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

If Not FRAMES, How About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., can also help:

▸ Open-ended questions. Encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Don't interrupt and don't judge. Use body language to acknowledge the speaker.

▸ Summarizing. Recap to make sure the patient has made the point: “Let me see if I understand. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Betsey LaForge at the annual meeting of the American College of Preventive Medicine

The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.” The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Reassert that problematic behavior and remind the patient of her responsibility in the matter—for example, “What you do about your drinking is up to you.”

▸ Advice. Avoid the use of the words “should” and “need,” when offering advice. “I encourage you to consider reducing your drinking” is better; this communicates your respect for the patient.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. But avoid saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

“Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

If Not FRAMES, How About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., can also help:

▸ Open-ended questions. Encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Don't interrupt and don't judge. Use body language to acknowledge the speaker.

▸ Summarizing. Recap to make sure the patient has made the point: “Let me see if I understand. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Betsey LaForge at the annual meeting of the American College of Preventive Medicine

The key to motivational interviewing is raising a subject without generating resistance, Sam Weir, M.D., explained at the annual meeting of the American College of Preventive Medicine.

“People are more likely to change when there is a discrepancy between their current behavior and their goals,” said Dr. Weir of the department of family medicine at the University of North Carolina, Chapel Hill.

Once the physical exam and behavioral assessment is completed, summarize the results of the visit for the patient, and consider adding some motivational interviewing strategies, Dr. Weir suggested.

The FRAMES acronym is a quick and easy way to summarize and address preventive medicine issues, Dr. Weir said:

▸ Feedback. Feedback means being nonjudgmental, and saying with a straight face, “You know Mrs. Jones, drinking a six-pack of beer every night is more than most of my patients drink, and it's more than is recommended for your health.” The doctor states a discrepancy in the behavior, compared with what is considered healthy, but makes no judgment. Ideally, the doctor would then ask the patient, “What do you think about that?” But when time is at a premium, move on to the next point.

▸ Responsibility. Reassert that problematic behavior and remind the patient of her responsibility in the matter—for example, “What you do about your drinking is up to you.”

▸ Advice. Avoid the use of the words “should” and “need,” when offering advice. “I encourage you to consider reducing your drinking” is better; this communicates your respect for the patient.

▸ Menu. Choices often provide motivation for behavior change. Remind patients that there are many ways to change their behavior, and offer to help them explore their options for doing so.

▸ Empathy. Tell patients that, “It might be hard for you to make this change,” because sometimes it is. But avoid saying that “it is hard” to change, because for some people it is not, once they make up their minds.

▸ Self-Efficacy. A statement such as, “But I'm confident that when you make up your mind to change, you will be able to do it,” reinforces the fact that behavior change starts with the patients.

“This FRAMES moniker is a way to give advice about a lot of things in a short period of time,” Dr. Weir noted, encouraging physicians to incorporate these principles in written materials, or in other communications with patients.

In his work with medical students, Dr. Weir teaches a 30-second version of FRAMES—a short statement to use with patients that touches all the FRAMES elements, not necessarily in the same order, that can be tweaked to specific behaviors. For example:

“Mrs. Jones, I strongly encourage you to consider quitting smoking. For most people, quitting is the single most important thing they can do to improve their health. The decision to quit is yours, and yours alone. There are many different ways that people can quit, and if you do decide that you want to quit, I'm confident that you can do it. If you decide at some point that you're interested, I'd be very willing to help you look at the options.”

Dr. Weir said that he encourages medical students to take the FRAMES approach and write their own 30-second versions that they feel comfortable using, as long as they include all the FRAMES elements. “It's like a rosary chain; you need to touch all the beads,” he said.

If Not FRAMES, How About OARS?

The acronym OARS, adapted from the work of William Miller, Ph.D., and Stephen Rollnick, Ph.D., can also help:

▸ Open-ended questions. Encourage the patient to talk about his or her reasons for change. For example, “What has been hardest for you about living with diabetes?”

▸ Affirmations. Recognize the patient's strengths and express your belief in the patient's ability to change.

▸ Reflective listening. Don't interrupt and don't judge. Use body language to acknowledge the speaker.

▸ Summarizing. Recap to make sure the patient has made the point: “Let me see if I understand. You want to stop smoking, but you are afraid that you'll gain weight.”

Source: Betsey LaForge at the annual meeting of the American College of Preventive Medicine

A new treatment in the works for Alzheimer's disease is designed to act at the cellular level to reverse plaque formation and prevent development of further disease.

Prana Biotechnology Ltd. has received approval from the Medicines and Healthcare Products Regulatory Agency in the United Kingdom to begin a phase II/phase III study of clioquinol, also known as PBT-1. The investigators maintain that clioquinol will target the formation of amyloid plaques in the brain and thereby slow the progression of Alzheimer's disease (AD).

Ideally, clioquinol will both break up existing plaques and stop new ones from forming by redistributing the buildup of excess metals that are thought to cause plaques. “We believe that this is potentially a disease-modifying agent,” Jonas Alsenas, D.V.M., Prana's chief executive officer told this newspaper in an interview.

Currently approved and available AD medications treat the symptoms; Prana is going after the source. Vaccines to prevent AD have fallen short because they target amyloid beta indiscriminately, whereas clioquinol goes after the toxic, aggregated form of the protein, Dr. Alsenas noted.

Known as the Progression Limitation in Alzheimer's: Clioquinol's Efficacy (PLACQUE) trial, the 1-year, randomized, double-blind, placebo-controlled study will include 435 adults with moderate AD, defined as baseline scores between 12 and 20 on the Mini-Mental State Examination (MMSE). Patients will take one pill in the morning and a second in the evening. One-third of them will take two 125-mg pills daily, one-third will take two 250-mg pills daily, and a third group will take a placebo. The researchers are targeting patients at a moderate stage of illness because these patients normally decline most rapidly, allowing the investigators to show an effect within the limits of a 1-year study.

Researchers will enroll both patients who have taken no other AD medications and those who have taken memantine or similar medications for at least 4 months prior to the study.

In a pilot study of 36 patients, clioquinol effectively slowed cognitive loss in patients who scored greater than 25 on the AD assessment scale cognitive instrument. It was also significantly associated with an increased concentration of zinc in the patients' plasma (Arch. Neurol. 2003;60:1685–91).

The drug was generally well tolerated by the patients. Both folate and vitamin B₁₂ were administered to all patients to counteract an observed association between oral clioquinol and myelo-opticoneuropathy that led to the drug's withdrawal from sale in 1970. A vitamin B₁₂ deficiency was posited to be the cause of the neuropathy and levels of the vitamin were monitored throughout the trial, the researchers noted.

Many AD patients have slightly lower levels of zinc than would normally be expected. Craig Ritchie, M.B., of the department of psychiatry, University College London, explained that when clioquinol breaks up plaques, it has the added effect of returning zinc levels to normal. “One explanation is that some of the body's zinc is being sequestered into plaques in AD,” said Dr. Ritchie, lead investigator on both the pilot study and the upcoming clinical trial.

However, the role of metals in maintaining the body's homeostatic functions is not fully understood, and a buildup of zinc has not been associated with dietary or environmental factors. “We are not saying that people should cut copper and zinc out of their diets,” Dr. Ritchie emphasized.

The study will be done at sites in the United Kingdom, Australia, and South Africa. The company's goal is to have results from the study by the end of 2006, Dr. Alsenas said.

A new treatment in the works for Alzheimer's disease is designed to act at the cellular level to reverse plaque formation and prevent development of further disease.

Prana Biotechnology Ltd. has received approval from the Medicines and Healthcare Products Regulatory Agency in the United Kingdom to begin a phase II/phase III study of clioquinol, also known as PBT-1. The investigators maintain that clioquinol will target the formation of amyloid plaques in the brain and thereby slow the progression of Alzheimer's disease (AD).

Ideally, clioquinol will both break up existing plaques and stop new ones from forming by redistributing the buildup of excess metals that are thought to cause plaques. “We believe that this is potentially a disease-modifying agent,” Jonas Alsenas, D.V.M., Prana's chief executive officer told this newspaper in an interview.

Currently approved and available AD medications treat the symptoms; Prana is going after the source. Vaccines to prevent AD have fallen short because they target amyloid beta indiscriminately, whereas clioquinol goes after the toxic, aggregated form of the protein, Dr. Alsenas noted.

Known as the Progression Limitation in Alzheimer's: Clioquinol's Efficacy (PLACQUE) trial, the 1-year, randomized, double-blind, placebo-controlled study will include 435 adults with moderate AD, defined as baseline scores between 12 and 20 on the Mini-Mental State Examination (MMSE). Patients will take one pill in the morning and a second in the evening. One-third of them will take two 125-mg pills daily, one-third will take two 250-mg pills daily, and a third group will take a placebo. The researchers are targeting patients at a moderate stage of illness because these patients normally decline most rapidly, allowing the investigators to show an effect within the limits of a 1-year study.

Researchers will enroll both patients who have taken no other AD medications and those who have taken memantine or similar medications for at least 4 months prior to the study.

In a pilot study of 36 patients, clioquinol effectively slowed cognitive loss in patients who scored greater than 25 on the AD assessment scale cognitive instrument. It was also significantly associated with an increased concentration of zinc in the patients' plasma (Arch. Neurol. 2003;60:1685–91).

The drug was generally well tolerated by the patients. Both folate and vitamin B₁₂ were administered to all patients to counteract an observed association between oral clioquinol and myelo-opticoneuropathy that led to the drug's withdrawal from sale in 1970. A vitamin B₁₂ deficiency was posited to be the cause of the neuropathy and levels of the vitamin were monitored throughout the trial, the researchers noted.

Many AD patients have slightly lower levels of zinc than would normally be expected. Craig Ritchie, M.B., of the department of psychiatry, University College London, explained that when clioquinol breaks up plaques, it has the added effect of returning zinc levels to normal. “One explanation is that some of the body's zinc is being sequestered into plaques in AD,” said Dr. Ritchie, lead investigator on both the pilot study and the upcoming clinical trial.

However, the role of metals in maintaining the body's homeostatic functions is not fully understood, and a buildup of zinc has not been associated with dietary or environmental factors. “We are not saying that people should cut copper and zinc out of their diets,” Dr. Ritchie emphasized.

The study will be done at sites in the United Kingdom, Australia, and South Africa. The company's goal is to have results from the study by the end of 2006, Dr. Alsenas said.

A new treatment in the works for Alzheimer's disease is designed to act at the cellular level to reverse plaque formation and prevent development of further disease.

Prana Biotechnology Ltd. has received approval from the Medicines and Healthcare Products Regulatory Agency in the United Kingdom to begin a phase II/phase III study of clioquinol, also known as PBT-1. The investigators maintain that clioquinol will target the formation of amyloid plaques in the brain and thereby slow the progression of Alzheimer's disease (AD).

Ideally, clioquinol will both break up existing plaques and stop new ones from forming by redistributing the buildup of excess metals that are thought to cause plaques. “We believe that this is potentially a disease-modifying agent,” Jonas Alsenas, D.V.M., Prana's chief executive officer told this newspaper in an interview.

Currently approved and available AD medications treat the symptoms; Prana is going after the source. Vaccines to prevent AD have fallen short because they target amyloid beta indiscriminately, whereas clioquinol goes after the toxic, aggregated form of the protein, Dr. Alsenas noted.

Known as the Progression Limitation in Alzheimer's: Clioquinol's Efficacy (PLACQUE) trial, the 1-year, randomized, double-blind, placebo-controlled study will include 435 adults with moderate AD, defined as baseline scores between 12 and 20 on the Mini-Mental State Examination (MMSE). Patients will take one pill in the morning and a second in the evening. One-third of them will take two 125-mg pills daily, one-third will take two 250-mg pills daily, and a third group will take a placebo. The researchers are targeting patients at a moderate stage of illness because these patients normally decline most rapidly, allowing the investigators to show an effect within the limits of a 1-year study.

Researchers will enroll both patients who have taken no other AD medications and those who have taken memantine or similar medications for at least 4 months prior to the study.

In a pilot study of 36 patients, clioquinol effectively slowed cognitive loss in patients who scored greater than 25 on the AD assessment scale cognitive instrument. It was also significantly associated with an increased concentration of zinc in the patients' plasma (Arch. Neurol. 2003;60:1685–91).

The drug was generally well tolerated by the patients. Both folate and vitamin B₁₂ were administered to all patients to counteract an observed association between oral clioquinol and myelo-opticoneuropathy that led to the drug's withdrawal from sale in 1970. A vitamin B₁₂ deficiency was posited to be the cause of the neuropathy and levels of the vitamin were monitored throughout the trial, the researchers noted.

Many AD patients have slightly lower levels of zinc than would normally be expected. Craig Ritchie, M.B., of the department of psychiatry, University College London, explained that when clioquinol breaks up plaques, it has the added effect of returning zinc levels to normal. “One explanation is that some of the body's zinc is being sequestered into plaques in AD,” said Dr. Ritchie, lead investigator on both the pilot study and the upcoming clinical trial.

However, the role of metals in maintaining the body's homeostatic functions is not fully understood, and a buildup of zinc has not been associated with dietary or environmental factors. “We are not saying that people should cut copper and zinc out of their diets,” Dr. Ritchie emphasized.

The study will be done at sites in the United Kingdom, Australia, and South Africa. The company's goal is to have results from the study by the end of 2006, Dr. Alsenas said.

BETHESDA, MD. — Follow-up data for women who underwent uterine artery embolization for the treatment of fibroids show that 73% still reported improved symptoms 5 years later.

Of 182 women who completed 5-year follow-up, 25 had undergone hysterectomies, 6 had undergone myomectomies, and 3 had undergone repeat embolizations. None of the hysterectomies were performed due to complications of embolization, and at least four were due to a condition other than recurrent fibroids. The failure rate after 5 years was 20%.

“The women most likely to go on to subsequent intervention were those with single, very large fibroids,” James Spies, M.D., the study's lead investigator, said in an interview. On the other hand, the women with large numbers of smaller fibroids were less likely to fail.

The initial cohort included 200 women: 95% completed follow-up at 1 year, 80% at 2 years, 91% at 3 years, 89% at four years, and 91% at 5 years. Three patients died during the 5-year follow-up—two from unrelated cancer and one from heart disease.

Dr. Spies, professor of radiology at Georgetown University, Washington, and his associates presented data on the 5-year follow-up in a poster presentation at an international congress on uterine leiomyoma research sponsored by the National Institutes of Health.

Dr. Spies and his colleagues also presented a poster on 1-year follow-up data on 1,701 women of the 3,166 who initially registered with the Fibroid Registry for Outcomes Data (FIBROID).

The registry is a collaborative effort of the Society of Interventional Radiology Foundation, the Duke Clinical Research Institute, the Food and Drug Administration, and corporate supporters, including Biosphere, a company that produces the particles used in uterine artery embolization. Dr. Spies, a member of the medical advisory board for Biosphere, said the company had no input into the gathering of data or analysis of the registry.

Overall, the women demonstrated a significant improvement in symptoms. Compared with baseline scores, 90% showed an improvement of greater than 10% on symptom scores on the Health-Related Quality of Life scale at both 6 months and 1 year.

After 1 year, the mean HRQoL score was 86.5, and the mean symptom score on the Uterine Fibroid Symptom Quality of Life scale was 19.2; both represented significant improvements from baseline and were in the range of scores for normal subjects.

“There was a striking and marked improvement in both symptom and quality of life scores, there is stable improvement between 6 and 12 months, there were relatively few complications and hospitalizations, and in general most patients were satisfied with the outcome,” said Dr. Spies, a member of the Steering Committee of FIBROID.

Most women reported a dramatic improvement in sexual function, although some reported no significant change, and 6%–7% reported a decrease.

This angiogram shows fibroids as they appeared before uterine artery embolization was performed.

Normal branches (white arrows) and uterine arteries (black) are open after the procedure is completed. Photos courtesy Dr. James Spies

BETHESDA, MD. — Follow-up data for women who underwent uterine artery embolization for the treatment of fibroids show that 73% still reported improved symptoms 5 years later.

Of 182 women who completed 5-year follow-up, 25 had undergone hysterectomies, 6 had undergone myomectomies, and 3 had undergone repeat embolizations. None of the hysterectomies were performed due to complications of embolization, and at least four were due to a condition other than recurrent fibroids. The failure rate after 5 years was 20%.

“The women most likely to go on to subsequent intervention were those with single, very large fibroids,” James Spies, M.D., the study's lead investigator, said in an interview. On the other hand, the women with large numbers of smaller fibroids were less likely to fail.

The initial cohort included 200 women: 95% completed follow-up at 1 year, 80% at 2 years, 91% at 3 years, 89% at four years, and 91% at 5 years. Three patients died during the 5-year follow-up—two from unrelated cancer and one from heart disease.

Dr. Spies, professor of radiology at Georgetown University, Washington, and his associates presented data on the 5-year follow-up in a poster presentation at an international congress on uterine leiomyoma research sponsored by the National Institutes of Health.

Dr. Spies and his colleagues also presented a poster on 1-year follow-up data on 1,701 women of the 3,166 who initially registered with the Fibroid Registry for Outcomes Data (FIBROID).

The registry is a collaborative effort of the Society of Interventional Radiology Foundation, the Duke Clinical Research Institute, the Food and Drug Administration, and corporate supporters, including Biosphere, a company that produces the particles used in uterine artery embolization. Dr. Spies, a member of the medical advisory board for Biosphere, said the company had no input into the gathering of data or analysis of the registry.

Overall, the women demonstrated a significant improvement in symptoms. Compared with baseline scores, 90% showed an improvement of greater than 10% on symptom scores on the Health-Related Quality of Life scale at both 6 months and 1 year.

After 1 year, the mean HRQoL score was 86.5, and the mean symptom score on the Uterine Fibroid Symptom Quality of Life scale was 19.2; both represented significant improvements from baseline and were in the range of scores for normal subjects.

“There was a striking and marked improvement in both symptom and quality of life scores, there is stable improvement between 6 and 12 months, there were relatively few complications and hospitalizations, and in general most patients were satisfied with the outcome,” said Dr. Spies, a member of the Steering Committee of FIBROID.

Most women reported a dramatic improvement in sexual function, although some reported no significant change, and 6%–7% reported a decrease.

This angiogram shows fibroids as they appeared before uterine artery embolization was performed.

Normal branches (white arrows) and uterine arteries (black) are open after the procedure is completed. Photos courtesy Dr. James Spies

BETHESDA, MD. — Follow-up data for women who underwent uterine artery embolization for the treatment of fibroids show that 73% still reported improved symptoms 5 years later.

Of 182 women who completed 5-year follow-up, 25 had undergone hysterectomies, 6 had undergone myomectomies, and 3 had undergone repeat embolizations. None of the hysterectomies were performed due to complications of embolization, and at least four were due to a condition other than recurrent fibroids. The failure rate after 5 years was 20%.

“The women most likely to go on to subsequent intervention were those with single, very large fibroids,” James Spies, M.D., the study's lead investigator, said in an interview. On the other hand, the women with large numbers of smaller fibroids were less likely to fail.

The initial cohort included 200 women: 95% completed follow-up at 1 year, 80% at 2 years, 91% at 3 years, 89% at four years, and 91% at 5 years. Three patients died during the 5-year follow-up—two from unrelated cancer and one from heart disease.

Dr. Spies, professor of radiology at Georgetown University, Washington, and his associates presented data on the 5-year follow-up in a poster presentation at an international congress on uterine leiomyoma research sponsored by the National Institutes of Health.

Dr. Spies and his colleagues also presented a poster on 1-year follow-up data on 1,701 women of the 3,166 who initially registered with the Fibroid Registry for Outcomes Data (FIBROID).

The registry is a collaborative effort of the Society of Interventional Radiology Foundation, the Duke Clinical Research Institute, the Food and Drug Administration, and corporate supporters, including Biosphere, a company that produces the particles used in uterine artery embolization. Dr. Spies, a member of the medical advisory board for Biosphere, said the company had no input into the gathering of data or analysis of the registry.

Overall, the women demonstrated a significant improvement in symptoms. Compared with baseline scores, 90% showed an improvement of greater than 10% on symptom scores on the Health-Related Quality of Life scale at both 6 months and 1 year.

After 1 year, the mean HRQoL score was 86.5, and the mean symptom score on the Uterine Fibroid Symptom Quality of Life scale was 19.2; both represented significant improvements from baseline and were in the range of scores for normal subjects.

“There was a striking and marked improvement in both symptom and quality of life scores, there is stable improvement between 6 and 12 months, there were relatively few complications and hospitalizations, and in general most patients were satisfied with the outcome,” said Dr. Spies, a member of the Steering Committee of FIBROID.

Most women reported a dramatic improvement in sexual function, although some reported no significant change, and 6%–7% reported a decrease.

This angiogram shows fibroids as they appeared before uterine artery embolization was performed.

Normal branches (white arrows) and uterine arteries (black) are open after the procedure is completed. Photos courtesy Dr. James Spies

BETHESDA, MD. — Large fibroids appear to grow faster than smaller fibroids, but symptoms, rather than growth rate, spur women to surgery.

A preliminary analysis of data from 120 women in the Fibroid Growth Study suggests that large fibroids (greater than 50 cm

“Most women have fibroids, but there is a subset of women that are symptomatic,” Barbara J. Davis, Ph.D., said at an international conference on uterine leiomyoma research sponsored by the National Institutes of Health.

Data on the factors that cause fibroids to grow and become clinically symptomatic are limited. “Our hypothesis was that fibroids are heterogenous and that growing tumors will have different cellular and molecular characteristics than nongrowing tumors,” said Dr. Davis, formerly chief of the Laboratory of Women's Health at the National Institute of Environmental Health Sciences and now a principal scientist at AstraZeneca.

She and her associates sought to compare leiomyoma growth over time as a function of the number and location of the tumors. To describe relationships between growth, clinical symptoms, and outcome, the investigators studied women at high risk for hysterectomy or myectomy.

The study results also indicated that intramural fibroids appeared to grow more slowly than did submucosal fibroids, fibroid growth might depend on the accumulation of fibrous tissue, and race had no effect on growth rate.

The study, funded by the National Institute of Environmental Health Sciences and the National Center on Minority Health and Health Disparities, included clinically symptomatic, premenopausal women with large uteri—the size of 12 weeks' gestation—who had tumors of at least 2 cm in diameter, confirmed by ultrasound at baseline.

Approximately 48% of the women were black and 41% were white.

The women had MRIs at baseline, 3 months, 6 months, and 1 year. They also underwent physicals, completed extensive medical history forms, donated blood and urine, and participated in monthly questionnaires via a 20-minute phone interview.

Women who opted for surgery donated their fibroid tissues to the study investigators and had a presurgical MRI to map the tumors for the surgeon so they could be identified by type and location.

A total of 31 women had either a hysterectomy or myomectomy during the course of the study. The average age of the surgery patients was slightly younger than the overall average (37.8 years vs. 39 years).

Overall, 1,076 fibroid volumes were calculated, including data from 52 women who completed all four MRIs—16 women who had surgery and 36 who did. The investigators used a computer program that allowed them to overlay MRI images of the fibroids at different times and determine their growth rates.

In this pulminary analysis, growth rate, defined by change in volume, was mostly a function of location and other factors.

“We were surprised that there were not significant differences in the rate of growth between women of different race or ethnicity,” Dr. Davis said. The difference in the prevalence of fibroids between blacks and whites appears not to be caused by tumors growing faster in blacks.

“We did find that size was a factor in determining rates of growth,” she noted. The investigators were surprised that both large and medium fibroids grew at a faster rate than small ones. “We thought that small tumors would be the fast-growing ones, and we thought we might find some that shrank, but we didn't,” Dr. Davis said. In fact, all the fibroids studied grew to some extent.

Intramural fibroid growth was slower than that of subserosal fibroids. However, growth rates between intramural vs. submucosal and between submucosal vs. subserosal tumors were not significantly different. As for the impact of growth rates on clinical outcomes, there were no significant differences in growth rates between patients who had surgery and those who did not. “That was a surprise to us,” Dr. Davis said. “We wondered why the women were going to surgery.”

The answer is their symptoms. Symptom severity scores related to bleeding in surgery patients were almost double those of nonsurgery patients. Similarly, there was a significant difference in reported pain before and after surgery among surgery patients, compared with pain scores of nonsurgery patients.

Although the clinical symptomology differed between women who chose surgery and those who did not, the fibroid growth rates appeared similar in both groups. Dr. Davis noted that the investigators have yet to review the impact of number of tumors on outcome. The total number of fibroids per woman ranged from 1 to 11.

The most common reasons for choosing surgery were to reduce heavy bleeding (40%) and to attempt pregnancy (20%).

The investigators found a greater proportion of fibrous tissues, compared with smooth tissues, in the large tumors than in smaller tumors. The large tumors were the fastest growing, suggesting that connective tissue contributes to tumor growth rather than regression. The vascularity varied as well—the fibroids had fewer blood vessels compared with normal tissue, but the fibroid tissue bled more. Larger fibroids had a larger total area of vascularity, but the smaller fibroids had a larger cross-section of blood vessels.

Ultimately, these results and future analyses might help physicians develop a model that they can use to predict fibroid growth over time, Dr. Davis noted.

BETHESDA, MD. — Large fibroids appear to grow faster than smaller fibroids, but symptoms, rather than growth rate, spur women to surgery.

A preliminary analysis of data from 120 women in the Fibroid Growth Study suggests that large fibroids (greater than 50 cm

“Most women have fibroids, but there is a subset of women that are symptomatic,” Barbara J. Davis, Ph.D., said at an international conference on uterine leiomyoma research sponsored by the National Institutes of Health.

Data on the factors that cause fibroids to grow and become clinically symptomatic are limited. “Our hypothesis was that fibroids are heterogenous and that growing tumors will have different cellular and molecular characteristics than nongrowing tumors,” said Dr. Davis, formerly chief of the Laboratory of Women's Health at the National Institute of Environmental Health Sciences and now a principal scientist at AstraZeneca.

She and her associates sought to compare leiomyoma growth over time as a function of the number and location of the tumors. To describe relationships between growth, clinical symptoms, and outcome, the investigators studied women at high risk for hysterectomy or myectomy.

The study results also indicated that intramural fibroids appeared to grow more slowly than did submucosal fibroids, fibroid growth might depend on the accumulation of fibrous tissue, and race had no effect on growth rate.

The study, funded by the National Institute of Environmental Health Sciences and the National Center on Minority Health and Health Disparities, included clinically symptomatic, premenopausal women with large uteri—the size of 12 weeks' gestation—who had tumors of at least 2 cm in diameter, confirmed by ultrasound at baseline.

Approximately 48% of the women were black and 41% were white.

The women had MRIs at baseline, 3 months, 6 months, and 1 year. They also underwent physicals, completed extensive medical history forms, donated blood and urine, and participated in monthly questionnaires via a 20-minute phone interview.

Women who opted for surgery donated their fibroid tissues to the study investigators and had a presurgical MRI to map the tumors for the surgeon so they could be identified by type and location.

A total of 31 women had either a hysterectomy or myomectomy during the course of the study. The average age of the surgery patients was slightly younger than the overall average (37.8 years vs. 39 years).

Overall, 1,076 fibroid volumes were calculated, including data from 52 women who completed all four MRIs—16 women who had surgery and 36 who did. The investigators used a computer program that allowed them to overlay MRI images of the fibroids at different times and determine their growth rates.

In this pulminary analysis, growth rate, defined by change in volume, was mostly a function of location and other factors.

“We were surprised that there were not significant differences in the rate of growth between women of different race or ethnicity,” Dr. Davis said. The difference in the prevalence of fibroids between blacks and whites appears not to be caused by tumors growing faster in blacks.

“We did find that size was a factor in determining rates of growth,” she noted. The investigators were surprised that both large and medium fibroids grew at a faster rate than small ones. “We thought that small tumors would be the fast-growing ones, and we thought we might find some that shrank, but we didn't,” Dr. Davis said. In fact, all the fibroids studied grew to some extent.

Intramural fibroid growth was slower than that of subserosal fibroids. However, growth rates between intramural vs. submucosal and between submucosal vs. subserosal tumors were not significantly different. As for the impact of growth rates on clinical outcomes, there were no significant differences in growth rates between patients who had surgery and those who did not. “That was a surprise to us,” Dr. Davis said. “We wondered why the women were going to surgery.”

The answer is their symptoms. Symptom severity scores related to bleeding in surgery patients were almost double those of nonsurgery patients. Similarly, there was a significant difference in reported pain before and after surgery among surgery patients, compared with pain scores of nonsurgery patients.

Although the clinical symptomology differed between women who chose surgery and those who did not, the fibroid growth rates appeared similar in both groups. Dr. Davis noted that the investigators have yet to review the impact of number of tumors on outcome. The total number of fibroids per woman ranged from 1 to 11.

The most common reasons for choosing surgery were to reduce heavy bleeding (40%) and to attempt pregnancy (20%).

The investigators found a greater proportion of fibrous tissues, compared with smooth tissues, in the large tumors than in smaller tumors. The large tumors were the fastest growing, suggesting that connective tissue contributes to tumor growth rather than regression. The vascularity varied as well—the fibroids had fewer blood vessels compared with normal tissue, but the fibroid tissue bled more. Larger fibroids had a larger total area of vascularity, but the smaller fibroids had a larger cross-section of blood vessels.

Ultimately, these results and future analyses might help physicians develop a model that they can use to predict fibroid growth over time, Dr. Davis noted.

BETHESDA, MD. — Large fibroids appear to grow faster than smaller fibroids, but symptoms, rather than growth rate, spur women to surgery.

A preliminary analysis of data from 120 women in the Fibroid Growth Study suggests that large fibroids (greater than 50 cm

“Most women have fibroids, but there is a subset of women that are symptomatic,” Barbara J. Davis, Ph.D., said at an international conference on uterine leiomyoma research sponsored by the National Institutes of Health.

Data on the factors that cause fibroids to grow and become clinically symptomatic are limited. “Our hypothesis was that fibroids are heterogenous and that growing tumors will have different cellular and molecular characteristics than nongrowing tumors,” said Dr. Davis, formerly chief of the Laboratory of Women's Health at the National Institute of Environmental Health Sciences and now a principal scientist at AstraZeneca.

She and her associates sought to compare leiomyoma growth over time as a function of the number and location of the tumors. To describe relationships between growth, clinical symptoms, and outcome, the investigators studied women at high risk for hysterectomy or myectomy.

The study results also indicated that intramural fibroids appeared to grow more slowly than did submucosal fibroids, fibroid growth might depend on the accumulation of fibrous tissue, and race had no effect on growth rate.

The study, funded by the National Institute of Environmental Health Sciences and the National Center on Minority Health and Health Disparities, included clinically symptomatic, premenopausal women with large uteri—the size of 12 weeks' gestation—who had tumors of at least 2 cm in diameter, confirmed by ultrasound at baseline.

Approximately 48% of the women were black and 41% were white.

The women had MRIs at baseline, 3 months, 6 months, and 1 year. They also underwent physicals, completed extensive medical history forms, donated blood and urine, and participated in monthly questionnaires via a 20-minute phone interview.

Women who opted for surgery donated their fibroid tissues to the study investigators and had a presurgical MRI to map the tumors for the surgeon so they could be identified by type and location.

A total of 31 women had either a hysterectomy or myomectomy during the course of the study. The average age of the surgery patients was slightly younger than the overall average (37.8 years vs. 39 years).

Overall, 1,076 fibroid volumes were calculated, including data from 52 women who completed all four MRIs—16 women who had surgery and 36 who did. The investigators used a computer program that allowed them to overlay MRI images of the fibroids at different times and determine their growth rates.

In this pulminary analysis, growth rate, defined by change in volume, was mostly a function of location and other factors.

“We were surprised that there were not significant differences in the rate of growth between women of different race or ethnicity,” Dr. Davis said. The difference in the prevalence of fibroids between blacks and whites appears not to be caused by tumors growing faster in blacks.

“We did find that size was a factor in determining rates of growth,” she noted. The investigators were surprised that both large and medium fibroids grew at a faster rate than small ones. “We thought that small tumors would be the fast-growing ones, and we thought we might find some that shrank, but we didn't,” Dr. Davis said. In fact, all the fibroids studied grew to some extent.

Intramural fibroid growth was slower than that of subserosal fibroids. However, growth rates between intramural vs. submucosal and between submucosal vs. subserosal tumors were not significantly different. As for the impact of growth rates on clinical outcomes, there were no significant differences in growth rates between patients who had surgery and those who did not. “That was a surprise to us,” Dr. Davis said. “We wondered why the women were going to surgery.”

The answer is their symptoms. Symptom severity scores related to bleeding in surgery patients were almost double those of nonsurgery patients. Similarly, there was a significant difference in reported pain before and after surgery among surgery patients, compared with pain scores of nonsurgery patients.

Although the clinical symptomology differed between women who chose surgery and those who did not, the fibroid growth rates appeared similar in both groups. Dr. Davis noted that the investigators have yet to review the impact of number of tumors on outcome. The total number of fibroids per woman ranged from 1 to 11.

The most common reasons for choosing surgery were to reduce heavy bleeding (40%) and to attempt pregnancy (20%).

The investigators found a greater proportion of fibrous tissues, compared with smooth tissues, in the large tumors than in smaller tumors. The large tumors were the fastest growing, suggesting that connective tissue contributes to tumor growth rather than regression. The vascularity varied as well—the fibroids had fewer blood vessels compared with normal tissue, but the fibroid tissue bled more. Larger fibroids had a larger total area of vascularity, but the smaller fibroids had a larger cross-section of blood vessels.

Ultimately, these results and future analyses might help physicians develop a model that they can use to predict fibroid growth over time, Dr. Davis noted.

HOUSTON — Most adolescents with gender identity issues initially are treated for comorbid conditions such as depression, Flynn O'Malley, Ph.D., said at the annual meeting of the American Society for Adolescent Psychiatry.

Managing adolescents with gender issues includes treating the comorbid conditions (if any) first, and then educating the patient about the realities of a sex change.

The clinician can help the adolescent develop a plan for life as a person of the opposite gender after his/her sex change treatment, and can assess family support and encourage discussion of the family's discomfort with the adolescent's transgendered feelings. A patient who expresses a desire for a sex change must be thoroughly assessed to determine whether he or she meets the DSM-IV criteria for gender identity disorder (GID) and shows commitment to the sex change process.

The problems faced by an adolescent with a gender issue include a personal struggle with his or her identity; fear of rejection, attack, or humiliation; a desire to keep gender preference a secret; concern about parental reaction; problems in school and community settings; and the wide range of professional attitudes about treatment, said Dr. O'Malley of Baylor College of Medicine, Houston. Dr. O'Malley, also of the Menninger Clinic, an inpatient facility in Houston for adolescents with unremitting psychiatric problems, reported no conflicts of interest related to his talk.

Many patients with gender issues also have mood disorders, substance abuse disorders, serious family problems, and a history of multiple suicide attempts, Dr. O'Malley said. In addition, many patients have a history of failure to improve or to regress after some improvement.

Suicidality, self-harm, and thought disorders may all occur in the context of gender dysphoria, Dr. O'Malley noted. Some patients reveal the gender dysphoria as part of their psychiatric treatment course; many report a history of sexual abuse. It is tempting to link gender dysphoria to sexual abuse, but the etiology of gender dysphoria is extremely complex.

“If gender dysphoria started early, whatever sexual experiences teenagers have had have been awkward and confusing for them,” Dr. O'Malley said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas.

Adolescents come to the Menninger Clinic in varying stages of intervention. Some have not identified their gender issues; others are already taking hormones. “There is enormous controversy when we admit someone with these difficulties,” he added.

Some adolescents with gender dysphoria are confused about their gender problems, while others are adamant that they are transsexuals and insist on treatment that would facilitate a sex change.

A controversy persists between professionals who support psychodynamic therapy and those who back sex reassignment. Careful diagnosis is important. Intersex conditions such as chromosomal abnormalities, pseudohermaphroditism, and enzyme deficiencies should not be confused with gender identity disorders. Intersex conditions, which arise from developmental problems with sexual differentiation, have clear physiologic and biologic aspects. People with those conditions may or may not suffer from psychiatric problems. In contrast, transgender patients do not have ambiguous genitalia or physical inconsistencies related to sex at birth.

Criteria for a GID diagnosis include a persistent, strong identification with the opposite gender, persistent discomfort with one's sex, and feelings of inappropriateness in the gender role for one's sex. To meet the GID diagnosis, these characteristics must not be concurrent with an intersex condition and must cause significant distress and impairment in important areas of everyday life.

Subcriteria for a GID diagnosis in children include repudiation of the genitals among young boys and preference for a penis among young girls. GID is categorized in the DSM-IV under Sexual and Gender Identity Disorders, not Psychosexual Disorders, which suggests something about the etiology of the disorders, Dr. O'Malley noted.

Transvestitism differs from gender dysphoria because it involves a feeling of sexual arousal created by putting on the clothes of the opposite sex. In dual-role transvestitism, the person dresses in the clothes of the opposite sex to feel like a person of the opposite sex for a while—with no desire for a permanent change.

Some relationship appears to exist between childhood gender identity disorder and adolescent transsexuality. However, many children who cross-dress and exhibit gender issues at an early age do not become adolescent gender dysphoric patients or undergo sex change procedures, Dr. O'Malley said. Most children who meet the diagnosis for GID become transsexuals, and early cross-gender behavior often leads to homosexuality.

Transgender Terminology

Although no consensus exists for these definitions, they can be useful when talking to adolescents with gender issues.

▸ Sex: biologic maleness or femaleness.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley

HOUSTON — Most adolescents with gender identity issues initially are treated for comorbid conditions such as depression, Flynn O'Malley, Ph.D., said at the annual meeting of the American Society for Adolescent Psychiatry.

Managing adolescents with gender issues includes treating the comorbid conditions (if any) first, and then educating the patient about the realities of a sex change.

The clinician can help the adolescent develop a plan for life as a person of the opposite gender after his/her sex change treatment, and can assess family support and encourage discussion of the family's discomfort with the adolescent's transgendered feelings. A patient who expresses a desire for a sex change must be thoroughly assessed to determine whether he or she meets the DSM-IV criteria for gender identity disorder (GID) and shows commitment to the sex change process.

The problems faced by an adolescent with a gender issue include a personal struggle with his or her identity; fear of rejection, attack, or humiliation; a desire to keep gender preference a secret; concern about parental reaction; problems in school and community settings; and the wide range of professional attitudes about treatment, said Dr. O'Malley of Baylor College of Medicine, Houston. Dr. O'Malley, also of the Menninger Clinic, an inpatient facility in Houston for adolescents with unremitting psychiatric problems, reported no conflicts of interest related to his talk.

Many patients with gender issues also have mood disorders, substance abuse disorders, serious family problems, and a history of multiple suicide attempts, Dr. O'Malley said. In addition, many patients have a history of failure to improve or to regress after some improvement.

Suicidality, self-harm, and thought disorders may all occur in the context of gender dysphoria, Dr. O'Malley noted. Some patients reveal the gender dysphoria as part of their psychiatric treatment course; many report a history of sexual abuse. It is tempting to link gender dysphoria to sexual abuse, but the etiology of gender dysphoria is extremely complex.

“If gender dysphoria started early, whatever sexual experiences teenagers have had have been awkward and confusing for them,” Dr. O'Malley said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas.

Adolescents come to the Menninger Clinic in varying stages of intervention. Some have not identified their gender issues; others are already taking hormones. “There is enormous controversy when we admit someone with these difficulties,” he added.

Some adolescents with gender dysphoria are confused about their gender problems, while others are adamant that they are transsexuals and insist on treatment that would facilitate a sex change.

A controversy persists between professionals who support psychodynamic therapy and those who back sex reassignment. Careful diagnosis is important. Intersex conditions such as chromosomal abnormalities, pseudohermaphroditism, and enzyme deficiencies should not be confused with gender identity disorders. Intersex conditions, which arise from developmental problems with sexual differentiation, have clear physiologic and biologic aspects. People with those conditions may or may not suffer from psychiatric problems. In contrast, transgender patients do not have ambiguous genitalia or physical inconsistencies related to sex at birth.

Criteria for a GID diagnosis include a persistent, strong identification with the opposite gender, persistent discomfort with one's sex, and feelings of inappropriateness in the gender role for one's sex. To meet the GID diagnosis, these characteristics must not be concurrent with an intersex condition and must cause significant distress and impairment in important areas of everyday life.

Subcriteria for a GID diagnosis in children include repudiation of the genitals among young boys and preference for a penis among young girls. GID is categorized in the DSM-IV under Sexual and Gender Identity Disorders, not Psychosexual Disorders, which suggests something about the etiology of the disorders, Dr. O'Malley noted.

Transvestitism differs from gender dysphoria because it involves a feeling of sexual arousal created by putting on the clothes of the opposite sex. In dual-role transvestitism, the person dresses in the clothes of the opposite sex to feel like a person of the opposite sex for a while—with no desire for a permanent change.

Some relationship appears to exist between childhood gender identity disorder and adolescent transsexuality. However, many children who cross-dress and exhibit gender issues at an early age do not become adolescent gender dysphoric patients or undergo sex change procedures, Dr. O'Malley said. Most children who meet the diagnosis for GID become transsexuals, and early cross-gender behavior often leads to homosexuality.

Transgender Terminology

Although no consensus exists for these definitions, they can be useful when talking to adolescents with gender issues.

▸ Sex: biologic maleness or femaleness.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley

HOUSTON — Most adolescents with gender identity issues initially are treated for comorbid conditions such as depression, Flynn O'Malley, Ph.D., said at the annual meeting of the American Society for Adolescent Psychiatry.

Managing adolescents with gender issues includes treating the comorbid conditions (if any) first, and then educating the patient about the realities of a sex change.

The clinician can help the adolescent develop a plan for life as a person of the opposite gender after his/her sex change treatment, and can assess family support and encourage discussion of the family's discomfort with the adolescent's transgendered feelings. A patient who expresses a desire for a sex change must be thoroughly assessed to determine whether he or she meets the DSM-IV criteria for gender identity disorder (GID) and shows commitment to the sex change process.

The problems faced by an adolescent with a gender issue include a personal struggle with his or her identity; fear of rejection, attack, or humiliation; a desire to keep gender preference a secret; concern about parental reaction; problems in school and community settings; and the wide range of professional attitudes about treatment, said Dr. O'Malley of Baylor College of Medicine, Houston. Dr. O'Malley, also of the Menninger Clinic, an inpatient facility in Houston for adolescents with unremitting psychiatric problems, reported no conflicts of interest related to his talk.

Many patients with gender issues also have mood disorders, substance abuse disorders, serious family problems, and a history of multiple suicide attempts, Dr. O'Malley said. In addition, many patients have a history of failure to improve or to regress after some improvement.

Suicidality, self-harm, and thought disorders may all occur in the context of gender dysphoria, Dr. O'Malley noted. Some patients reveal the gender dysphoria as part of their psychiatric treatment course; many report a history of sexual abuse. It is tempting to link gender dysphoria to sexual abuse, but the etiology of gender dysphoria is extremely complex.

“If gender dysphoria started early, whatever sexual experiences teenagers have had have been awkward and confusing for them,” Dr. O'Malley said at the meeting, cosponsored by the University of Texas Southwestern Medical Center at Dallas.

Adolescents come to the Menninger Clinic in varying stages of intervention. Some have not identified their gender issues; others are already taking hormones. “There is enormous controversy when we admit someone with these difficulties,” he added.

Some adolescents with gender dysphoria are confused about their gender problems, while others are adamant that they are transsexuals and insist on treatment that would facilitate a sex change.

A controversy persists between professionals who support psychodynamic therapy and those who back sex reassignment. Careful diagnosis is important. Intersex conditions such as chromosomal abnormalities, pseudohermaphroditism, and enzyme deficiencies should not be confused with gender identity disorders. Intersex conditions, which arise from developmental problems with sexual differentiation, have clear physiologic and biologic aspects. People with those conditions may or may not suffer from psychiatric problems. In contrast, transgender patients do not have ambiguous genitalia or physical inconsistencies related to sex at birth.

Criteria for a GID diagnosis include a persistent, strong identification with the opposite gender, persistent discomfort with one's sex, and feelings of inappropriateness in the gender role for one's sex. To meet the GID diagnosis, these characteristics must not be concurrent with an intersex condition and must cause significant distress and impairment in important areas of everyday life.

Subcriteria for a GID diagnosis in children include repudiation of the genitals among young boys and preference for a penis among young girls. GID is categorized in the DSM-IV under Sexual and Gender Identity Disorders, not Psychosexual Disorders, which suggests something about the etiology of the disorders, Dr. O'Malley noted.

Transvestitism differs from gender dysphoria because it involves a feeling of sexual arousal created by putting on the clothes of the opposite sex. In dual-role transvestitism, the person dresses in the clothes of the opposite sex to feel like a person of the opposite sex for a while—with no desire for a permanent change.

Some relationship appears to exist between childhood gender identity disorder and adolescent transsexuality. However, many children who cross-dress and exhibit gender issues at an early age do not become adolescent gender dysphoric patients or undergo sex change procedures, Dr. O'Malley said. Most children who meet the diagnosis for GID become transsexuals, and early cross-gender behavior often leads to homosexuality.

Transgender Terminology

Although no consensus exists for these definitions, they can be useful when talking to adolescents with gender issues.

▸ Sex: biologic maleness or femaleness.

▸ Sexual orientation: sexual attraction of one person toward another person of the same sex or the opposite sex.

▸ Gender identity: concept of one's self as male or female.

▸ Gender role: society's expected behaviors for males and females.

▸ Gender dysphoria: distress related to one's gender identity and sex at birth.

▸ Gender identity disorder: a DSM-IV diagnosis. Criteria include strong identification with the opposite gender, persistent discomfort with one's own sex, inappropriate behavior in his or her existing gender role, and significant distress in important areas of daily functioning.

▸ Transsexual: usually refers to someone with gender dysphoria who is in the process of or desires sex-changing medical procedures.

▸ Transgender: refers to someone who is gender dysphoric but may not be interested in sex-changing medical procedures or may not meet the diagnostic criteria for gender identity disorder.

▸ MF: an anatomic male who identifies with women and wishes to become a woman.

▸ FM: an anatomic female who identifies with men and wishes to become a man.

Source: Dr. O'Malley

Sex Change: One Step at a Time

If and when an adolescent makes the choice to change his or her sex, the steps toward sex and gender reassignment should begin with a thorough psychiatric assessment and discussion of plans for the future. Among the steps are the following:

▸ A clinician determines whether the adolescent meets the DSM-IV criteria for gender identity disorder, and assesses his or her personal and social stability and levels of support from family and friends.

▸ If he or she meets the assessment criteria, the adolescent starts to live in a cross-gender role and initiates reversible hormone treatments. The fully reversible hormones suppress estrogen and testosterone and delay the physical changes of puberty. Reversible hormone treatments usually do not begin unless the adolescent is aged at least 16 years. Many experts also believe that the adolescent should be in at least Tanner stage 2 of development before initiating hormones.

▸ If he or she still desires change, the adolescent continues living in a cross-gender role and proceeds to partly reversible hormone treatment, which takes about 1 year for females working to become male and 1.5 years for males working to become female.

The difference in duration reflects the sense that it is more difficult for males who want to be females to pass as women than it is for women to pass as men. In fact, many adolescent girls can start to look like males relatively quickly.

Most physicians recommend that the adolescent wait until age 18 to receive the partly reversible hormone treatment, since these hormones masculinize or feminize the body and could lead to surgery to reverse the results, such as breast development in males.

▸ The final step is a continuation of hormones and a referral for sex change surgery.

Source: Dr. O'Malley

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they stick to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. S. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

In a retrospective study of 6,285 women, 48% were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women vs. noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women vs. nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, their effectiveness depends on compliance for an extended period of time. And compliance is notoriously poor.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and may improve compliance.

Dr. Siris is a consultant for and has received honoraria from Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter & Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they stick to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. S. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

In a retrospective study of 6,285 women, 48% were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women vs. noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women vs. nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, their effectiveness depends on compliance for an extended period of time. And compliance is notoriously poor.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and may improve compliance.

Dr. Siris is a consultant for and has received honoraria from Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter & Gamble Pharmaceuticals, and Novartis.

WASHINGTON — Postmenopausal women with osteoporosis can reduce their risk for fractures by 26% if they stick to their bisphosphonate regimens, Ethel Siris, M.D., reported in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation.

However, that “if” is a very big one, said Dr. S. Siris, director of the metabolic bone diseases program at Columbia University Medical Center, New York.

In a retrospective study of 6,285 women, 48% were compliant in terms of refilling their prescriptions, and 21% were persistent in terms of staying on the medication beyond the 2-year follow-up.

Overall, the relative risk of fracture over a 2-year period was 26% lower among refill-compliant women vs. noncompliant women (9.4% vs. 12.6%) and 21% lower among treatment persistent women vs. nonpersistent women (9.1% vs. 11.6%).

More than half (52%) of the women were noncompliant, based on insufficient refills, and approximately 21% were nonpersistent, defined as having a discontinuation of therapy within the 2-year period.

Data on the pharmaceutical claims of women aged 45 years and older who met the criteria for postmenopausal osteoporosis were taken from the Medstat MarketScan Research Database. The women had received at least one prescription for a bisphosphonate; 85% received alendronate (Fosamax) and 15% received risedronate (Actonel).

Although bisphosphonates are a popular choice for fracture risk reduction in osteoporotic women, their effectiveness depends on compliance for an extended period of time. And compliance is notoriously poor.

“If we actually get people to take these drugs, we might cut as many as 400,000 fractures in a given year,” Dr. Siris said. Studies on less frequent dosing regimens, such as the once-monthly regimen for the newly approved ibandronate (Boniva), suggest they are effective and may improve compliance.

Dr. Siris is a consultant for and has received honoraria from Eli Lilly & Co., Merck & Co., Sanofi Aventis, Procter & Gamble Pharmaceuticals, and Novartis.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55-80 years, will continue for 2 years, Michael Bolognese, M.D., said in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

At 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups. Similar increases occurred at the femoral neck and hip trochanter. All treatment also groups had significant decreases in serum CTX, a bone resorption marker. The 150-mg group showed the most robust response.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg; it has been shown to have maximal effectiveness when taken 60 minutes before eating, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across treatment groups. About 70%-80% of the adverse events were gastrointestinal, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%) vs. the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Proctor & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55-80 years, will continue for 2 years, Michael Bolognese, M.D., said in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

At 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups. Similar increases occurred at the femoral neck and hip trochanter. All treatment also groups had significant decreases in serum CTX, a bone resorption marker. The 150-mg group showed the most robust response.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg; it has been shown to have maximal effectiveness when taken 60 minutes before eating, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across treatment groups. About 70%-80% of the adverse events were gastrointestinal, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%) vs. the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Proctor & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.

WASHINGTON — A monthly dose of oral ibandronate is at least as safe and as effective at increasing bone mineral density as a daily dose, according to data from a study of more than 1,200 postmenopausal women with osteoporosis.

The Monthly Oral Ibandronate in Ladies (MOBILE) study, a multinational randomized, double-blind, phase III study of women aged 55-80 years, will continue for 2 years, Michael Bolognese, M.D., said in a poster presented at an international symposium sponsored by the National Osteoporosis Foundation. Dr. Bolognese and his colleagues presented their 1-year results at the meeting.

A total of 318 women received a 2.5-mg dose of oral ibandronate (Boniva) daily; another 328 women received a 50/50 mg dose (two 50-mg single doses on 2 consecutive days) monthly; 311 received one 100-mg dose monthly; and 320 received one 150-mg dose monthly.

At 1 year, the increase in BMD at the lumbar spine was 3.9% in the daily group, compared with 4.3%, 4.1%, and 4.9% in the groups receiving 50/50 mg, 100 mg, and 150 mg monthly.

Increases in the total hip BMD were 2.2% in the daily group, compared with 2.2%, 2.7%, and 3.1% in the 50/50 mg, and monthly groups. Similar increases occurred at the femoral neck and hip trochanter. All treatment also groups had significant decreases in serum CTX, a bone resorption marker. The 150-mg group showed the most robust response.

The dosage of the newly approved monthly formulation of ibandronate (Boniva) is 150 mg; it has been shown to have maximal effectiveness when taken 60 minutes before eating, said Dr. Bolognese, of Bethesda (Md.) Health Research.

The incidence of adverse events and withdrawal rates were comparable across treatment groups. About 70%-80% of the adverse events were gastrointestinal, but the incidence was relatively low and comparable across all treatment groups. In fact, the rate of discontinuation due to upper GI events was lower among patients in the 150-mg group (3.3%), 100-mg group (4.0%), and 50/50-mg group (4.0%) vs. the daily group (5.3%).

Dr. Bolognese is a consultant for Eli Lilly & Co. and Proctor & Gamble, and he has received grants or research support from Sanofi-Aventis, Pfizer, Lilly, and Wyeth Pharmaceuticals.