Kate Johnson

Àt the time of the MRI, the patient's findings were considered to be most consistent with a viral myositis or Guillain-Barré syndrome, reported Kristina P. Callis, M.D., a dermatology resident at the University of Utah Health System in Salt Lake City.

In addition, a painful nodule in his left thigh with overlying erythema was diagnosed as thrombophlebitis. He was referred to dermatology 4 months later with scrotal ulcers and follicular papules and pustules elsewhere on his skin.

The scrotal ulcers and varied skin lesions developed 6 weeks after the onset of myositis. A skin biopsy from a scrotal ulcer showed the destruction of venule-like vascular structures and an interstitial inflammatory response of neutrophils; a muscle biopsy from the calf showed scattered atrophic muscle fibers and foci of perivascular infiltrate of chronic inflammatory cells consistent with an active myopathy.

The differential diagnosis initially included Behçet's syndrome, syphilis, Crohn's disease, pyoderma gangrenosum, other vasculitides, or other infections, Dr. Callis said.

The patient had no gastrointestinal, CNS, visual, or urinary symptoms. He had minimal joint symptoms (knee arthralgias), and—although he initially denied oral ulceration—the appearance of an oral ulcer clinched the diagnosis of Behçet's syndrome.

The International Study Group criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year, plus any two of the following: recurrent genital ulceration; eye lesions (uveitis, cells in the vitreous, or retinal vasculitis); cutaneous lesions (erythema multiforme, papulopustular lesions, pseudofolliculitis, or acneiform nodules); or a pathergy test interpreted at 24-48 hours.

Myositis is a rare presentation of Behçet's syndrome, having been reported only 11 times in the English literature, according to Dr. Callis.

The patient was started on 60 mg of prednisone daily, with both the scrotal ulcers and myositis resolving. However, because of the long-term side effects of prednisone, other therapies including colchicine were under consideration at the time of the case report.

A biopsy of the calf muscle showed atrophic fibers and inflammatory cells consistent with myopathy.

Criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year. Photos courtesy Dr. Kristina P. Callis

Àt the time of the MRI, the patient's findings were considered to be most consistent with a viral myositis or Guillain-Barré syndrome, reported Kristina P. Callis, M.D., a dermatology resident at the University of Utah Health System in Salt Lake City.

In addition, a painful nodule in his left thigh with overlying erythema was diagnosed as thrombophlebitis. He was referred to dermatology 4 months later with scrotal ulcers and follicular papules and pustules elsewhere on his skin.

The scrotal ulcers and varied skin lesions developed 6 weeks after the onset of myositis. A skin biopsy from a scrotal ulcer showed the destruction of venule-like vascular structures and an interstitial inflammatory response of neutrophils; a muscle biopsy from the calf showed scattered atrophic muscle fibers and foci of perivascular infiltrate of chronic inflammatory cells consistent with an active myopathy.

The differential diagnosis initially included Behçet's syndrome, syphilis, Crohn's disease, pyoderma gangrenosum, other vasculitides, or other infections, Dr. Callis said.

The patient had no gastrointestinal, CNS, visual, or urinary symptoms. He had minimal joint symptoms (knee arthralgias), and—although he initially denied oral ulceration—the appearance of an oral ulcer clinched the diagnosis of Behçet's syndrome.

The International Study Group criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year, plus any two of the following: recurrent genital ulceration; eye lesions (uveitis, cells in the vitreous, or retinal vasculitis); cutaneous lesions (erythema multiforme, papulopustular lesions, pseudofolliculitis, or acneiform nodules); or a pathergy test interpreted at 24-48 hours.

Myositis is a rare presentation of Behçet's syndrome, having been reported only 11 times in the English literature, according to Dr. Callis.

The patient was started on 60 mg of prednisone daily, with both the scrotal ulcers and myositis resolving. However, because of the long-term side effects of prednisone, other therapies including colchicine were under consideration at the time of the case report.

A biopsy of the calf muscle showed atrophic fibers and inflammatory cells consistent with myopathy.

Criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year. Photos courtesy Dr. Kristina P. Callis

Àt the time of the MRI, the patient's findings were considered to be most consistent with a viral myositis or Guillain-Barré syndrome, reported Kristina P. Callis, M.D., a dermatology resident at the University of Utah Health System in Salt Lake City.

In addition, a painful nodule in his left thigh with overlying erythema was diagnosed as thrombophlebitis. He was referred to dermatology 4 months later with scrotal ulcers and follicular papules and pustules elsewhere on his skin.

The scrotal ulcers and varied skin lesions developed 6 weeks after the onset of myositis. A skin biopsy from a scrotal ulcer showed the destruction of venule-like vascular structures and an interstitial inflammatory response of neutrophils; a muscle biopsy from the calf showed scattered atrophic muscle fibers and foci of perivascular infiltrate of chronic inflammatory cells consistent with an active myopathy.

The differential diagnosis initially included Behçet's syndrome, syphilis, Crohn's disease, pyoderma gangrenosum, other vasculitides, or other infections, Dr. Callis said.

The patient had no gastrointestinal, CNS, visual, or urinary symptoms. He had minimal joint symptoms (knee arthralgias), and—although he initially denied oral ulceration—the appearance of an oral ulcer clinched the diagnosis of Behçet's syndrome.

The International Study Group criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year, plus any two of the following: recurrent genital ulceration; eye lesions (uveitis, cells in the vitreous, or retinal vasculitis); cutaneous lesions (erythema multiforme, papulopustular lesions, pseudofolliculitis, or acneiform nodules); or a pathergy test interpreted at 24-48 hours.

Myositis is a rare presentation of Behçet's syndrome, having been reported only 11 times in the English literature, according to Dr. Callis.

The patient was started on 60 mg of prednisone daily, with both the scrotal ulcers and myositis resolving. However, because of the long-term side effects of prednisone, other therapies including colchicine were under consideration at the time of the case report.

A biopsy of the calf muscle showed atrophic fibers and inflammatory cells consistent with myopathy.

Criteria for Behçet's syndrome requires recurrent oral ulceration at least three times per year. Photos courtesy Dr. Kristina P. Callis

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

Bone density screening was associated with fewer hip fractures compared with usual medical care in a study of more than 3,000 adults aged 65 and older.

“Although some groups recommend screening, no study had proved that screening prevents fractures. Our study provides new evidence for the effectiveness of osteoporosis screening,” lead researcher Lisa M. Kern, M.D., of Cornell University, New York, said in a statement.

“We believe that our study is the first to measure and find a direct link between screening for osteoporosis and fewer incident hip fractures,” the researchers said.

But because the study was not randomized, “the observed relationship between screening and hip fracture could be diminished by a small unmeasured confounder,” the investigators noted (Ann. Intern. Med. 2005;142:173-81).

The study included 3,107 participants in the larger Cardiovascular Health Study (CHS). Participants were assigned to a study arm based on the state where they resided.

In one arm, 1,422 participants from California and Pennsylvania were offered osteoporosis screening using dual-energy x-ray absorptiometry (DXA) at the hip. Both the participants and their primary care providers were given a graph showing the results of their bone scan in relation to the normal range of bone mineral density (BMD). The graph did not label the participants as normal, osteopenic, or osteoporotic and did not recommend any particular intervention.

In the other arm, 1,685 participants in Maryland and North Carolina received usual medical care.

The participants were followed for 6 years from the time of their BMD scan, or if they did not receive a scan, from the date of their annual appointment as a CHS participant.

They were observed until one of the following events occurred: a hip fracture, death, loss to follow-up, or end of the surveillance period.

Participants also were analyzed for 31 variables including demographic characteristics, medical histories, medications, and physical examination findings.

Compared with usual care, osteoporosis screening was associated with a statistically significant reduction in the risk of hip fracture. The incidence of fractures per 1,000 person-years was 4.8 in the screened group (total 33) and 8.2 in the usual care group (total 69), linking screening to a 36% reduction in hip fractures.

The largest benefit for screening was in participants aged 85 years and older. “If this result is replicated in other studies, it suggests that guidelines should not set an upper age limit for osteoporosis screening among ambulatory adults,” the researchers wrote.

While acknowledging that the mechanism of the association between screening and a reduction in fractures is unclear, the authors offered several possible explanations.

They found limited evidence that screening may have led to interventions for low bone density.

A total of 33% of participants who were offered screening had a BMD below the age-matched mean, and these participants were more likely to start using calcium or bisphosphonates in the year after screening, compared with those participants whose bone densities were above average.

More screened than nonscreened participants began using multivitamins, Dr. Kern said.

In addition, a smaller percentage of the screened group had falls in the year after screening, compared with the nonscreened group (16% vs. 20%, respectively), although no information on fall prevention was collected.

“There were some other differences between the groups besides screening that could partially explain the difference in hip fractures,” Dr. Kern said.

Most patients with primary Sjögren's syndrome test negative for anti-cyclic citrullinated peptide antibody and anti-keratin antibodies, in contrast to patients with rheumatoid arthritis, a new study shows.

However, primary Sjögren's syndrome should not be ruled out in patients testing positive for these antibodies, reported J. E. Gottenberg from Bicetre Hospital in Le Kremlin Bicetre, France and colleagues (Ann. Rheum. Dis. 2005;64:114-7).

The clinical manifestations of Sjögren's syndrome and rheumatoid arthritis may be very similar, and the prevalence of rheumatoid factor is the same in both conditions, noted the authors.

The study involved 134 patients who fulfilled the American-European Consensus Group criteria for primary Sjögren's syndrome, and who did not fulfill American College of Rheumatology criteria for rheumatoid arthritis.

Patients were tested for anti-cyclic citrullinated peptide (anti-CCP) antibodies using enzyme-linked immunosorbent assay, while anti-keratin antibodies (AKA) were assessed using indirect immunofluorescence. Tests were also done for rheumatoid factor and Sjögren's syndrome antibodies, and patients were clinically evaluated for the presence of synovitis and extraglandular involvement.

Radiographs of the hands and feet were taken to rule out the presence of erosions that would indicate a primary diagnosis of rheumatoid arthritis.

Ten of the patients (7.5%), tested positive for anti-CCP, and 7 (5.2%) tested positive for AKA. This compared to data from an unpublished study showing a 68.9% prevalence of anti-CCP in patients with rheumatoid arthritis by other investigators.

“To our knowledge, this is the first study to analyze the prevalence of anti-CCP and AKA in a cohort of patients with primary Sjögren's syndrome,” they reported.

“Our study confirms that anti-CCP and AKA may be detected in patients with no radiographic evidence of erosions after a long follow-up.”

The possibility that patients with anti-CCP antibodies could be prone to developing rheumatoid arthritis should not be ruled out, noted the authors.

“It is known that anti-CCP can be present years before the first signs of rheumatoid arthritis. In three anti-CCP-positive patients with polysynovitis, the use of DMARDs [disease-modifying anti-rheumatic drugs] might have prevented progression to rheumatoid arthritis,” they wrote.

They recommend that anti-CCP-positive patients receive cautious clinical and radiographic follow-up to confirm that their disease does not evolve into rheumatoid arthritis.

However, the fact that the anti-CCP-positive patients had a mean disease duration of 11 years without erosions suggests that “the production of anti-CCP antibodies … could be less intimately related to the pathogenesis of rheumatoid arthritis than was previously hypothesized.”

Most patients with primary Sjögren's syndrome test negative for anti-cyclic citrullinated peptide antibody and anti-keratin antibodies, in contrast to patients with rheumatoid arthritis, a new study shows.

However, primary Sjögren's syndrome should not be ruled out in patients testing positive for these antibodies, reported J. E. Gottenberg from Bicetre Hospital in Le Kremlin Bicetre, France and colleagues (Ann. Rheum. Dis. 2005;64:114-7).

The clinical manifestations of Sjögren's syndrome and rheumatoid arthritis may be very similar, and the prevalence of rheumatoid factor is the same in both conditions, noted the authors.

The study involved 134 patients who fulfilled the American-European Consensus Group criteria for primary Sjögren's syndrome, and who did not fulfill American College of Rheumatology criteria for rheumatoid arthritis.

Patients were tested for anti-cyclic citrullinated peptide (anti-CCP) antibodies using enzyme-linked immunosorbent assay, while anti-keratin antibodies (AKA) were assessed using indirect immunofluorescence. Tests were also done for rheumatoid factor and Sjögren's syndrome antibodies, and patients were clinically evaluated for the presence of synovitis and extraglandular involvement.

Radiographs of the hands and feet were taken to rule out the presence of erosions that would indicate a primary diagnosis of rheumatoid arthritis.

Ten of the patients (7.5%), tested positive for anti-CCP, and 7 (5.2%) tested positive for AKA. This compared to data from an unpublished study showing a 68.9% prevalence of anti-CCP in patients with rheumatoid arthritis by other investigators.

“To our knowledge, this is the first study to analyze the prevalence of anti-CCP and AKA in a cohort of patients with primary Sjögren's syndrome,” they reported.

“Our study confirms that anti-CCP and AKA may be detected in patients with no radiographic evidence of erosions after a long follow-up.”

The possibility that patients with anti-CCP antibodies could be prone to developing rheumatoid arthritis should not be ruled out, noted the authors.

“It is known that anti-CCP can be present years before the first signs of rheumatoid arthritis. In three anti-CCP-positive patients with polysynovitis, the use of DMARDs [disease-modifying anti-rheumatic drugs] might have prevented progression to rheumatoid arthritis,” they wrote.

They recommend that anti-CCP-positive patients receive cautious clinical and radiographic follow-up to confirm that their disease does not evolve into rheumatoid arthritis.

However, the fact that the anti-CCP-positive patients had a mean disease duration of 11 years without erosions suggests that “the production of anti-CCP antibodies … could be less intimately related to the pathogenesis of rheumatoid arthritis than was previously hypothesized.”

Most patients with primary Sjögren's syndrome test negative for anti-cyclic citrullinated peptide antibody and anti-keratin antibodies, in contrast to patients with rheumatoid arthritis, a new study shows.

However, primary Sjögren's syndrome should not be ruled out in patients testing positive for these antibodies, reported J. E. Gottenberg from Bicetre Hospital in Le Kremlin Bicetre, France and colleagues (Ann. Rheum. Dis. 2005;64:114-7).

The clinical manifestations of Sjögren's syndrome and rheumatoid arthritis may be very similar, and the prevalence of rheumatoid factor is the same in both conditions, noted the authors.

The study involved 134 patients who fulfilled the American-European Consensus Group criteria for primary Sjögren's syndrome, and who did not fulfill American College of Rheumatology criteria for rheumatoid arthritis.

Patients were tested for anti-cyclic citrullinated peptide (anti-CCP) antibodies using enzyme-linked immunosorbent assay, while anti-keratin antibodies (AKA) were assessed using indirect immunofluorescence. Tests were also done for rheumatoid factor and Sjögren's syndrome antibodies, and patients were clinically evaluated for the presence of synovitis and extraglandular involvement.

Radiographs of the hands and feet were taken to rule out the presence of erosions that would indicate a primary diagnosis of rheumatoid arthritis.

Ten of the patients (7.5%), tested positive for anti-CCP, and 7 (5.2%) tested positive for AKA. This compared to data from an unpublished study showing a 68.9% prevalence of anti-CCP in patients with rheumatoid arthritis by other investigators.

“To our knowledge, this is the first study to analyze the prevalence of anti-CCP and AKA in a cohort of patients with primary Sjögren's syndrome,” they reported.

“Our study confirms that anti-CCP and AKA may be detected in patients with no radiographic evidence of erosions after a long follow-up.”

The possibility that patients with anti-CCP antibodies could be prone to developing rheumatoid arthritis should not be ruled out, noted the authors.

“It is known that anti-CCP can be present years before the first signs of rheumatoid arthritis. In three anti-CCP-positive patients with polysynovitis, the use of DMARDs [disease-modifying anti-rheumatic drugs] might have prevented progression to rheumatoid arthritis,” they wrote.

They recommend that anti-CCP-positive patients receive cautious clinical and radiographic follow-up to confirm that their disease does not evolve into rheumatoid arthritis.

However, the fact that the anti-CCP-positive patients had a mean disease duration of 11 years without erosions suggests that “the production of anti-CCP antibodies … could be less intimately related to the pathogenesis of rheumatoid arthritis than was previously hypothesized.”

Standard physiotherapy appears more effective than a brief, cognitive behavioral-type intervention for neck pain, although patient preference for the brief intervention can enhance its effectiveness, according to a randomized trial.

However, because confidence intervals overlapped in the trial results, “some may argue that there is a role for the brief intervention for all patients,” noted Jennifer A. Klaber Moffett, Ph.D., of the University of Hull (England), and her colleagues (BMJ 2005;330:75). “It seems that the brief intervention should in any case be available for those who prefer it.”

According to the researchers, previous studies have suggested that patients' expectations or preferences for a particular treatment may influence the outcome of that treatment.

A total of 268 adult patients with subacute or chronic neck pain were randomized to receive either standard physiotherapy or the brief intervention. Prior to randomization, all patients were asked to complete a questionnaire, which included the Northwick Park neck pain questionnaire (NPQ), a measure of the level of neck pain and resulting disability; the short form 36 questionnaire (SF-36), a generic health and quality of life questionnaire that includes physical and psychological factors; and the Tampa scale for kinesophobia (a measure of fear and avoidance of movement). Distress was also measured on a scale of 0-10, with 10 representing extreme distress.

Patients were then asked if they had a preference for standard physiotherapy or brief intervention and were then randomized to a treatment independent of their preference.

The 139 patients in the brief intervention arm received between one and three hands-off sessions with a physiotherapist, during which time cognitive behavioral therapy strategies were emphasized and patients were encouraged to return to normal daily activities as soon as possible through self-management.

The 129 standard physiotherapy patients received any combination of electrotherapy, manual therapy or mobilization, advice, home exercises, and other approaches according to therapists' judgments.

Follow-up questionnaires at 3 and 12 months post intervention showed that for the NPQ, the main outcome, the standard physiotherapy group showed more improvement than the brief intervention group—although this difference did not reach significance.

The SF-36 results showed a similar trend. And although the Tampa scores on fear of movement were in favor of brief intervention initially at 3 months, this trend was reversed at 12 months.

When patients' treatment preferences were factored in, those who wanted the brief intervention and got it had the biggest improvement on the NPQ score, although the difference was not statistically significant. Among patients who were indifferent about which treatment they wanted, there was an advantage to being assigned to standard physiotherapy.

Among patients who stated a preference for standard physiotherapy and then received it, the overall treatment effect did not seem to be enhanced. However, if these patients were randomized to the brief intervention, their pain scores at 12 months were increased from baseline.

“Usual physiotherapy produced marginally better treatment outcomes at 12 months than the shorter, hands-off intervention,” reported the authors.

Standard physiotherapy appears more effective than a brief, cognitive behavioral-type intervention for neck pain, although patient preference for the brief intervention can enhance its effectiveness, according to a randomized trial.

However, because confidence intervals overlapped in the trial results, “some may argue that there is a role for the brief intervention for all patients,” noted Jennifer A. Klaber Moffett, Ph.D., of the University of Hull (England), and her colleagues (BMJ 2005;330:75). “It seems that the brief intervention should in any case be available for those who prefer it.”

According to the researchers, previous studies have suggested that patients' expectations or preferences for a particular treatment may influence the outcome of that treatment.

A total of 268 adult patients with subacute or chronic neck pain were randomized to receive either standard physiotherapy or the brief intervention. Prior to randomization, all patients were asked to complete a questionnaire, which included the Northwick Park neck pain questionnaire (NPQ), a measure of the level of neck pain and resulting disability; the short form 36 questionnaire (SF-36), a generic health and quality of life questionnaire that includes physical and psychological factors; and the Tampa scale for kinesophobia (a measure of fear and avoidance of movement). Distress was also measured on a scale of 0-10, with 10 representing extreme distress.

Patients were then asked if they had a preference for standard physiotherapy or brief intervention and were then randomized to a treatment independent of their preference.

The 139 patients in the brief intervention arm received between one and three hands-off sessions with a physiotherapist, during which time cognitive behavioral therapy strategies were emphasized and patients were encouraged to return to normal daily activities as soon as possible through self-management.

The 129 standard physiotherapy patients received any combination of electrotherapy, manual therapy or mobilization, advice, home exercises, and other approaches according to therapists' judgments.

Follow-up questionnaires at 3 and 12 months post intervention showed that for the NPQ, the main outcome, the standard physiotherapy group showed more improvement than the brief intervention group—although this difference did not reach significance.

The SF-36 results showed a similar trend. And although the Tampa scores on fear of movement were in favor of brief intervention initially at 3 months, this trend was reversed at 12 months.

When patients' treatment preferences were factored in, those who wanted the brief intervention and got it had the biggest improvement on the NPQ score, although the difference was not statistically significant. Among patients who were indifferent about which treatment they wanted, there was an advantage to being assigned to standard physiotherapy.

Among patients who stated a preference for standard physiotherapy and then received it, the overall treatment effect did not seem to be enhanced. However, if these patients were randomized to the brief intervention, their pain scores at 12 months were increased from baseline.

“Usual physiotherapy produced marginally better treatment outcomes at 12 months than the shorter, hands-off intervention,” reported the authors.

Standard physiotherapy appears more effective than a brief, cognitive behavioral-type intervention for neck pain, although patient preference for the brief intervention can enhance its effectiveness, according to a randomized trial.

However, because confidence intervals overlapped in the trial results, “some may argue that there is a role for the brief intervention for all patients,” noted Jennifer A. Klaber Moffett, Ph.D., of the University of Hull (England), and her colleagues (BMJ 2005;330:75). “It seems that the brief intervention should in any case be available for those who prefer it.”

According to the researchers, previous studies have suggested that patients' expectations or preferences for a particular treatment may influence the outcome of that treatment.

A total of 268 adult patients with subacute or chronic neck pain were randomized to receive either standard physiotherapy or the brief intervention. Prior to randomization, all patients were asked to complete a questionnaire, which included the Northwick Park neck pain questionnaire (NPQ), a measure of the level of neck pain and resulting disability; the short form 36 questionnaire (SF-36), a generic health and quality of life questionnaire that includes physical and psychological factors; and the Tampa scale for kinesophobia (a measure of fear and avoidance of movement). Distress was also measured on a scale of 0-10, with 10 representing extreme distress.

Patients were then asked if they had a preference for standard physiotherapy or brief intervention and were then randomized to a treatment independent of their preference.

The 139 patients in the brief intervention arm received between one and three hands-off sessions with a physiotherapist, during which time cognitive behavioral therapy strategies were emphasized and patients were encouraged to return to normal daily activities as soon as possible through self-management.

The 129 standard physiotherapy patients received any combination of electrotherapy, manual therapy or mobilization, advice, home exercises, and other approaches according to therapists' judgments.

Follow-up questionnaires at 3 and 12 months post intervention showed that for the NPQ, the main outcome, the standard physiotherapy group showed more improvement than the brief intervention group—although this difference did not reach significance.

The SF-36 results showed a similar trend. And although the Tampa scores on fear of movement were in favor of brief intervention initially at 3 months, this trend was reversed at 12 months.

When patients' treatment preferences were factored in, those who wanted the brief intervention and got it had the biggest improvement on the NPQ score, although the difference was not statistically significant. Among patients who were indifferent about which treatment they wanted, there was an advantage to being assigned to standard physiotherapy.

Among patients who stated a preference for standard physiotherapy and then received it, the overall treatment effect did not seem to be enhanced. However, if these patients were randomized to the brief intervention, their pain scores at 12 months were increased from baseline.

“Usual physiotherapy produced marginally better treatment outcomes at 12 months than the shorter, hands-off intervention,” reported the authors.

CHICAGO — The two most important things to gather from an ultrasound study of thyroid nodules is the solidity and the presence or absence of calcifications, according to one expert.

These characteristics, not size, should guide a physician's decision about whether to perform a fine-needle aspiration to check for cancer, said Mary C. Frates, M.D., of Brigham and Women's Hospital in Boston.

“There is a misconception that larger size and the presence of a solitary rather than multiple nodules are predictors of malignancy, but this is not true,” she told this newspaper.

Speaking at the annual meeting of the Radiological Society of North America, Dr. Frates outlined her prospective study looking at the likelihood of malignancy based on ultrasound characteristics of more than 1,000 thyroid nodules.

All nodules had a diameter of at least 10 mm and were assessed on ultrasound, followed by ultrasound-guided fine-needle aspiration, as well as surgery when necessary.

The study found a malignancy rate of 11%, confirmed by pathology or cytology, among the 1,060 nodules.

The ultrasound characteristics measured included size, solidity, echogenicity, presence or absence of a halo, margins, presence or absence of calcifications, and whether there were single or multiple nodules.

Imaging indicated that the main differences between malignant and benign nodules lay in their solidity and calcifications.

Nodules that were at least 75% cystic had a low malignancy rate of almost 2%, compared with nodules that were at least 75% solid, which had a malignancy rate of 13%.

The presence of calcifications also was a strong predictor of malignancy. Fine punctate calcifications had the highest malignancy rate, at almost 24%, followed by calcifications on the rim only (17%), and coarse calcifications (16%). Nodules with no calcifications had a malignancy rate of 8%.

When the sonographic characteristics were combined, solitary nodules that were mostly cystic and without calcifications had a very low malignancy rate (2%), whereas solitary, mostly solid nodules with calcifications had a high malignancy rate (34%).

The same trend was seen in nonsolitary nodules. Those that were mostly cystic and without calcifications had a malignancy rate of 1%, while those that were mostly solid with calcifications had a malignancy rate of 19%.

Dr. Frates said ultrasound reports that do not include details about a nodule's solidity and calcifications offer little information regarding its malignancy potential. However, she says the ultrasound information must be considered along with the patient's history.

“The clinical evaluation of the patient is also critical,” she told this newspaper. “There are clinical characteristics that determine which patients are at increased risk for thyroid cancer—patients with a family history, patients with enlarged lymph nodes or hard masses, and patients who were radiated as children,” she said. “You have to consider the clinical history and the imaging findings together.”

Although large size should not influence a physician's decision to aspirate a nodule, Dr. Frates added that small size, under 10 mm, does influence her against a biopsy. And she cautioned physicians against doing unnecessary biopsies.

“By doing unnecessary biopsies, you increase your risk of getting insufficient cells. When you get two or three results that are insufficient, most institutions recommend performing a thyroidectomy because a small percentage of nodules that are persistently nondiagnostic turn out to be cancer,” she explained.

The appropriate management of thyroid nodules remains controversial because thyroid cancer is such a slow-growing disease and is not often fatal, she said.

CHICAGO — The two most important things to gather from an ultrasound study of thyroid nodules is the solidity and the presence or absence of calcifications, according to one expert.

These characteristics, not size, should guide a physician's decision about whether to perform a fine-needle aspiration to check for cancer, said Mary C. Frates, M.D., of Brigham and Women's Hospital in Boston.

“There is a misconception that larger size and the presence of a solitary rather than multiple nodules are predictors of malignancy, but this is not true,” she told this newspaper.

Speaking at the annual meeting of the Radiological Society of North America, Dr. Frates outlined her prospective study looking at the likelihood of malignancy based on ultrasound characteristics of more than 1,000 thyroid nodules.

All nodules had a diameter of at least 10 mm and were assessed on ultrasound, followed by ultrasound-guided fine-needle aspiration, as well as surgery when necessary.

The study found a malignancy rate of 11%, confirmed by pathology or cytology, among the 1,060 nodules.

The ultrasound characteristics measured included size, solidity, echogenicity, presence or absence of a halo, margins, presence or absence of calcifications, and whether there were single or multiple nodules.

Imaging indicated that the main differences between malignant and benign nodules lay in their solidity and calcifications.

Nodules that were at least 75% cystic had a low malignancy rate of almost 2%, compared with nodules that were at least 75% solid, which had a malignancy rate of 13%.

The presence of calcifications also was a strong predictor of malignancy. Fine punctate calcifications had the highest malignancy rate, at almost 24%, followed by calcifications on the rim only (17%), and coarse calcifications (16%). Nodules with no calcifications had a malignancy rate of 8%.

When the sonographic characteristics were combined, solitary nodules that were mostly cystic and without calcifications had a very low malignancy rate (2%), whereas solitary, mostly solid nodules with calcifications had a high malignancy rate (34%).

The same trend was seen in nonsolitary nodules. Those that were mostly cystic and without calcifications had a malignancy rate of 1%, while those that were mostly solid with calcifications had a malignancy rate of 19%.

Dr. Frates said ultrasound reports that do not include details about a nodule's solidity and calcifications offer little information regarding its malignancy potential. However, she says the ultrasound information must be considered along with the patient's history.

“The clinical evaluation of the patient is also critical,” she told this newspaper. “There are clinical characteristics that determine which patients are at increased risk for thyroid cancer—patients with a family history, patients with enlarged lymph nodes or hard masses, and patients who were radiated as children,” she said. “You have to consider the clinical history and the imaging findings together.”

Although large size should not influence a physician's decision to aspirate a nodule, Dr. Frates added that small size, under 10 mm, does influence her against a biopsy. And she cautioned physicians against doing unnecessary biopsies.

“By doing unnecessary biopsies, you increase your risk of getting insufficient cells. When you get two or three results that are insufficient, most institutions recommend performing a thyroidectomy because a small percentage of nodules that are persistently nondiagnostic turn out to be cancer,” she explained.

The appropriate management of thyroid nodules remains controversial because thyroid cancer is such a slow-growing disease and is not often fatal, she said.

CHICAGO — The two most important things to gather from an ultrasound study of thyroid nodules is the solidity and the presence or absence of calcifications, according to one expert.

These characteristics, not size, should guide a physician's decision about whether to perform a fine-needle aspiration to check for cancer, said Mary C. Frates, M.D., of Brigham and Women's Hospital in Boston.

“There is a misconception that larger size and the presence of a solitary rather than multiple nodules are predictors of malignancy, but this is not true,” she told this newspaper.

Speaking at the annual meeting of the Radiological Society of North America, Dr. Frates outlined her prospective study looking at the likelihood of malignancy based on ultrasound characteristics of more than 1,000 thyroid nodules.

All nodules had a diameter of at least 10 mm and were assessed on ultrasound, followed by ultrasound-guided fine-needle aspiration, as well as surgery when necessary.

The study found a malignancy rate of 11%, confirmed by pathology or cytology, among the 1,060 nodules.

The ultrasound characteristics measured included size, solidity, echogenicity, presence or absence of a halo, margins, presence or absence of calcifications, and whether there were single or multiple nodules.

Imaging indicated that the main differences between malignant and benign nodules lay in their solidity and calcifications.

Nodules that were at least 75% cystic had a low malignancy rate of almost 2%, compared with nodules that were at least 75% solid, which had a malignancy rate of 13%.

The presence of calcifications also was a strong predictor of malignancy. Fine punctate calcifications had the highest malignancy rate, at almost 24%, followed by calcifications on the rim only (17%), and coarse calcifications (16%). Nodules with no calcifications had a malignancy rate of 8%.

When the sonographic characteristics were combined, solitary nodules that were mostly cystic and without calcifications had a very low malignancy rate (2%), whereas solitary, mostly solid nodules with calcifications had a high malignancy rate (34%).

The same trend was seen in nonsolitary nodules. Those that were mostly cystic and without calcifications had a malignancy rate of 1%, while those that were mostly solid with calcifications had a malignancy rate of 19%.

Dr. Frates said ultrasound reports that do not include details about a nodule's solidity and calcifications offer little information regarding its malignancy potential. However, she says the ultrasound information must be considered along with the patient's history.

“The clinical evaluation of the patient is also critical,” she told this newspaper. “There are clinical characteristics that determine which patients are at increased risk for thyroid cancer—patients with a family history, patients with enlarged lymph nodes or hard masses, and patients who were radiated as children,” she said. “You have to consider the clinical history and the imaging findings together.”

Although large size should not influence a physician's decision to aspirate a nodule, Dr. Frates added that small size, under 10 mm, does influence her against a biopsy. And she cautioned physicians against doing unnecessary biopsies.

“By doing unnecessary biopsies, you increase your risk of getting insufficient cells. When you get two or three results that are insufficient, most institutions recommend performing a thyroidectomy because a small percentage of nodules that are persistently nondiagnostic turn out to be cancer,” she explained.

The appropriate management of thyroid nodules remains controversial because thyroid cancer is such a slow-growing disease and is not often fatal, she said.

QUEBEC CITY — The long-term complications of childhood type 2 diabetes can stretch beyond the patient and into the next generation, according to new data from the University of Manitoba, Winnipeg.

In a cohort of almost 90 children born to mothers diagnosed with childhood type 2 diabetes, 3 of the 9 children who are older than 7 years have already developed the disease themselves, Elizabeth Sellers, M.D., reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The results are part of an ongoing study led by Heather Dean, M.D., a colleague of Dr. Sellers. The study is looking into the high rate of youth-onset type 2 diabetes in northern Manitoba, where the majority of the population is First Nations Ojee-Cree.

A previous study by Dr. Sellers found that this population has a 14-fold increased risk of youth-onset type 2 diabetes. “We do not yet know how generalizable our findings our to other populations,” Dr. Sellers said.

An earlier study of 76 “graduates” of the first childhood type 2 diabetes cohort, who have now reached early adulthood (ages 18-30), documented 7 deaths, with 5 patients on dialysis for end-stage renal disease, 2 patients with blindness, and 1 who had had an amputation, she said.

That study has also documented a high rate of obstetrical complications among 56 young women in this cohort, with 13 first-trimester miscarriages, 3 second-trimester losses, and 2 stillbirths, Dr. Sellers said.

The latest study, called the Next Generation project, is following the offspring of young adults with type 2 diabetes, who were diagnosed when they themselves were children. These offspring are thought to be at high risk for developing youth-onset type 2 diabetes, and the preliminary findings back that up, she said.

The project will follow the offspring through childhood with annual screening for diabetes and will describe the evolution and natural history of the problem, she said.

QUEBEC CITY — The long-term complications of childhood type 2 diabetes can stretch beyond the patient and into the next generation, according to new data from the University of Manitoba, Winnipeg.

In a cohort of almost 90 children born to mothers diagnosed with childhood type 2 diabetes, 3 of the 9 children who are older than 7 years have already developed the disease themselves, Elizabeth Sellers, M.D., reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The results are part of an ongoing study led by Heather Dean, M.D., a colleague of Dr. Sellers. The study is looking into the high rate of youth-onset type 2 diabetes in northern Manitoba, where the majority of the population is First Nations Ojee-Cree.

A previous study by Dr. Sellers found that this population has a 14-fold increased risk of youth-onset type 2 diabetes. “We do not yet know how generalizable our findings our to other populations,” Dr. Sellers said.

An earlier study of 76 “graduates” of the first childhood type 2 diabetes cohort, who have now reached early adulthood (ages 18-30), documented 7 deaths, with 5 patients on dialysis for end-stage renal disease, 2 patients with blindness, and 1 who had had an amputation, she said.

That study has also documented a high rate of obstetrical complications among 56 young women in this cohort, with 13 first-trimester miscarriages, 3 second-trimester losses, and 2 stillbirths, Dr. Sellers said.

The latest study, called the Next Generation project, is following the offspring of young adults with type 2 diabetes, who were diagnosed when they themselves were children. These offspring are thought to be at high risk for developing youth-onset type 2 diabetes, and the preliminary findings back that up, she said.

The project will follow the offspring through childhood with annual screening for diabetes and will describe the evolution and natural history of the problem, she said.

QUEBEC CITY — The long-term complications of childhood type 2 diabetes can stretch beyond the patient and into the next generation, according to new data from the University of Manitoba, Winnipeg.

In a cohort of almost 90 children born to mothers diagnosed with childhood type 2 diabetes, 3 of the 9 children who are older than 7 years have already developed the disease themselves, Elizabeth Sellers, M.D., reported at the joint annual meeting of the Canadian Diabetes Association and the Canadian Society of Endocrinology and Metabolism.

The results are part of an ongoing study led by Heather Dean, M.D., a colleague of Dr. Sellers. The study is looking into the high rate of youth-onset type 2 diabetes in northern Manitoba, where the majority of the population is First Nations Ojee-Cree.

A previous study by Dr. Sellers found that this population has a 14-fold increased risk of youth-onset type 2 diabetes. “We do not yet know how generalizable our findings our to other populations,” Dr. Sellers said.

An earlier study of 76 “graduates” of the first childhood type 2 diabetes cohort, who have now reached early adulthood (ages 18-30), documented 7 deaths, with 5 patients on dialysis for end-stage renal disease, 2 patients with blindness, and 1 who had had an amputation, she said.

That study has also documented a high rate of obstetrical complications among 56 young women in this cohort, with 13 first-trimester miscarriages, 3 second-trimester losses, and 2 stillbirths, Dr. Sellers said.

The latest study, called the Next Generation project, is following the offspring of young adults with type 2 diabetes, who were diagnosed when they themselves were children. These offspring are thought to be at high risk for developing youth-onset type 2 diabetes, and the preliminary findings back that up, she said.

The project will follow the offspring through childhood with annual screening for diabetes and will describe the evolution and natural history of the problem, she said.

Soy supplementation was not associated with significant improvements in cognition, bone density, or lipid profiles, compared with placebo, in more than 200 older postmenopausal women followed for 1 year, Dutch investigators reported.

The findings conflict with those of previous studies on the subject. “Before now, there were a few clinical trials that suggested some benefits of soy for bone, and at least four that suggested cognitive benefits, and some strong suggestion of lipid improvements, but a lot of those trials were both small and only about 3 months long,” Pauline Maki, Ph.D., of the Center for Cognitive Medicine at the University of Illinois at Chicago, said in an interview.

The current study, a randomized, double-blind, placebo-controlled trial, included 202 healthy women aged 60–75. But because only older women participated in the study, Dr. Maki, who was not involved in the research, said she was not ready to write off the possible benefits of soy in younger postmenopausal women. “There might indeed be some benefit of soy for women if they start it early enough,” she noted.

Study participants were randomly assigned to receive a daily supplement consisting of either 36.5 g of isoflavone-rich powdered soy protein (containing genistein, daidzein, and glycitein) or an equal amount of a powdered milk protein placebo, said Sanne Kreijkamp-Kaspers, M.D., of University Medical Center, Utrecht, the Netherlands, and associates.

Supplementation continued for 12 months. Adherence was checked by measuring plasma genistein levels in the final blood sample. A total of 49 participants dropped out of the trial, divided equally between the soy and placebo groups. Of those who remained, 90% of the women used at least 80% of their supplements over the course of the study (JAMA 2004;292:65–74).

At baseline, both groups performed similarly on cognitive function tests of short-term and long-term verbal and visual memory, naming and verbal fluency, and complex attention. At the end of the study, there were no statistically significant differences in test scores between groups. Body mass index, history of estrogen use, and smoking status did not affect these results.

Plasma lipids were also similar between groups at baseline. At the end of the study the LDL and total cholesterol levels remained constant in the soy group, and the placebo group experienced a small but statistically insignificant decrease.

Overall, bone mineral density (BMD), measured at the hip and lumbar spine using dual-energy x-ray absorptiometry (DXA), had decreased in both groups at the end of the 12 months. One BMD measurement, the intertrochanter region of the hip, was 1.3% higher in the soy group– a significant difference– but “it was only one comparison among 13 BMD measurements and may well be a chance finding,” the investigators said.

When the results were analyzed according to the number of years since a woman's menopause, there was a hint that the timing of soy supplementation may be important–at least for bone. “In women who were recently menopausal, our intervention seemed to improve BMD while in the late menopausal women such effect was absent,” the authors wrote. “However, only the intertrochanter region of the hip showed a statistically significant interaction” with years since menopause.

This subgroup of newly menopausal women did not experience any differences with soy supplementation on their lipid levels or cognitive function, but Dr. Maki holds out hope that earlier supplementation may have a positive effect on cognition.

“The bone data show that the 'estrogenicity' of soy, if you will, was only observed in the younger women. Even though this study does not show a similar effect on cognition, my hope for the cognitive benefits for younger women comes from two other randomized trials that were composed of younger women between the ages of 50 and 65, which did show a cognitive benefit,” she said.

For their part, the researchers acknowledged that their 1-year study might have been too short to fully capture any positive effect of soy supplementation on bone. They also pointed out that many previous studies in men have reported a positive effect of soy supplementation on lipids.

Soy supplementation was not associated with significant improvements in cognition, bone density, or lipid profiles, compared with placebo, in more than 200 older postmenopausal women followed for 1 year, Dutch investigators reported.

The findings conflict with those of previous studies on the subject. “Before now, there were a few clinical trials that suggested some benefits of soy for bone, and at least four that suggested cognitive benefits, and some strong suggestion of lipid improvements, but a lot of those trials were both small and only about 3 months long,” Pauline Maki, Ph.D., of the Center for Cognitive Medicine at the University of Illinois at Chicago, said in an interview.

The current study, a randomized, double-blind, placebo-controlled trial, included 202 healthy women aged 60–75. But because only older women participated in the study, Dr. Maki, who was not involved in the research, said she was not ready to write off the possible benefits of soy in younger postmenopausal women. “There might indeed be some benefit of soy for women if they start it early enough,” she noted.

Study participants were randomly assigned to receive a daily supplement consisting of either 36.5 g of isoflavone-rich powdered soy protein (containing genistein, daidzein, and glycitein) or an equal amount of a powdered milk protein placebo, said Sanne Kreijkamp-Kaspers, M.D., of University Medical Center, Utrecht, the Netherlands, and associates.

Supplementation continued for 12 months. Adherence was checked by measuring plasma genistein levels in the final blood sample. A total of 49 participants dropped out of the trial, divided equally between the soy and placebo groups. Of those who remained, 90% of the women used at least 80% of their supplements over the course of the study (JAMA 2004;292:65–74).

At baseline, both groups performed similarly on cognitive function tests of short-term and long-term verbal and visual memory, naming and verbal fluency, and complex attention. At the end of the study, there were no statistically significant differences in test scores between groups. Body mass index, history of estrogen use, and smoking status did not affect these results.

Plasma lipids were also similar between groups at baseline. At the end of the study the LDL and total cholesterol levels remained constant in the soy group, and the placebo group experienced a small but statistically insignificant decrease.

Overall, bone mineral density (BMD), measured at the hip and lumbar spine using dual-energy x-ray absorptiometry (DXA), had decreased in both groups at the end of the 12 months. One BMD measurement, the intertrochanter region of the hip, was 1.3% higher in the soy group– a significant difference– but “it was only one comparison among 13 BMD measurements and may well be a chance finding,” the investigators said.

When the results were analyzed according to the number of years since a woman's menopause, there was a hint that the timing of soy supplementation may be important–at least for bone. “In women who were recently menopausal, our intervention seemed to improve BMD while in the late menopausal women such effect was absent,” the authors wrote. “However, only the intertrochanter region of the hip showed a statistically significant interaction” with years since menopause.

This subgroup of newly menopausal women did not experience any differences with soy supplementation on their lipid levels or cognitive function, but Dr. Maki holds out hope that earlier supplementation may have a positive effect on cognition.

“The bone data show that the 'estrogenicity' of soy, if you will, was only observed in the younger women. Even though this study does not show a similar effect on cognition, my hope for the cognitive benefits for younger women comes from two other randomized trials that were composed of younger women between the ages of 50 and 65, which did show a cognitive benefit,” she said.

For their part, the researchers acknowledged that their 1-year study might have been too short to fully capture any positive effect of soy supplementation on bone. They also pointed out that many previous studies in men have reported a positive effect of soy supplementation on lipids.

Soy supplementation was not associated with significant improvements in cognition, bone density, or lipid profiles, compared with placebo, in more than 200 older postmenopausal women followed for 1 year, Dutch investigators reported.

The findings conflict with those of previous studies on the subject. “Before now, there were a few clinical trials that suggested some benefits of soy for bone, and at least four that suggested cognitive benefits, and some strong suggestion of lipid improvements, but a lot of those trials were both small and only about 3 months long,” Pauline Maki, Ph.D., of the Center for Cognitive Medicine at the University of Illinois at Chicago, said in an interview.

The current study, a randomized, double-blind, placebo-controlled trial, included 202 healthy women aged 60–75. But because only older women participated in the study, Dr. Maki, who was not involved in the research, said she was not ready to write off the possible benefits of soy in younger postmenopausal women. “There might indeed be some benefit of soy for women if they start it early enough,” she noted.

Study participants were randomly assigned to receive a daily supplement consisting of either 36.5 g of isoflavone-rich powdered soy protein (containing genistein, daidzein, and glycitein) or an equal amount of a powdered milk protein placebo, said Sanne Kreijkamp-Kaspers, M.D., of University Medical Center, Utrecht, the Netherlands, and associates.

Supplementation continued for 12 months. Adherence was checked by measuring plasma genistein levels in the final blood sample. A total of 49 participants dropped out of the trial, divided equally between the soy and placebo groups. Of those who remained, 90% of the women used at least 80% of their supplements over the course of the study (JAMA 2004;292:65–74).

At baseline, both groups performed similarly on cognitive function tests of short-term and long-term verbal and visual memory, naming and verbal fluency, and complex attention. At the end of the study, there were no statistically significant differences in test scores between groups. Body mass index, history of estrogen use, and smoking status did not affect these results.

Plasma lipids were also similar between groups at baseline. At the end of the study the LDL and total cholesterol levels remained constant in the soy group, and the placebo group experienced a small but statistically insignificant decrease.

Overall, bone mineral density (BMD), measured at the hip and lumbar spine using dual-energy x-ray absorptiometry (DXA), had decreased in both groups at the end of the 12 months. One BMD measurement, the intertrochanter region of the hip, was 1.3% higher in the soy group– a significant difference– but “it was only one comparison among 13 BMD measurements and may well be a chance finding,” the investigators said.

When the results were analyzed according to the number of years since a woman's menopause, there was a hint that the timing of soy supplementation may be important–at least for bone. “In women who were recently menopausal, our intervention seemed to improve BMD while in the late menopausal women such effect was absent,” the authors wrote. “However, only the intertrochanter region of the hip showed a statistically significant interaction” with years since menopause.

This subgroup of newly menopausal women did not experience any differences with soy supplementation on their lipid levels or cognitive function, but Dr. Maki holds out hope that earlier supplementation may have a positive effect on cognition.

“The bone data show that the 'estrogenicity' of soy, if you will, was only observed in the younger women. Even though this study does not show a similar effect on cognition, my hope for the cognitive benefits for younger women comes from two other randomized trials that were composed of younger women between the ages of 50 and 65, which did show a cognitive benefit,” she said.

For their part, the researchers acknowledged that their 1-year study might have been too short to fully capture any positive effect of soy supplementation on bone. They also pointed out that many previous studies in men have reported a positive effect of soy supplementation on lipids.

CHICAGO – Children with attention-deficit hyperactivity disorder have anatomical brain abnormalities that can be seen with a novel technique called diffusion tensor imaging.

“Our hope is, in the future, to be able to diagnose ADHD with this technique,” said lead investigator Manzar Ashtari, Ph.D., of North Shore-Long Island Jewish Health System in New Hyde Park, N.Y.

Speaking at a press conference at the annual meeting of the Radiological Society of North America, Dr. Ashtari explained that until now, imaging of the brain in patients with ADHD has revealed mostly “macroscopic” findings.

“For example, we know that the frontal lobe and cerebellum are smaller in these patients.” But she said her work with diffusion tensor imaging (DTI) looks “deeper”–at a more microscopic level–showing abnormalities in the corticopontocerebellar circuit, the fiber pathways that communicate between the frontal lobe and the cerebellum.

The study compared DTI of the brain in 18 children with ADHD, aged 7–11 years, and 15 healthy controls matched for age, sex and socioeconomic status.

“We found abnormalities in the fiber pathways in the frontal cortex, basal ganglia, brain stem, and cerebellum in the ADHD patients,” she said, explaining that these areas of the brain regulate attention, impulsive behavior, motor activity, and inhibition.

“These findings suggest that the circuit which connects the frontal lobe and the cerebellum is not efficient in ADHD,” she said.

Dr. Ashtari was also colead investigator on a second study that used DTI to compare the brain anatomy of 20 children with ADHD, half of whom were medicated for their condition, and half of whom were medication naïve.

Fiber pathway abnormalities are less pronounced in children who have been treated with stimulant medication, compared with those who have not.

“These results are definitely very exciting,” said Dr. Ashtari. “They suggest that perhaps the medication is doing something to normalize the brain abnormalities, such as remyelinating the axons.”

However, she cautions against jumping to the conclusion that the study shows stimulants can reverse, or partially correct, the brain abnormalities seen in ADHD.

“Other studies into the effect of medication have shown that the white matter of the brain increases to close to normal in medicated children. But medicated children also are usually older.

“So could the improvement be just an effect of age–as the brain grows?” she said in an interview.

“The more conclusive study will be to follow drug-naïve children prospectively and then see what happens when you medicate them,” she said.

Dr. Ashtari added that her team has received funding to start such a study of drug-naïve children.

While brain imaging using MRI has mostly revealed macroscopic findings, DTI shows a more microscopic view.

DTI shows frontal cortex and cerebellum abnormalities in an ADHD patient. Photos courtesy Dr. Manzar Ashtari

CHICAGO – Children with attention-deficit hyperactivity disorder have anatomical brain abnormalities that can be seen with a novel technique called diffusion tensor imaging.

“Our hope is, in the future, to be able to diagnose ADHD with this technique,” said lead investigator Manzar Ashtari, Ph.D., of North Shore-Long Island Jewish Health System in New Hyde Park, N.Y.

Speaking at a press conference at the annual meeting of the Radiological Society of North America, Dr. Ashtari explained that until now, imaging of the brain in patients with ADHD has revealed mostly “macroscopic” findings.

“For example, we know that the frontal lobe and cerebellum are smaller in these patients.” But she said her work with diffusion tensor imaging (DTI) looks “deeper”–at a more microscopic level–showing abnormalities in the corticopontocerebellar circuit, the fiber pathways that communicate between the frontal lobe and the cerebellum.

The study compared DTI of the brain in 18 children with ADHD, aged 7–11 years, and 15 healthy controls matched for age, sex and socioeconomic status.

“We found abnormalities in the fiber pathways in the frontal cortex, basal ganglia, brain stem, and cerebellum in the ADHD patients,” she said, explaining that these areas of the brain regulate attention, impulsive behavior, motor activity, and inhibition.

“These findings suggest that the circuit which connects the frontal lobe and the cerebellum is not efficient in ADHD,” she said.

Dr. Ashtari was also colead investigator on a second study that used DTI to compare the brain anatomy of 20 children with ADHD, half of whom were medicated for their condition, and half of whom were medication naïve.

Fiber pathway abnormalities are less pronounced in children who have been treated with stimulant medication, compared with those who have not.

“These results are definitely very exciting,” said Dr. Ashtari. “They suggest that perhaps the medication is doing something to normalize the brain abnormalities, such as remyelinating the axons.”

However, she cautions against jumping to the conclusion that the study shows stimulants can reverse, or partially correct, the brain abnormalities seen in ADHD.

“Other studies into the effect of medication have shown that the white matter of the brain increases to close to normal in medicated children. But medicated children also are usually older.

“So could the improvement be just an effect of age–as the brain grows?” she said in an interview.

“The more conclusive study will be to follow drug-naïve children prospectively and then see what happens when you medicate them,” she said.

Dr. Ashtari added that her team has received funding to start such a study of drug-naïve children.

While brain imaging using MRI has mostly revealed macroscopic findings, DTI shows a more microscopic view.

DTI shows frontal cortex and cerebellum abnormalities in an ADHD patient. Photos courtesy Dr. Manzar Ashtari

CHICAGO – Children with attention-deficit hyperactivity disorder have anatomical brain abnormalities that can be seen with a novel technique called diffusion tensor imaging.

“Our hope is, in the future, to be able to diagnose ADHD with this technique,” said lead investigator Manzar Ashtari, Ph.D., of North Shore-Long Island Jewish Health System in New Hyde Park, N.Y.

Speaking at a press conference at the annual meeting of the Radiological Society of North America, Dr. Ashtari explained that until now, imaging of the brain in patients with ADHD has revealed mostly “macroscopic” findings.

“For example, we know that the frontal lobe and cerebellum are smaller in these patients.” But she said her work with diffusion tensor imaging (DTI) looks “deeper”–at a more microscopic level–showing abnormalities in the corticopontocerebellar circuit, the fiber pathways that communicate between the frontal lobe and the cerebellum.

The study compared DTI of the brain in 18 children with ADHD, aged 7–11 years, and 15 healthy controls matched for age, sex and socioeconomic status.

“We found abnormalities in the fiber pathways in the frontal cortex, basal ganglia, brain stem, and cerebellum in the ADHD patients,” she said, explaining that these areas of the brain regulate attention, impulsive behavior, motor activity, and inhibition.

“These findings suggest that the circuit which connects the frontal lobe and the cerebellum is not efficient in ADHD,” she said.

Dr. Ashtari was also colead investigator on a second study that used DTI to compare the brain anatomy of 20 children with ADHD, half of whom were medicated for their condition, and half of whom were medication naïve.

Fiber pathway abnormalities are less pronounced in children who have been treated with stimulant medication, compared with those who have not.

“These results are definitely very exciting,” said Dr. Ashtari. “They suggest that perhaps the medication is doing something to normalize the brain abnormalities, such as remyelinating the axons.”

However, she cautions against jumping to the conclusion that the study shows stimulants can reverse, or partially correct, the brain abnormalities seen in ADHD.

“Other studies into the effect of medication have shown that the white matter of the brain increases to close to normal in medicated children. But medicated children also are usually older.

“So could the improvement be just an effect of age–as the brain grows?” she said in an interview.

“The more conclusive study will be to follow drug-naïve children prospectively and then see what happens when you medicate them,” she said.

Dr. Ashtari added that her team has received funding to start such a study of drug-naïve children.

While brain imaging using MRI has mostly revealed macroscopic findings, DTI shows a more microscopic view.

DTI shows frontal cortex and cerebellum abnormalities in an ADHD patient. Photos courtesy Dr. Manzar Ashtari