ISUOG Practice Guidelines: ultrasound assessment of fetal biometry and growth

INTRODUCTION These Guidelines aim to describe appropriate assessment of fetal biometry and diagnosis of fetal growth disorders. These disorders consist mainly of fetal growth restriction (FGR), also referred to as intrauterine growth restriction (IUGR) and often associated with small‐for‐gestational age (SGA), and large‐for‐gestational age (LGA), which may lead to fetal macrosomia; both have been associated with a variety of adverse maternal and perinatal outcomes. Screening for, and adequate management of, fetal growth abnormalities are essential components of antenatal care, and fetal ultrasound plays a key role in assessment of these conditions. The fetal biometric parameters measured most commonly are biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur diaphysis length (FL). These biometric measurements can be used to estimate fetal weight (EFW) using various different formulae1. It is important to differentiate between the concept of fetal size at a given timepoint and fetal growth, the latter being a dynamic process, the assessment of which requires at least two ultrasound scans separated in time. Maternal history and symptoms, amniotic fluid assessment and Doppler velocimetry can provide additional information that may be used to identify fetuses at risk of adverse pregnancy outcome. Accurate estimation of gestational age is a prerequisite for determining whether fetal size is appropriate‐for‐gestational age (AGA). Except for pregnancies arising from assisted reproductive technology, the date of conception cannot be determined precisely. Clinically, most pregnancies are dated by the last menstrual period, though this may sometimes be uncertain or unreliable. Therefore, dating pregnancies by early ultrasound examination at 8–14 weeks, based on measurement of the fetal crown–rump length (CRL), appears to be the most reliable method to establish gestational age. Once the CRL exceeds 84 mm, HC should be used for pregnancy dating2–4. HC, with or without FL, can be used for estimation of gestational age from the mid‐trimester if a first‐trimester scan is not available and the menstrual history is unreliable. When the expected delivery date has been established by an accurate early scan, subsequent scans should not be used to recalculate the gestational age1. Serial scans can be used to determine if interval growth has been normal. In these Guidelines, we assume that the gestational age is known and has been determined as described above, the pregnancy is singleton and the fetal anatomy is normal. Details of the grades of recommendation used in these Guidelines are given in Appendix 1. Reporting of levels of evidence is not applicable to these Guidelines.

Antenatal Anxiety: Prevalence and Patterns in a Routine Obstetric Population

Introduction: Expectant mothers may appear anxious even during healthy pregnancies. Unfortunately, little is known about antenatal anxiety, and affected women may remain undetected and untreated. This study aimed to examine the prevalence, incidence, course and associations of high state anxiety in routine obstetric care. Materials and Methods: This was an observational prospective cohort study at a large maternity unit. Obstetric outpatients with low-risk singleton pregnancies were recruited during first trimester consultations. Participants provided sociodemographic data and completed the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale. The STAI was re-administered at each subsequent trimester. Results: Prevalence and incidence of  high state anxiety among 634 completers were 29.5% (95% CI 25.6%-33.6%) and 13.9% (95% CI 9.9%-18.0%), respectively. Anxiety was persistent in 17.0% (95% CI 14.3%-20.2%) and transient in 26.3% (95% CI 23.1%-29.9%). Only persistently anxious participants had high mean second trimester state anxiety scores. Odds for anxiety of greater persistence increased by 29% (95% CI 24%-35%) per 1-point increase in first trimester depression scores, and decreased by 36% (95% CI 7%-56%) with tertiary education. Conclusion: Antenatal anxiety symptoms are common even in normal pregnancies, especially among women with depression and lower education. Our study indicates value in exploring diagnostic criteria and quantitative measures for antenatal anxiety. Key words: Depression, Pregnancy, State-Trait Anxiety Inventory

Antenatal Anxiety: Prevalence and Patterns in a Routine Obstetric Population

INTRODUCTION

Expectant mothers may appear anxious even during healthy pregnancies. Unfortunately, little is known about antenatal anxiety, and affected women may remain undetected and untreated. This study aimed to examine the prevalence, incidence, course and associations of high state anxiety in routine obstetric care.

MATERIALS AND METHODS

This was an observational prospective cohort study at a large maternity unit. Obstetric outpatients with low-risk singleton pregnancies were recruited during first trimester consultations. Participants provided sociodemographic data and completed the State-Trait Anxiety Inventory (STAI) and Edinburgh Postnatal Depression Scale. The STAI was re-administered at each subsequent trimester.

RESULTS

Prevalence and incidence of  high state anxiety among 634 completers were 29.5% (95% CI 25.6%-33.6%) and 13.9% (95% CI 9.9%-18.0%), respectively. Anxiety was persistent in 17.0% (95% CI 14.3%-20.2%) and transient in 26.3% (95% CI 23.1%-29.9%). Only persistently anxious participants had high mean second trimester state anxiety scores. Odds for anxiety of greater persistence increased by 29% (95% CI 24%-35%) per 1-point increase in first trimester depression scores, and decreased by 36% (95% CI 7%-56%) with tertiary education.

CONCLUSION

Antenatal anxiety symptoms are common even in normal pregnancies, especially among women with depression and lower education. Our study indicates value in exploring diagnostic criteria and quantitative measures for antenatal anxiety.

Prediction of neonatal respiratory morbidity by quantitative ultrasound lung texture analysis: a multicenter study

BACKGROUND

Prediction of neonatal respiratory morbidity may be useful to plan delivery in complicated pregnancies. The limited predictive performance of the current diagnostic tests together with the risks of an invasive procedure restricts the use of fetal lung maturity assessment.

OBJECTIVE

The objective of the study was to evaluate the performance of quantitative ultrasound texture analysis of the fetal lung (quantusFLM) to predict neonatal respiratory morbidity in preterm and early-term (<39.0 weeks) deliveries.

STUDY DESIGN

This was a prospective multicenter study conducted in 20 centers worldwide. Fetal lung ultrasound images were obtained at 25.0-38.6 weeks of gestation within 48 hours of delivery, stored in Digital Imaging and Communication in Medicine format, and analyzed with quantusFLM. Physicians were blinded to the analysis. At delivery, perinatal outcomes and the occurrence of neonatal respiratory morbidity, defined as either respiratory distress syndrome or transient tachypnea of the newborn, were registered. The performance of the ultrasound texture analysis test to predict neonatal respiratory morbidity was evaluated.

RESULTS

A total of 883 images were collected, but 17.3% were discarded because of poor image quality or exclusion criteria, leaving 730 observations for the final analysis. The prevalence of neonatal respiratory morbidity was 13.8% (101 of 730). The quantusFLM predicted neonatal respiratory morbidity with a sensitivity, specificity, positive and negative predictive values of 74.3% (75 of 101), 88.6% (557 of 629), 51.0% (75 of 147), and 95.5% (557 of 583), respectively. Accuracy was 86.5% (632 of 730) and positive and negative likelihood ratios were 6.5 and 0.3, respectively.

CONCLUSION

The quantusFLM predicted neonatal respiratory morbidity with an accuracy similar to that previously reported for other tests with the advantage of being a noninvasive technique.

Solutions of some two-sided boundary problems for sums of variables with alternating distributions

In this paper we present a method for obtaining explicit results for some two-sided boundary problems involving sums of independent random variables with alternating distributions. We apply the method to finding the first passage time to either one of two finite barriers, and to some situations arising in queueing and dam theory. The results can be expressed in terms of a finite sum of simple repeated integrals (or sums) of known functions (cf. formulae (3.6)– (3.11)).

Pain Levels after Local Anaesthetic with or without Hyaluronidase in Carpal Tunnel Release: A Randomised Controlled Trial

Purpose. Hyaluronidase is an enzyme that temporarily liquefies the interstitial barrier, allowing easy dispersal of local anaesthetic through cleavage of tissue planes. This prospective, blinded, randomised controlled study investigates the utility of adding hyaluronidase to local anaesthetic in the setting of carpal tunnel release. Methods. 70 consecutive carpal tunnel release patients were recruited and randomised into a control group only receiving local anaesthetic and a hyaluronidase group receiving both hyaluronidase and local anaesthetic. Pain scores were rated using the visual analogue scale (VAS) by patients immediately after local anaesthetic injection and again immediately after the carpal tunnel release. Results. Preoperative VAS scores, taken after local anaesthetic injection, were greater than postoperative VAS scores. Postoperative VAS scores were significantly lower in the hyaluronidase group and tourniquet times were significantly shorter in the hyaluronidase group. Conclusion. Hyaluronidase addition to local anaesthetic in carpal tunnel release resulted in significant reductions in operative time and pain immediately after operation.

Associations of maternal retinal vasculature with subsequent fetal growth and birth size

OBJECTIVE

We aimed to study the maternal retinal microvasculature at mid-trimester and its relationship with subsequent fetal growth and birth size.

METHODS

We recruited 732 pregnant women aged 18-46 years in the first trimester with singleton pregnancies. All had retinal photography and fetal scan performed at 26-28 weeks gestation, and subsequent fetal scan at 32-34 weeks gestation. Infant anthropometric measurements were done at birth. Retinal microvasculature was measured using computer software from the retinal photographs.

RESULTS

In multiple linear regression models, each 10 μm narrowing in maternal retinal arteriolar caliber was associated with decreases of 1.36 mm in fetal head circumference at 32-34 weeks gestation, as well as decreases of 1.50 mm and 2.30 mm in infant head circumference and birth length at delivery, respectively. Each standard deviation decrease in maternal retinal arteriolar fractal dimension was associated with decreases of 1.55 mm in fetal head circumference at 32-34 weeks gestation, as well as decreases of 1.08 mm and 46.42 g in infant head circumference and birth weight at delivery, respectively.

CONCLUSIONS

Narrower retinal arteriolar caliber and a sparser retinal vascular network in mothers, reflecting a suboptimal uteroplacental microvasculature during mid-pregnancy, were associated with poorer fetal growth and birth size.

Contraction in human myometrium is associated with changes in small heat shock proteins

The myometrium undergoes substantial remodeling at the time of labor including rearrangement of the cellular contractile machinery. The regulation of this process in human myometrium at the time of labor is poorly defined, but evidence in other muscle types suggests modulation by small heat shock proteins (sHSP). The aim of this study was to investigate whether similar changes in sHSP occur in the myometrium at labor. Using a quantitative proteomic approach (two-dimensional difference gel electrophoresis), we found a 69% decrease in the sHSP alphaB-crystallin in the myometrium at labor plus multiple isoforms of HSP27. Immunoblotting using phosphospecific HSP27 antibodies (HSP27-serine15, -78, and -82) detected marked changes in HSP27 phosphorylation at labor. Although total HSP27 levels were unchanged, HSP27-Ser15 was 3-fold higher at labor. Coimmunoprecipitation studies showed that HSP27 coprecipitates with alphaB-crystallin and also smooth muscle alpha-actin. Coimmunofluorescence studies demonstrated a relocation of HSP27 from the perinuclear region to the actin cytoskeleton at labor. The functional significance of these changes was demonstrated in vitro where myometrial strips stimulated to contract with oxytocin exhibited increased HSP27-Ser15 phosphorylation. Our findings provide data consistent with a novel pathway regulating human myometrial contraction at labor and identify HSP27 and alphaB-crystallin as potential targets for future tocolytic design.

Functional characterization of human NTRK2 mutations identified in patients with severe early-onset obesity

OBJECTIVE

The neurotrophin receptor TrkB has been implicated in the regulation of energy homeostasis in rodents. We have previously identified four rare missense mutations in the gene encoding TrkB, NTRK2, in 198 severely obese children with developmental delay. We have now undertaken a more detailed analysis of the in vitro functional consequences of the mutations identified: I98V, P660L, T821A and Y722C.

DESIGN

Wild-type and mutant TrkB receptor constructs were stably transfected into PC12 cells and the signaling responses to the endogenous ligand, brain-derived neurotrophic factor (BDNF), were examined by Western blotting of cell lysates. In the case of Y722C, PC12 cells stably expressing this mutant were studied for their ability to respond to BDNF by promoting neurite outgrowth and cell survival.

RESULTS

Further functional characterization of the previously reported Y722C TrkB mutation reveals impaired activation of mitogen-activated protein kinase, phospholipase C-gamma and Akt, as well as reduced BDNF-induced neurite outgrowth and cell survival in stably transfected PC12 cell lines. However, the signaling properties of I98V, P660L and T821A were all indistinguishable from wild type.

CONCLUSION

We provide further evidence for the impairment in signaling by Y722C and show that as well as a loss of signaling, this mutation affects the ability of TrkB to promote neurite outgrowth in response to BDNF. Thus, impaired hypothalamic neurogenesis may contribute to the severe hyperphagia and obesity seen in the individual harboring the Y722C variant. The other three rare TrkB variants do not show reduced autophosphorylation or impaired downstream signaling in vitro and, as yet, it is unclear whether these variants contribute to obesity in these patients.

Inflammatory aetiology of human myometrial activation tested using directed graphs

There are three main hypotheses for the activation of the human uterus at labour: functional progesterone withdrawal, inflammatory stimulation, and oxytocin receptor activation. To test these alternatives we have taken information and data from the literature to develop causal pathway models for the activation of human myometrium. The data provided quantitative RT-PCR results on key genes from samples taken before and during labour. Principal component analysis showed that pre-labour samples form a homogenous group compared to those during labour. We therefore modelled the alternative causal pathways in non-labouring samples using directed graphs and statistically compared the likelihood of the different models using structural equations and D-separation approaches. Using the computer program LISREL, inflammatory activation as a primary event was highly consistent with the data (p = 0.925), progesterone withdrawal, as a primary event, is plausible (p = 0.499), yet comparatively unlikely, oxytocin receptor mediated initiation is less compatible with the data (p = 0.091). DGraph, a software program that creates directed graphs, produced similar results (p= 0.684, p= 0.280, and p = 0.04, respectively). This outcome supports an inflammatory aetiology for human labour. Our results demonstrate the value of directed graphs in determining the likelihood of causal relationships in biology in situations where experiments are not possible.

This paper describes how novel computational approaches have been used to test hypotheses for important physiological events when the traditional approaches of animal studies and experiment are not possible. The processes that regulate the onset of human labour are presently unknown, principally because there are no good animal models for human pregnancy and because it is unethical to conduct experiments on pregnant women undergoing labour. However, several hypotheses have been advanced to explain the trigger for labour, including: a functional withdrawal of the hormone progesterone, increased inflammation in the uterus, and increased signalling through the hormone oxytocin. To test these hypotheses the researchers used data on the messenger RNA concentrations of critical variables in samples of uterine muscle taken from 12 women undergoing caesarean section prior to labour and 12 women during labour. Directed graphs for each of the proposed hypotheses were then generated, where the graphs represent the direction of causal influence between different variables. Statistical testing determined how well the graphs of each hypothesis matched the experimental data. The results strongly support an inflammatory origin for the onset of human labour. This approach could be applied to other problems in human biology where the traditional approaches of experiments and animal models are not possible.

The Randomized Nitric Oxide Tocolysis Trial (RNOTT) for the treatment of preterm labor

OBJECTIVE

This study was undertaken to assess the effectiveness of glyceryl trinitrate (GTN) patches in comparison with beta2 sympathomimetics (beta2) for the treatment of preterm labor.

STUDY DESIGN

A multicenter, multinational, randomized controlled trial was conducted in tertiary referral teaching hospitals. Women in threatened preterm labor with positive fetal fibronectin or ruptured membranes between 24 and 35 weeks' gestation were recruited and randomly assigned to either beta2 or GTN with rescue beta2 tocolysis if moderate-to-strong contractions persisted at 2 hours. Obstetric and neonatal outcomes were assessed.

RESULTS

Two hundred thirty-eight women were recruited and randomly assigned, 117 to beta2 and 121 to GTN. On a strict intention-to-treat basis, there was no significant difference in the time to delivery using Kaplan-Meier curves (P = .451). At 2 hours, 27% of women receiving beta2 had moderate or stronger contractions compared with 53% in the GTN group (P < .001). This led to 35% of women in the GTN group receiving rescue treatment. If delivery or requirement for beta2 rescue are regarded as treatment failure, then a significant difference was observed between the 2 arms (P = .0032). There were no significant differences in neonatal outcomes.

CONCLUSION

GTN is a less efficacious tocolytic compared with ss2 sympathomimetics.

Genetic variants of insulin receptor substrate-1 (IRS-1) in syndromes of severe insulin resistance. Functional analysis of Ala513Pro and Gly1158Glu IRS-1

AIMS

To define further the role of IRS-1 mutations in human syndromes of severe insulin resistance.

METHODS

The IRS-1 gene was scanned for mutations in 83 unrelated affected subjects and 47 unaffected individuals using fluorescent single-strand conformation polymorphism (fSSCP) analysis. A novel heterozygous mutation, Gly1158Glu, was found in one affected subject. Four and two subjects were heterozygous for the previously reported variants Gly972Arg and Ala513Pro, respectively. The previously identified variant Gly819Arg was found in one affected and one unaffected subject. While Gly972Arg has been described to alter the signalling properties of IRS-1, no functional studies of Ala513Pro or Gly1158Glu have been reported.

RESULTS

Chinese hamster ovary (CHO) cells stably over-expressing the insulin receptor were transiently transfected with vectors expressing either wild-type, Glu1158 or Pro513 IRS-1. A modest increase in insulin-stimulated tyrosine phosphorylation of Glu1158 IRS-1 was observed. However, this did not result in any significant change in the association of Grb2 or the p85 alpha subunit of PI3-kinase or of PI3-kinase activity. In parallel studies, the Pro513 IRS-1 variant was indistinguishable from wild-type IRS-1.

CONCLUSIONS

While subtle effects of these variants cannot be excluded in this system, it is unlikely that these variants are responsible for the extreme insulin resistance seen in the subjects harbouring them. Although IRS proteins play a central role in insulin signalling, functionally significant mutations in the IRS-1 gene are a rare cause of human syndromes of severe insulin resistance.

Human myometrial genes are differentially expressed in labor: a suppression subtractive hybridization study

Human parturition is effected by a cascade of factors, of which many are unknown. We aim to identify the genes that are changed by labor in the human myometrium by suppression subtractive hybridization. We also seek to ascertain whether these genes are differentially expressed in the myometrium at the upper or fundal and lower segments of the uterus. Term myometrial tissues were obtained from laboring and nonlaboring women undergoing cesarean section after obtaining informed consent. Total RNA was used in suppression subtractive hybridization (CLONTECH PCR Select) to produce two subtracted cDNA libraries enriched for genes expressed during or before labor, labor and not-in-labor libraries, respectively. Dot blot screening of 400 positive clones, constituting 20% of the two subtracted libraries, revealed 30 differentially expressed clones, 14 of which were up-regulated by labor. Among the 10 known genes that were up-regulated in labor, 6 had apparent immune regulatory and inflammatory roles. Three are well-known inflammatory mediators and modulators that were previously linked with parturition: IL-8, manganese superoxide dismutase (MnSOD), and metalloproteinase-9. Three others, interferon-inducible 1-8d gene, elongation factor 1alpha, and nucleophosmin, have not been previously linked with labor. Constitutively expressed genes, including cyclophilin and alpha-actin, were found to be altered by labor. Quantitative real-time RT-PCR using Taqman probes further confirmed the up-regulation of some of these genes. The amounts of the specific genes assayed were standardized to 18S ribosomal RNA and are expressed as mean +/- SEM. Quantitative real-time RT-PCR showed that IL-8 mRNA rose from 0.003 +/- 0.002 in nonlaboring samples (n = 38) to 0.24 +/- 0.11 (n = 20) in gestational-age-matched spontaneously laboring women (P = 0.035). Similarly, MnSOD rose from 0.11 +/- 0.02 (n = 24) to 1.23 +/- 0.56 (n = 24) in gestational-age-matched women (P = 0.047). Additionally, cyclophilin, often used as a constitutive or housekeeping gene marker, increased from 0.0008 +/- 0.0002 (n = 6) to 0.002 +/- 0.0004 (n = 6; P = 0.008) during labor. Notably, MnSOD mRNA was differentially distributed between the upper (0.63 +/- 0.18) and lower (0.15 +/- 0.05; n = 15; P = 0.022) segments of the uterus, but IL-8 was not (n = 17; P = 0.97). Induced labor further showed significantly higher levels of IL-8 (0.63 +/- 0.21; n = 14) than spontaneous labor (0.22 +/- 0.11; n = 20; P = 0.046), but not MnSOD (P = 0.1). This work identifies novel as well as known genes that were not previously associated with parturition. It extends previous data indicating that there is differential expression of some, but not all genes within the gravid human uterus. Inflammatory genes constitute a major proportion of the known genes found to be up-regulated in labor, lending support to the hypothesis of an inflammatory mechanism for human parturition. This work further indicates that many factors associated with human labor and their complex interactions remain to be elucidated.

Progesterone withdrawal and estrogen activation in human parturition are coordinated by progesterone receptor A expression in the myometrium

In human parturition, progesterone withdrawal and estrogen activation are not mediated by changes in progesterone and estrogen levels. Instead, these events could be facilitated by changes in the responsiveness of the myometrium to progesterone and estrogens via changes in PR and ER expression. We hypothesized that functional progesterone withdrawal occurs by increased expression of the type A PR (PR-A), which suppresses progesterone responsiveness, and that functional estrogen activation occurs by increased myometrial expression of ERalpha and/or ERbeta. To test this hypothesis we compared the abundance of mRNAs (assessed by quantitative RT-PCR) encoding PR-A, PR-B, ERalpha, and ERbeta in nonlaboring (n = 12) and laboring (n = 12) term human myometrium. PR-A, PR-B, the PR-A/PR-B mRNA ratio, and ERalpha mRNA were significantly increased in laboring myometrium, whereas ERbeta mRNA was low and unchanged. The PR-A/PR-B mRNA ratio correlated positively with ERalpha mRNA levels in nonlaboring myometrium and with HOXA10 mRNA levels in laboring myometrium. Because progesterone inhibits ERalpha and HOXA10 expression, these findings indicate that myometrial progesterone responsiveness is inversely related to the extent of expression of PR-A relative to PR-B. ERalpha mRNA levels correlated positively with cyclooxygenase type 2 and oxytocin receptor mRNA levels in nonlaboring myometrium, indicating that the increase in ERalpha expression is directly associated with the activation of contraction-associated genes and estrogen responsiveness. These data indicate that in the term human myometrium, responsiveness to progesterone is controlled by the expression of PR-A relative to PR-B and that a significant increase in this ratio underlies functional progesterone withdrawal. Our data also indicate that functional estrogen activation occurs by increased expression of ERalpha and is linked to functional progesterone withdrawal. Interaction between the PR and ER systems in the human myometrium may be critical for the control of human parturition and the coordination of progesterone withdrawal and estrogen activation required for parturition.

Identification of Chlamydia trachomatis antigens recognized by human CD4+ T lymphocytes by screening an expression library

Identification of the immunogenic proteins that induce Chlamydia trachomatis (CT)-specific T cell responses is crucial to the development of protective vaccines and understanding the mechanisms of chlamydia-induced pathology. To characterize the targets of the human T cell response we have used chlamydia-reactive human T cell clones as cellular probes to screen a CT genomic library expressed in Escherichia coli using peripheral blood mononuclear cells to present antigens. The library was screened with three chlamydia-reactive T cell clones of unknown specificity and three novel stimulatory chlamydia antigens were identified. These E. coli recombinants were shown to express the chlamydia proteins, enolase, pmpD and CT579. Enolase and pmpD proteins were purified and shown to induce the proliferation of synovial fluid mononuclear cells isolated from the knee joints of patients suffering from chlamydia-associated reactive arthritis. We suggest that these stimulatory antigens are common targets of the T cell response in this group of patients. A greater understanding of T cell-mediated immunity in uncomplicated CT infection, and in patients with CT-induced chronic inflammatory disease (trachoma, salpingitis, arthritis) may identify the principal immune responses associated with immunopathology.

Pathological missense mutations of neural cell adhesion molecule L1 affect homophilic and heterophilic binding activities

Mutations in the gene for neural cell adhesion molecule L1 (L1CAM) result in a debilitating X-linked congenital disorder of brain development. At the neuronal cell surface L1 may interact with a variety of different molecules including itself and two other CAMs of the immunoglobulin superfamily, axonin-1 and F11. However, whether all of these interactions are relevant to normal or abnormal development has not been determined. Over one-third of patient mutations are single amino acid changes distributed across 10 extracellular L1 domains. We have studied the effects of 12 missense mutations on binding to L1, axonin-1 and F11 and shown for the first time that whereas many mutations affect all three interactions, others affect homophilic or heterophilic binding alone. Patient pathology is therefore due to different types of L1 malfunction. The nature and functional consequence of mutation is also reflected in the severity of the resultant phenotype with structural mutations likely to affect more than one binding activity and result in early mortality. Moreover, the data indicate that several extracellular domains of L1 are required for homophilic and heterophilic interactions.

Using explanatory models to understand chronic symptoms of Cambodian refugees

BACKGROUND

Case reports indicate that understanding patients' "explanatory models" can improve diagnosis, patient compliance, and satisfaction. However, few studies have examined explanatory models within specific cultural groups to understand their symptoms.

METHODS

Seventy-six older Cambodian refugees were interviewed using measures of symptom frequency, explanatory models, help-seeking patterns, and use of traditional Cambodian remedies. Psychiatric patients were compared with non-patients.

RESULTS

Headache was the most common symptom, reported by 58% of those interviewed, and also the most frequent chief complaint (41%). Headache was reported in both groups but was reported by significantly more psychiatric patients. Headache was positively associated with the diagnosis of depression. More than half explained their headaches as a result of sadness, grief, and anxiety. Explanatory models did not differ significantly between groups. All participants maintained Cambodian medical beliefs, and 83% used traditional Cambodian remedies.

CONCLUSIONS

Results suggest a high prevalence of headache among older Cambodian refugees, for whom it may be a manifestation of depression. Emphasis on this somatic complaint does not preclude patients' recognition of psychological factors. Addressing explanatory models can help clinicians determine underlying etiology and understand challenging patients.

Ethical considerations in Asian and Pacific Island elders

A brief overview of the demographic and psychosocial characteristics and medical problems of African Americans age 65 and older provide the context for a discussion of the mental health issues of older African Americans. With this background, specific concerns regarding diagnostic bias are reviewed. Existing epidemiologic data on the prevalence of psychiatric symptoms and disorders are summarized and the specific mental health issues affecting older African Americans are described. Specific research strategies are suggested to address the areas of absent data.

Effects of a geriatric clinic on functional health and well-being of elders

Using a prospective, randomized design, the effects on self-reported functional health and well being of 18 months of primary outpatient care in a geriatric clinic staffed by a multidisciplinary team with geriatric training were compared with traditional Veterans Administration care for 205 elders. Significantly less decline in functional health was found for the geriatric clinic participants on the total Sickness Impact Profile (SIP) (M = .18 vs. 3.12, p = .029) and its physical dimension (M = .28 vs. 4.39, p = .011), but not for the psychosocial dimension of the SIP, life satisfaction, depression, self-rated health, or affect balance. In addition, twice as many geriatrics clinic patients died (p = .10) during the study. Further clarification of the impact of a multidisciplinary geriatrics clinic on health outcomes and cost in VA and other settings are needed prior to recommending that this model of geriatric health care be adopted.

Successful components of interdisciplinary education

Although interdisciplinary education of health care professionals for more effective health care provision has been widely recommended, barriers such as specialization and lack of recognition and support for interdisciplinary teaching remain. This paper presents ten ideas for developing successful interdisciplinary curricula as suggested in the allied health literature. Implementation of the ideas is illustrated by examples from a clinical geriatric course involving physical therapy, physician assistant, nurse practitioner, and medical students.

An interdisciplinary teaching program in geriatrics for physician's assistants

An interdisciplinary curriculum committee within the Division of Family Medicine, Stanford University Medical Center, developed and taught a beginning course in clinical geriatrics for medical students and student physician's assistants, physical therapists, and nurse practitioners. Through a series of Saturday classes held in community facilities serving seniors, physician's assistant students had the opportunity to learn clinical geriatrics from a faculty team including a physician's assistant, physician, nurse, physical therapist, social worker, gerontologist, and health educator. Local seniors served as consumer consultants and models of health and vigor. This interdisciplinary approach was modeled by the faculty to demonstrate the need for a team approach to deliver quality care to seniors. In this well-received course, the role of the physician's assistant in health care was made evident to their future physician employers and physical therapy co-workers through faculty modeling as well as through informal contacts and patient conferences. Older people constitute a growing and increasingly medically underserved population. Team training may serve to stimulate physician's assistant students to include geriatrics in their career plans while educating their future physician employers about their role.