Virtual reality-guided mindfulness for chronic pain in cancer survivors: protocol for the virtual mind study-a single-group feasibility trial

Background

Chronic cancer-related pain (CRP) can have a significant negative impact on quality of life. Mindfulness is hypothesized to mitigate chronic CRP by regulating both physical and emotional resistance to pain. In recent years, there has been interest in the use of virtual reality (VR) to deliver mindfulness meditation. VR provides an immersive and engaging environment, which may enhance one's focused attention to present-moment experiences, potentially making mindfulness less effortful and more efficacious for individuals with chronic pain. There has been little research in this area for people with a history of cancer.

Objective

The aim of this mixed methods study is to evaluate the feasibility of a VR-guided mindfulness (VRGM) intervention offered to adult cancer survivors with chronic CRP.

Methods

This mixed methods feasibility study will employ a single-arm, pretest-posttest design with semistructured interviews. In total, 15 cancer survivors will be enrolled in a 6-week home-based intervention that consists of 10-15 min of daily VRGM practice. The primary outcome is feasibility as assessed by accrual rates, retention in the study, intervention adherence, questionnaire completion, and side effect rates. Participants will be assessed on psychosocial outcome measures (i.e., pain, sleep, depressive and anxiety symptoms, fatigue, quality of life, and mindfulness) before and after the intervention, and 6 weeks post intervention (follow-up). Changes in pain will be described in relation to levels of immersion and presence in the virtual environment, trait mindfulness, and amount of VRGM practice. Qualitative information will provide subjective detail on participants' experience with VRGM to complement quantitative data. This study has been approved by the Health Research Ethics Board of Alberta Cancer Committee (HREBA.CC-20-0411).

Conclusions

This novel intervention provides a potential alternative treatment to pharmacological pain management. Results from this study may inform future larger VGRM trials for chronic CRP to help reduce suffering in people with cancer. Study findings will be disseminated through open access publications, traditional conference presentations, professional cancer organizations, and social media platforms.

Making sense of the cancer journey: Pediatric cancer survivors' and their parents' autobiographical memories

PURPOSE

Youth diagnosed with acute lymphoblastic leukemia (ALL) and their caregiver's experience a myriad of challenges in all domains of health that extend beyond treatment. Yet, little is known about how the cancer experience, and recollections associated with the experience, impact survivorship. We explored pediatric ALL survivors' and their caregivers' autobiographical memories of the cancer experience from diagnosis onwards.

METHODS

Survivors of ALL, and one of their caregivers, were recruited through a local clinic. Survivors and their caregivers completed a demographic survey and semi-structured, private, one-on-one interviews. Demographic information were analyzed using descriptive statistics. Interviews were transcribed verbatim and analyzed using reflexive thematic analysis at the level of the individual and dyad.

RESULTS

Insights from survivors (N = 19; Mage = 15.3 years) and their caregivers (n = 19; Mage = 45.4 years) were captured. Analyses generated two themes contingent on role (i.e., survivor or caregiver): (1) It is hard to recall my cancer experience and (2) We did as much as we could to manage our child's cancer experience and two unified themes (present in both survivors and their caregivers): (3) It took a village to get through the cancer experience and (4) The cancer diagnosis and experience has had a lasting impact.

CONCLUSIONS

Findings highlight the varied and long-lasting ways cancer impacts survivors of pediatric ALL and their caregivers. Survivors had difficultly remembering their experience or felt that information was withheld and were acutely aware of their caregiver's distress. Caregivers were cautious and intentionally limited the information they shared.

IMPLICATIONS FOR CANCER SURVIVORS

Survivors desired to be included within, or told about, decisions related to their healthcare and were acutely aware of their caregiver's distress. Efforts should be made to communicate with survivors (from diagnosis onward) openly and to consider strategies to minimize the short- and long-term impacts of pediatric ALL among survivors and their caregivers.

Internet-Delivered Cognitive Behavioral Treatment for Chronic Pain in Adolescent Survivors of Childhood Cancer: Protocol for a Single-Group Feasibility Trial

BACKGROUND

There are over 500,000 survivors of childhood cancer in North America alone. One in 4 survivors experiences chronic pain after treatment has been completed. Youths with chronic pain report increased anxiety, depression, activity limitations, and sleep disturbances. An 8-week web-based cognitive behavioral treatment for chronic pain (Web-Based Management of Adolescent Pain [WebMAP]) has demonstrated a reduction in pain in youths but has not yet been explored in survivors.

OBJECTIVE

The objectives of this study are to (1) test the feasibility and acceptability of WebMAP for a sample of survivors with chronic pain and their parents; (2) assess the acceptability of WebMAP using qualitative interviews; (3) assess WebMAP's effect on activity limitations, pain intensity, depression and anxiety symptoms, and sleep disturbances; and (4) assess WebMAP's effect on parent pain catastrophizing and parental response to their child's pain.

METHODS

A single-arm mixed methods pre-post intervention study design will be used. Participants will be 34 survivors and at least one of their parents or caregivers. Inclusion criteria are (1) a cancer history, (2) current age of 10-17 years, (3) >2 years post treatment or >5 years post diagnosis, (4) pain present over prior 3 months impairing >1 area of daily life and occurring >1 time per month, and (5) computer access with broadband internet. Survivors will complete a pretreatment questionnaire, which will include the following: the Child Activity Limitations Interview, the pain intensity Numerical Rating Scale, Patient-Reported Outcomes Measurement Information System (PROMIS)-Pain Interference, Anxiety, Depression, Insomnia Severity Index, and Adolescent Sleep Wake Scale. Parents will complete the Pain Catastrophizing Scale-Parent Version and the Adult Responses to Child Symptoms. Upon completion of pretreatment questionnaires (T0), survivors will begin WebMAP. After the 8-week intervention, survivors will complete the same measures (T1), and at 3-month follow-up (T2). Posttreatment interviews will be conducted to determine acceptability. Feasibility will be assessed via recruitment and retention rates. Treatment engagement will be measured by number of modules completed. Pre-post outcome data will be assessed using linear mixed models. Qualitative data will be analyzed using thematic analysis. Patient partners will be involved in study design, recruitment, interpretation of results, and knowledge translation.

RESULTS

This study has been funded in January 2022. Data collection started in May 2022 and is projected to end in August 2023. We have enrolled 10 participants as of December 2022.

CONCLUSIONS

Investigating whether WebMAP is useful to survivors will be an important step in improving pain management in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05241717; https://clinicaltrials.gov/ct2/show/NCT05241717.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45804.

Exploring pain among young people who have completed treatment for acute lymphoblastic leukemia: experiences of youth and caregivers

PURPOSE

Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed among individuals <14 years of age. The disease and its treatments are associated with negative side effects, including pain, which is both prevalent and distressing. Little is known about pain experiences in this population, which has slowed efforts to identify strategies to mitigate and cope with this adverse effect. This study sought to explore youth's and their caregiver's experiences with, and perspectives of, pain in the context of pediatric cancer treatment.

METHODS

Youth and one of their caregivers were recruited through (omitted for peer review). Following completion of a demographic survey, youth and one of their caregivers were interviewed separately using a semi-structured, one-on-one interview guide. Demographic information was analyzed with descriptive statistics, and interviews were transcribed verbatim and analyzed using reflexive thematic analysis.

RESULTS

Youth (n = 19; M_age = 15.3 years) and caregiver (n = 19; M_age = 45.4 years) perspectives informed 4 themes: (1) my pain experience is nuanced, multidimensional, and is changing over time; (2) the cancer experience has changed the way I experience and respond to pain; (3) I used strategies to manage pain, and not all of them worked; and (4) my pain experience was influenced by people around me.

CONCLUSIONS

Findings extend prior work, suggesting that pain is common, distressing, multidimensional, and influenced by social context. Results highlight the number of ways in which youth and their caregivers attempt to manage their pain and factors influencing pain experiences. Greater efforts are needed to address pain during cancer treatment and survivorship.

Measuring Fear of Cancer Recurrence in Survivors of Childhood Cancer: Development and Preliminary Validation of the FCRI-Child and FCRI-Parent Versions

OBJECTIVE

Fear of cancer recurrence (FCR) is a common and distressing psychosocial concern for adult cancer survivors. Data on this construct in child survivors is limited and there are no validated measures for this population. This study aimed to adapt the Fear of Cancer Recurrence Inventory-Short Form (FCRI-SF) for survivors of childhood cancer aged 8-18 years (FCRI-C) and their parents (FCRI-P) to self-report on their own FCR and to examine the initial psychometric properties.

METHODS

The FCRI-SF was adapted through expert panel input and cognitive interviews with child survivors <18 years. The factor structure, internal consistency and construct and criterion validity of the FCRI-C and FCRI-P were examined in 124 survivors of childhood cancer (43% female; M_age =14.58 years, SD=2.90) and 106 parents (90% mothers).

RESULTS

All FCRI-SF items were retained for the FCRI-C with simplified language. The internal consistencies of the FCRI-C (α= .88) and FCRI-P (α= .83) were good. Exploratory factor analyses yielded one-factor structures for both measures. Higher scores on the FCRI-C and FCRI-P were associated with greater intolerance of uncertainty and pain catastrophizing. Higher child FCR was also related to more hypervigilance to bodily symptoms. Parents with higher FCR reported contacting their child's doctors and nurses and scheduling medical appointments for their child more frequently. Children reported significantly lower FCR compared to parents.

CONCLUSIONS

The FCRI-C and FCRI-P demonstrated strong reliability and preliminary validity. This study offers preliminary data to support the use of the FCRI-C and FCRI-P to measure FCR in survivors of childhood cancer aged 8-18 years and their parents. This article is protected by copyright. All rights reserved.

The pain of survival: Prevalence, patterns, and predictors of pain in survivors of childhood cancer

OBJECTIVE

Survivors of childhood cancer experience late effects as a result of their cancer treatment. Evidence for the prevalence of pain as a late effect has been equivocal. This study aimed to describe the prevalence and patterns of pain and biospsychosocial variables that may be related to pain in this population.

METHOD

Survivors of childhood cancer (n = 299; 52.5% male; median age = 16.1[4.6-32.6] years; years off therapy = 9.1[2.0-23.7]) were included. Survivors completed a health assessment questionnaire as part of their long-term survivor clinic appointment (median = 3.0 appointments, range = 1.0-7.0) annually or biannually between 2014 and 2017 (Time 1-Time 4). Prevalence of pain was examined and latent class analysis (LCA) was used to identify patterns of pain based on longitudinal reports of pain. Binary logistic regression examined biopsychosocial variables at Time 1 (T1) associated with class membership.

RESULTS

Forty-seven percent of survivors reported pain during at least one clinic visit. Headaches were the most prevalent type of pain (26.4%). Survivors of Wilms' Tumor and Ewing's Sarcoma reported the highest prevalence of pain (51.5% and 50.0%, respectively). LCA revealed two clinically relevant profiles: "infrequent or no pain" (74.3%) and "persistent pain" (25.7%). Logistic regression showed that female sex (odds ratio, OR = 2.69, 95% confidence interval, CI [.99, 7.31]), depressive symptomatology at T1 (OR = 2.27, 95% CI [1.31, 3.94]), and drinking to intoxication at T1 (OR = 3.07, 95% CI [1.03, 9.15]), were related to persistent pain.

CONCLUSION

Pain is prevalent among survivors of childhood cancer. Future research should characterize the experience of pain in this population so interventions may be developed. Assessment of pain during regular long-term follow-up appointments is warranted. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Worry about somatic symptoms as a sign of cancer recurrence: prevalence and associations with fear of recurrence and quality of life in survivors of childhood cancer

OBJECTIVE

Somatic symptoms (e.g., pain, fatigue) are common after childhood cancer and are associated with greater fear of cancer recurrence and poorer health-related quality of life (HRQoL). Qualitative studies indicate that survivors of childhood cancer (SCCs) worry about somatic symptoms as indicating cancer recurrence, which could in part explain associations between symptoms and poorer psychosocial outcomes. However, the prevalence, characteristics, and impact of symptom worry has not been quantitatively studied.

METHODS

SCCs (N = 111; 52% female; Mage at study = 17.67 years, range = 8-25 years; Mage at diagnosis = 6.70 years) across a variety of diagnoses were recruited from a pediatric cancer center in Canada and completed self-report measures of symptom worry, symptom frequency, general anxiety, fear of cancer recurrence, and HRQoL.

RESULTS

A majority (62%) of SCCs worried about at least one symptom as a sign of recurrence. Pain was the most worrisome symptom, but SCCs also reported worrying about symptoms that are rarely associated with cancer recurrence such as hunger, dizziness, and feeling cold. Symptom worry was more strongly associated with fear of cancer recurrence than the mere frequency of those symptoms, and this relationship held while controlling for treatment factors and general anxiety. Symptom worry and frequency each explained unique variance in HRQoL.

CONCLUSIONS

Worry about somatic symptoms as a sign of cancer recurrence is common and may be impactful after childhood cancer. Excessive worry about somatic symptoms could be an important target to reduce fear of recurrence and increase HRQoL in SCCs.

Childhood Cancer Survivorship: Daily Challenges

Survivors of childhood cancer are at risk of experiencing fatigue, pain, lower levels of physical activity, increased engagement in risky health behavior, and poor social adjustment, after finishing treatment. Risks are more pronounced for survivors of specific diagnoses or receiving specific treatment protocols. Interventions to address these outcomes are in their infancy. Future research should focus on exploring the antecedents and consequences of these outcomes. In the meantime, researchers and cancer centers should attempt to provide high-quality and accessible health information to survivors through various media outlets to encourage healthy behaviors.

The Intergenerational Transmission of Chronic Pain from Parents to Survivors of Childhood Cancer

BACKGROUND

Among youth with chronic non-cancer pain, 50% have parents with chronic pain. These youth report significantly more pain interference and posttraumatic stress symptoms (PTSS), and worse health-related quality of life (HRQL) than youth whose parents do not have chronic pain. Additionally, parent chronic pain is linked to increased child anxiety and depressive symptoms. Survivors of childhood cancer (SCCs) are at risk of pain and negative psychosocial outcomes and therefore may be especially vulnerable if their parents have chronic pain. Thus, the aims of the current study were to (1) identify rates of chronic pain among parents of SCCs, (2) test group differences in psychological symptoms in parents with chronic pain versus without, and (3) test group differences in pain interference, HRQL, anxiety, depression, and PTSS in SCCs with parents with chronic pain versus without.

METHODS

122 SCCs (Mean age = 15.8, SD = 4.8, 45.7% male, Mean age at diagnosis = 5.9, SD = 4.7) and their parents were recruited from across Canada to complete online questionnaires. Parents were asked if they have had pain for at least three consecutive months and completed the brief symptom inventory (BSI) as a measure of psychological symptomatology. Survivors completed the pain questionnaire, patient reported outcomes measurement information system (PROMIS)-pain interference, anxiety, and depression measures, child posttraumatic stress scale, posttraumatic stress disorder checklist for the Diagnostic and Statistical Manual of Mental Disorders, and the pediatric quality of life inventory.

RESULTS

Forty-three (39%) parents of SCCs reported having chronic pain. Of the 29 survivors who had chronic pain, 14 (48%) also had parents with chronic pain. Parents with chronic pain reported significantly higher scores on the BSI than parents without chronic pain, F(1, 116) = 5.07, p = 0.026. SCCs with parents with versus without chronic pain reported significantly higher PTSS F(1, 105) = 10.53, p = 0.002 and depressive symptoms F(1, 102) = 6.68, p = 0.011. No significant differences were found across the other variables tested.

CONCLUSIONS

Findings suggest that survivors' parents' own pain is prevalent and is related to survivors' increased depressive symptoms and PTSS, but not anxiety, pain interference, or HRQL. Future research should explore whether parents may benefit from psychological intervention after their child has been diagnosed with cancer and how this could improve outcomes for their child.

Fear of cancer recurrence among survivors of childhood cancer

OBJECTIVES

Fear of cancer recurrence (FCR) has not been widely explored in survivors of childhood cancer. Yet, childhood survivors are at risk of experiencing late effects and may be especially vulnerable. The aims of the current study were to conduct a retrospective chart review to determine the prevalence and persistence of FCR among survivors of childhood cancer and to examine factors that may be related to FCR.

METHODS

Survivors of childhood cancer (n = 228, mean attained age = 14.5 years [range = 4.7-21 years]; mean diagnosis age = 4.4 years [range = 0-16.5 years]; mean time off treatment = 8.7 years [range = 2.8-19.3 years]) seen in a Long-Term Survivor Clinic (LTSC) completed questionnaires at each clinic visit detailing their current health. FCR was measured with a single item. Data from questionnaires from 2011 to 2018 were analyzed retrospectively. Descriptive statistics and a random effects model were used to address study aims.

RESULTS

FCR was reported in 43% (n = 98) of survivors at least once across all clinic visits. Among survivors reporting FCR at least once, 66% were diagnosed with cancer under the age of 5, and 64% were 13 years or older at their most recent follow-up. Twenty-one percent of survivors (n = 48/224) reported FCR during at least 50% of their visits. Survivors with a higher number of depressive symptoms were more likely to report FCR (OR = 1.66, P = .03).

CONCLUSIONS

FCR is prevalent among survivors of childhood cancer and is related to other health concerns. Research is needed to understand who is at risk and how to.

Pain in long-term survivors of childhood cancer: A systematic review of the current state of knowledge and a call to action from the Children's Oncology Group

Survivors of childhood cancer may be at risk of experiencing pain, and a systematic review would advance our understanding of pain in this population. The objective of this study was to describe: 1) the prevalence of pain in survivors of childhood cancer, 2) methods of pain measurement, 3) associations between pain and biopsychosocial factors, and 4) recommendations for future research. Data sources for the study were articles published from January 1990 to August 2019 identified in the PubMed, PsycINFO, EMBASE, and Web of Science data bases. Eligible studies included: 1) original research, 2) quantitative assessments of pain, 3) articles published in English, 4) cancers diagnosed between birth and age 21 years, 5) survivors at 5 years from diagnosis and/or at 2 years after therapy completion, and 6) a sample size >20. Seventy-three articles were included in the final review. Risk of bias was considered using the Cochrane risk of bias tool. The quality of evidence was evaluated according to Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria. Common measures of pain were items created by the authors for the purpose of the study (45.2%) or health-related quality-of-life/health status questionnaires (42.5%). Pain was present in from 4.3% to 75% of survivors across studies. Three studies investigated chronic pain according the definition in the International Classification of Diseases. The findings indicated that survivors of childhood cancer are at higher risk of experiencing pain compared with controls. Fatigue was consistently associated with pain, females reported more pain than males, and other factors related to pain will require stronger evidence. Theoretically grounded, multidimensional measurements of pain are absent from the literature.

Posttraumatic stress disorder symptoms in youth with vs without chronic pain

Chronic pain and posttraumatic stress disorder (PTSD) symptoms have been found to co-occur in adults; however, research has not examined this co-occurrence in adolescence, when pediatric chronic pain often first emerges. The aims of this study were to compare the frequency and intensity of PTSD symptoms and stressful life events in cohorts of youth with (n = 95) and without (n = 100) chronic pain and their parents and to determine the association between PTSD symptoms, health-related quality of life, and pain symptoms within the chronic pain sample. All participants completed questionnaire measures through an online survey. Findings revealed that youth with chronic pain and their parents had significantly higher levels of PTSD symptoms as compared with pain-free peers. More youth with chronic pain (32%) and their parents (20%) reported clinically significant elevations in PTSD symptoms than youth without chronic pain (8%) and their parents (1%). Youth with chronic pain also reported a greater number of stressful life events than those without chronic pain, and this was associated with higher PTSD symptoms. Among the chronic pain cohort, higher levels of PTSD symptoms were predictive of worse health-related quality of life and were associated with higher pain intensity, unpleasantness, and interference. Results suggest that elevated PTSD symptoms are common and linked to reduced functioning among youth with chronic pain. Future research is needed to examine PTSD at the diagnostic level and the underlying mechanisms that may explain why this co-occurrence exists.

Outcomes of trauma patients who survive prolonged lengths of stay in the intensive care unit

OBJECTIVE

To examine a subgroup of severely injured patients spending > or = 3 weeks in the intensive care unit (ICU) and to determine their disposition and eventual functional outcome.

METHODS

A retrospective review of our trauma registry and medical records over a 7-year period (January of 1991 to December of 1997) identified 115 patients with ICU length of stay (LOS) > or = 3 weeks. Variables selected included age, length of stay, injury severity score, injuries, disposition, and charges. Functional independence measures (FIM) were obtained in patients requiring inpatient rehabilitation and a written questionnaire (Rand 36-item Health Survey) was mailed to all patients alive at discharge.

RESULTS

Mean ICU length of stay of the 115 patients was 36 days (range, 21-106 days); mean age, 49 years (range, 4-89 years); 73 patients (63%) were males, 42 patients (37%) were females. Overall mortality was 22% (n = 25). The remaining 90 patients survived to discharge with the following disposition: rehabilitation facility 60% (n = 54), home with temporary disability 22% (n = 20), nursing home 8% (n = 7), home with permanent disability 4% (n = 4), transferred 6% (n = 5). Mean hospital charge was $193,000 (range, $77,000-$528,000). No variable or combination could predict outcome except age. Elderly patients (age > or = 75, n = 24) had an overall mortality of 42% (n = 10). Eight of 14 survivors fulfilled admission criteria and entered our rehabilitation facility. The remaining six elderly patients either went to nursing homes or were permanently disabled. Complete FIM scores were available on 47 of 54 patients who went to rehabilitation facility. The mean rehabilitation facility admission FIM score was 52, indicating either complete dependence or the need for moderate assistance. After they had remained at the rehabilitation facility for a mean of 48 days (range, 7-278 days), patients' FIM scores improved to a mean of 86, signifying minimal contact assistance or supervision only. Three-month follow-up FIM scores continued to improve to a mean of 101, a score denoting complete independence. Elderly patients within the rehabilitation facility fared as well as the younger group. For the Rand-36 survey, 47 of 90 patients or family members were contacted. Twelve patients died since discharge, leaving 35 patients to complete the survey. Despite excellent FIM scores, overall mean health was only fair to good, with limitations to activity and lack of energy cited as the main problems.

CONCLUSION

Despite tremendous resource utilization, the majority of trauma patients with prolonged ICU stays can eventually return to varying degrees of functional daily living and independence, but not to preinjury levels. A subgroup of severely injured elderly patients had a significantly higher mortality rate. However, elderly survivors that entered our rehabilitation facility fared as well as the younger patients.

Comparative baseline levels of mercury, Hsp 70 and Hsp 60 in subsistence fish from the Yukon-Kuskokwim delta region of Alaska

In subsistence fish; northern pike (Esox lucius), burbot (Lota lota), whitefish (Coregonus nelsoni), grayling (Thymallus arcticus) and sheefish (Stenodus lencichthys), we determined the Hsp 60 and Hsp 70 levels in 31 samples from adult fish gills. A dot-blot analysis using antibodies to either Hsp 70 or Hsp 60 showed the average Hsp 70 concentration was 9.1 microg/mg protein, while the average Hsp 60 concentration was 147.4 microg/mg protein. Mercury levels in muscle tissue in these fish averaged 0.382 ppm. Using a subset of samples (n = 24), we determined that the major component in the muscle of Alaskan subsistence fish was methyl mercury. No correlation was observed between Hsp 60 or Hsp 70 expression in gill tissue and mercury concentrations in muscle tissue. Hsp 60 and Hsp 70 protein levels in the gills were correlated.

Prenatal diagnosis and the subsequent mutation analysis in a family with carbohydrate-deficient glycoprotein type I syndrome: growing evidence to support founder effects within CDG1 populations

Carbohydrate deficient-glycoprotein syndrome type I (CDG1 or Jaeken Syndrome) is an autosomal recessive multisystem disease with severe early involvement of the nervous system. Mutations in the phosphomannomutase 2 (PMM2) gene have recently been identified in 16 affected individuals. In the current study, we have described a CDG1 family where gene tracking had been used to perform prenatal diagnosis before the isolation of the CDG1 gene. Haplotype analysis indicated that the unborn child had inherited the maternal 'normal' allele, but a critical recombination event meant that it was impossible to determine if the child had inherited the paternal mutation. Single-strand conformation polymorphism and sequence analysis revealed that the mother was a carrier of a C-->A transversion at position 357 (F119L), and that the father was a carrier of a G-->A transition at position 425 (R141H). The unborn child had inherited the paternal R141H mutation. Because only three mutations have previously been reported in UK families, of which F119L and R141H are two, and given that there is evidence of allelic association in CDG1 families, it is possible that a limited number of ancestral mutations have given rise to most cases of CDG1 in any one population.

Heterozygous mutations in the gene encoding noggin affect human joint morphogenesis

The secreted polypeptide noggin (encoded by the Nog gene) binds and inactivates members of the transforming growth factor beta superfamily of signalling proteins (TGFbeta-FMs), such as BMP4 (ref. 1). By diffusing through extracellular matrices more efficiently than TGFbeta-FMs, noggin may have a principal role in creating morphogenic gradients. During mouse embryogenesis, Nog is expressed at multiple sites, including developing bones. Nog-/- mice die at birth from multiple defects that include bony fusion of the appendicular skeleton. We have identified five dominant human NOG mutations in unrelated families segregating proximal symphalangism (SYM1; OMIM 185800) and a de novo mutation in a patient with unaffected parents. We also found a dominant NOG mutation in a family segregating multiple synostoses syndrome (SYNS1; OMIM 186500); both SYM1 and SYNS1 have multiple joint fusion as their principal feature. All seven NOG mutations alter evolutionarily conserved amino acid residues. The findings reported here confirm that NOG is essential for joint formation and suggest that NOG requirements during skeletogenesis differ between species and between specific skeletal elements within species.

Regional health assessment relating to mercury content of fish caught in the Yukon-Kuskokwim Delta rivers system

Seven species of fish were surveyed for muscle tissue mercury content across a broad area of western Alaska. Total mercury levels were determined by cold vapor atomic fluorescence spectroscopy in 66 fish sampled during 1997. Methylmercury in sampled fish amounted to 97 to 100% of total mercury values. Using mercury consumption risk levels derived from U.S. Environmental Protection Agency hazard assessment models, mean total mercury was determined to be above the human critical value of 0.2 g/g (ppm) in 29% of the fish species, and 62% of the fish species contained mercury exceeding the wildlife critical value for piscivorous mammals. Overall, 24% of the fish exceed the critical value for human consumption and 58% the wildlife critical value. Similarly 31% of sites sampled exceeded the human consumption critical value. Based on the mean of all fish sampled and a small number of river otters, a biomagnification factor of 12 was calculated for the Yukon-Kuskokwim Delta Region of Alaska.

Linkage mapping in 29 Bardet-Biedl syndrome families confirms loci in chromosomal regions 11q13, 15q22.3-q23, and 16q21

Bardet-Biedl syndrome (BBS) is a clinically and genetically heterogeneous autosomal recessive disorder characterized by retinitis pigmentosa, polydactyly, obesity, hypogenitalism, mental retardation, and renal anomalies. To detect linkage to BBS loci, 29 BBS families, of mixed but predominantly European ethnic origin, were typed with 37 microsatellite markers on chromosomes 2, 3, 11, 15, 16, and 17. The results show that an estimated 36-56% of the families are linked to the 11q13 chromosomal site (BBS1) previously described by M. Leppert et al. (1994, Nature Genet. 7, 108-112), with the gene order cen-D11S480-5 cM-BBS1-3 cM-D11S913/D11S987-qter. A further 32-35% of the families are linked to the BBS4 locus, reported by R. Carmi et al. (1995, Hum. Mol. Genet. 4, 9-13) in chromosomal region 15q22.3-q23, with the gene order cen-D15S125-5 cM-BBS4-2 cM-D15S131/D15S204-qter. Three consanguineous BBS families are homozygous for three adjacent chromosome 15 markers, consistent with identity by descent for this region. In one of these families haplotype analysis supports a localization for BBS4 between D15S131 and D15S114, a distance of about 2 cM. Weak evidence of linkage to the 16q21 (BBS2) region reported by A. E. Kwitek-Black et al. (1993, Nature Genet. 5, 392-396) was observed in 24-27% of families with the gene order cen-D16S408-2 cM-BBS2-5 cM-D16S400. A fourth group of families, estimated at 8%, are unlinked to all three of the above loci, showing that at least one other BBS locus remains to be found. No evidence of linkage was found to markers on chromosome 3, corresponding to the BBS3 locus, reported by V. C. Sheffield et al. (1994, Hum. Mol. Genet. 3, 1331-1335), or on chromosome 2 or 17, arguing against the involvement of a BBS locus in a patient with a t(2;17) translocation.

The frequency of posterior urethral valves in Oman

OBJECTIVE

To ascertain the frequency of posterior urethral valves (PUV) in Oman, using hospital records.

MATERIALS AND METHODS

The resident population of Oman is 1.5 million and all complex paediatric surgical cases are referred to a single unit in the capital city of Muscat. A register of patients has been kept in that unit since 1988. Hospital case-records were reviewed to determine associated abnormalities, date and place of birth, tribal origin and, from further interviews, the family pedigree and degree of consanguinity.

RESULTS

This retrospective survey identified 56 Omani children born between 1989 and 1994 who were treated in the Paediatric Surgery Department at the Royal Hospital, Muscat for congenital PUV. The calculated incidence was 1 in 2375 newborn males, which is 2-4 times higher than that previously reported in other populations. There was no relation to the estimated month of conception and therefore environmental hyperthermia due to the extreme ambient temperature does not seems not to be a causative factor. There was consanguinity in 40 of 46 cases (87%) where a complete family history was available. Parents were first cousins in 54% of cases, compared with the background rate of 24% in over 6000 families interviewed in the antenatal clinics at six hospitals in Oman. There was also a concentration of PUV within specific tribes. About one-third of the cases also had associated congenital abnormalities, the most frequent of which were genitourinary (17%), but gastrointestinal (9%) and spinal (7%) defects were also observed.

CONCLUSION

The frequency of PUV in newborn Omani males was 1 in 2375, which is considerably higher than any previously reported series. This was associated with an increased rate of consanguinity, but there was no clear pattern of inheritance.

Huntington's disease: a molecular genetic and CT comparison

Huntington's disease is a progressive neurodegenerative disease in which the molecular abnormality has recently been described. Before the availability of this molecular marker diagnosis depended on clinical findings, supported in some instances by neuroimaging using CT or MRI. The imaging modalities may show atrophy of the heads of caudate nuclei in affected people. An attempt was made to validate these imaging findings using the molecular test as "gold standard." Retrospective analysis of cranial CT in 16 patients with Huntington's disease and 16 age and sex matched controls was performed. There was a highly significant difference in caudate head size (P < 0.00001) between patients with Huntington's disease and control subjects. However, the sensitivity of diagnosis based on radiological examination alone was only 87.5% in this study. Thus the sensitivity of CT is insufficient to justify its routine use in the investigation of suspected Huntington's disease, unless genetic tests are negative and other diagnoses need to be excluded.

A new X-linked mental retardation syndrome

There are now more than 70 X-linked mental retardation syndromes associated with physical findings documented in McKusick's "Mendelian Inheritance in Man". We describe a boy and his maternal uncle who appear to have a previously unreported X-linked mental retardation syndrome, consisting of moderate mental retardation, coarse facial features, epilepsy and slowly progressive joint contractures.

Genetic analysis of 20 families with autosomal dominant adult polycystic kidney disease from South West Thames Region

Twenty families with autosomal dominant polycystic kidney disease from S. W. Thames Region were analysed using markers for chromosome 16p13.3, the site of the common mutation (PKD1). Six families gave a negative lod-score for 3'HVR, the most informative distal marker. This could be explained in four cases by recombination events. Of the two families where this was not an explanation, one, of Italian origin, was unequivocally unlinked for all markers, and the other was more likely to be non-PKD1 than linked to 16p13.3. The Italian family was ascertained through the Blood Pressure Unit, and the other via the Genetic Clinic. No members of either family had ever attended a renal clinic. The remaining 18 families either came via renal clinics, or had at least one member attending such a centre.

Secretion of atrial and brain natriuretic peptides from human cardiac atrial explants in culture: effect of dynorphin

We have previously developed a method for maintaining human cardiac explants in culture under serum-free conditions, for the assessment of cardiac endocrine function and myocardial growth factors. In order to assess the local role of dynorphin in the human heart, we studied the effects of dynorphin on the secretion of atrial natriuretic peptide and brain natriuretic peptide by human cardiac atrial explants. Dynorphin did not affect the basal secretion of brain natriuretic peptide, but clearly enhanced the release of atrial natriuretic peptide from the human cardiac explants in culture. The atrial content of brain natriuretic peptide was not significantly reduced, whereas the atrial content of atrial natriuretic peptide in cultured explants was reduced two-fold in the presence of dynorphin. These findings indicate that dynorphin may have a direct stimulatory effect on the release of atrial natriuretic peptide, but not brain natriuretic peptide, from human cardiac atria.

Antibacterial activities of OPC-17116, ofloxacin, and ciprofloxacin against 200 isolates of Neisseria gonorrhoeae

OPC-17116 is a new fluoroquinolone with potent activity against aerobic and anaerobic organisms. We evaluated the susceptibilities of 200 clinical gonococcal isolates including organisms with plasmid and chromosomally mediated resistance to beta-lactams and tetracycline. The antibiotics studied included OPC-17116, ofloxacin, ciprofloxacin, penicillin, tetracycline, erythromycin, azithromycin, and ceftriaxone. All isolates tested were susceptible to the quinolone class of antibiotics. The MICs of ciprofloxacin, ofloxacin, and OPC-17116 for 90% of isolates tested were 0.004, 0.03, and 0.004 micrograms/ml, respectively. For organisms with chromosomally mediated resistance to penicillin and tetracycline, geometric mean MICs of all antibiotics including the quinolones were increased.

Cardiologic abnormalities in Noonan syndrome: phenotypic diagnosis and echocardiographic assessment of 118 patients

OBJECTIVES

The purpose of this study was to determine the incidence of cardiologic abnormalities in Noonan syndrome.

BACKGROUND

The incidence of cardiac abnormalities in Noonan syndrome remains unknown, largely because of such difficulties as assembling a substantial cohort, ensuring a correct phenotypic diagnosis and providing accurate definitions of the most frequent abnormalities--pulmonary stenosis and left ventricular hypertrophy.

METHODS

A cohort of 145 patients was assembled, and before cardiologic assessment two independent geneticists scrutinized the phenotype. The diagnosis was confirmed in 118 patients, and they were studied by two-dimensional and Doppler echocardiography.

RESULTS

A dysplastic pulmonary valve was present in eight patients (7%) and was associated with significant stenosis in six (75%) of the eight. Significant stenosis was present in 22 (20%) of 110 patients without dysplasia. Left ventricular hypertrophy was present in 29 patients (25%) without significant pulmonary stenosis. Localized anterior septal hypertrophy was the most common pattern in 12 (41%) of 29 patients. Diffuse hypertrophy involving the entire septum and the free wall was present in nine patients (31%) and was severe (> 1.7 cm) in five. Other abnormalities included secundum atrial septal defects (10%).

CONCLUSIONS

The high incidence of cardiac abnormalities suggests that echocardiographic and Doppler evaluation of patients with the Noonan phenotype is important because it will aid in genetic counseling and in the assessment of the natural history of--and, ultimately, identification of the gene(s) responsible for--Noonan syndrome.

The efficacy of dental sealants for an adult population

A 1-year pilot study was conducted to determine the retentive capacities of dental sealants on adult teeth. It proposed to utilize the knowledge and experience gained in sealant application, as a means of attacking the problem of the increase in restored teeth at risk in the aging population. Eighty patients aged 30-50 had Delton tinted sealant applied on one to four contralateral nonhomologous, first or second, acceptable molar pairs. Fifty-five patients completed the evaluation at 1 year, with a 68% retention for 250 teeth: teeth listed as sound, 94.1%; IC and IC-amalgam, 93.7%, and amalgam, 44.9%.

Mutations in the PAX3 gene causing Waardenburg syndrome type 1 and type 2

Waardenburg syndrome (WS) is a combination of deafness and pigmentary disturbances, normally inherited as an autosomal dominant trait. The pathology involves neural crest derivatives, but WS is heterogeneous clinically and genetically. Some type I WS families show linkage with markers on distal 2q and in three cases the disease has been attributed to mutations in the PAX3 gene. PAX3 encodes a paired domain, a highly conserved octapeptide and probably also a paired-type homeodomain. Here we describe a further three PAX3 mutations which cause WS; one alters the octapeptide motif plus the presumed homeodomain; a second alters all three elements and the third alters the paired box alone. The latter occurs in a family with probable type 2 WS, a clinical variant usually considered not to be allelic with type 1 WS.

Use of probes for ZFY, SRY, and the Y pseudoautosomal boundary in XX males, XX true hermaphrodites, and an XY female

Three XX males, two XX true hermaphrodites, and an XY female were studied for possible deletions using probes for the recently characterised SRY gene and the pseudoautosomal boundary. The XX males and true hermaphrodites were negative for all three probes, while the XY female was positive. One XX male and one XX true hermaphrodite were sibs. A previous sib pair of an XX male and an XX true hermaphrodite have been shown to be positive for Y chromosomal material near the pseudoautosomal boundary. Thus, both phenotypes can be produced from different mutations, some involving the SRY gene and others not.

Pallister-Killian syndrome diagnosed by chorionic villus sampling

The first prenatal diagnosis of Pallister-Killian syndrome by chorionic villus sampling is presented. Fetal hydrops was noted on ultrasound in early pregnancy, and the karyotype revealed isochromosome 12p mosaicism.

Adult polycystic kidney disease in a kindred of West Indian origin exhibits linkage with the 3'HVR probe on chromosome 16

In a large pedigree of Caribbean origin with adult polycystic kidney disease, linkage has been established to the 3'HVR probe on chromosome 16. Although there are five different fathers in this pedigree, only one of whom was available for DNA analysis, the polymorphic nature of 3'HVR has enabled gene tracking to be carried out. The same allele cosegregates with the disease in every affected family member.

Direct sequence evaluation of the major outer membrane protein gene variant regions of Chlamydia trachomatis subtypes D', I', and L2'

The nucleotide sequences of variable segments (VS) 1, 2, and 4 for the major outer membrane protein gene (omp1) of Chlamydia trachomatis were determined for serologically defined subtypes D', I', and L2'. Asymmetric DNA amplification was used to produce single-stranded DNA for direct sequencing. Amino acid substitutions were detected in VS1, VS2, and VS4 for I', in VS2 for L2', and in VS4 for D'. DNA sequencing of omp1 variant regions may be an important method for evaluating the molecular epidemiology of Chlamydia spp.

The virus in our midst

AIDS and HIV-seropositivity have shown increasing prevalence in the Mountain State. Charleston Area Medical Center (CAMC), being the state's largest tertiary health center, has attracted a number of seropositive patients. This sample, though small by comparison to the experience of other tertiary centers, constitutes the largest single cluster of patients so studied in a single West Virginia hospital to date. This study documents both sociological and economic issues associated with the AIDS population. A clear profile of the typical AIDS patient in West Virginia emerges: 1) gay male; 2) native son; 3) unemployed; 4) Medicaid-dependent; 5) clinically well advanced; 6) infected out of state; 7) under age 30; 8) tertiary care dependent; and 9) homeless. The paper closes with a discussion of the possible growth of the AIDS population in West Virginia in the years ahead. Strategies are set forth to serve as guidelines for managing effectively the AIDS population's needs in both the clinical settings and in society at large.

The Angelman (Happy Puppet) syndrome: is it autosomal recessive?

We report seven cases of Angelman's syndrome from three families. Recurrence risks are not small, as previously suggested.