Multiple pilomatricomas with somatic CTNNB1 mutations in children with constitutive mismatch repair deficiency

Constitutional mismatch repair deficiency (CMMR-D) due to biallelic germline mutations in one of four mismatch repair genes causes a childhood cancer syndrome characterized by a broad tumor spectrum including hematological malignancies, and brain and Lynch syndrome-associated tumors. Herein, we report three children who had in addition to CMMR-D-associated malignancies multiple pilomatricomas. These are benign skin tumors of hair matrical differentiation frequently associated with somatic activating mutations in the ß-catenin gene CTNNB1. In two of the children, the diagnosis of CMMR-D was confirmed by the identification of biallelic germline PMS2 mutations. In the third individual, we only found a heterozygous germline PMS2 mutation. In all nine pilomatricomas with basophilic cells, we detected CTNNB1 mutations. Our findings indicate that CTNNB1 is a target for mutations when mismatch repair is impaired due to biallelic PMS2 mutations. An elevated number of activating CTNNB1 alterations in hair matrix cells may explain the development of multiple pilomatricomas in CMMR-D patients. Of note, two of the children presented with multiple pilomatricomas and other nonmalignant features of CMMR-D before they developed malignancies. To offer surveillance programs to CMMR-D patients, it may be justified to suspect CMMR-D syndrome in individuals fulfilling multiple nonmalignant features of CMMR-D (including multiple pilomatricomas) and offer molecular testing in combination with interdisciplinary counseling.

Multiple pilomatricomas and gliomatosis cerebri--a new association?

Pilomatricomas are benign skin tumors originating from hair follicle matrix cells. In 2% to 3.5% of cases they occur in multiplicity and then may be associated with genetic diseases, such as myotonic dystrophy Curschmann-Steinert, familial adenomatous polyposis (Gardner syndrome), and Rubinstein-Taybi syndrome. A 15-year-old boy treated with temozolomide and oxcarbazepine for gliomatosis cerebri with symptomatic epilepsy developed four firm cutaneous nodules on his face and right upper arm in the course of 1 year. All four tumors were excised under local anesthesia. Histological examination confirmed the clinical diagnosis of pilomatricomas. This is the first published case of a patient suffering from gliomatosis cerebri and developing multiple pilomatricomas. Whether this observation represents a new association or is a mere coincidence cannot be clarified at present.

High dose pulsatile dexamethasone therapy in children with opsoclonus-myoclonus syndrome

Opsoclonus-myoclonus syndrome (OMS) is a rare movement disorder characterized by chaotic eye movements, myoclonus, and ataxia associated with severe irritability. Different treatment modalities including steroids and cyclophosphamide have been tried in the past often with significant side effects and variable success. Here we present 11 children, diagnosed with OMS between 1999 and 2005 and treated with high dose dexamethasone pulses. Main symptoms at presentation were opsoclonus (11/11), ataxia and/or myoclonus (11/11), irritability (10/11) associated with a neuroblastoma in four children. Number of dexamethasone pulses ranged from 6 to 60 pulses. No major side effects were reported. In 6/11 children a complete and sustained remission of OMS symptoms was achieved after 6 to 29 pulses of dexamethasone. Two children from this group have a normal development and no neurological sequelae. Two further children have minor delays in fine- and gross-motor skills. Two children despite a complete recovery of OMS symptoms have persisting developmental problems. 5/11 children still require regular dexamethasone pulses in addition to daily prednisolone (n = 1) or have received cyclophosphamide pulses meanwhile (n = 2). All children continue to have developmental and neurological difficulties. In summary treatment with high dose pulsatile dexamethasone appears to be safe and beneficial in a subgroup of patients with OMS.

Infantile postural asymmetry and osteopathic treatment: a randomized therapeutic trial

The aim of this study was to assess the therapeutic efficacy of osteopathic treatment in infants with postural asymmetry. A randomized clinical trial of efficacy with blinded videoscoring was performed. Sixty-one infants with postural asymmetry aged 6 to 12 weeks (mean 9wks) were recruited. Thirty-two infants (18 males, 14 females) with a gestational age of at least 36 weeks were found to be eligible and randomly assigned to the intervention groups, 16 receiving osteopathic treatment and 16 sham therapy. After a treatment period of 4 weeks the outcome was measured using a standardized scale (4-24 points). With sham therapy, five infants improved (at least 3 points), eight infants were unchanged (within 3 points), and three infants deteriorated (not more than -3 points); the mean improvement was 1.2 points (SD 3.5). In the osteopathic group, 13 infants improved and three remained unchanged; the mean improvement was 5.9 points (SD 3.8). The difference was significant (p=0.001). We conclude that osteopathic treatment in the first months of life improves the degree of asymmetry in infants with postural asymmetry.

The development of childhood asthma: lessons from the German Multicentre Allergy Study (MAS)

Epidemiological surveys have indicated that there has been a notable increase in the prevalence of both asthma and other allergic symptoms in children and young adults. Since it seems unlikely that genetic factors would contribute to the rising trend, environmental factors might play a major part in the development of childhood asthma. In a prospective birth-cohort study, we assessed the relevance of different exposures such as mite and cat allergen exposure, environmental tobacco smoke (ETS) exposure, early infectious diseases and vaccinations for the development of childhood asthma up to the age of 10 years. Data up to 7 years of age have been evaluated. Of 1314 newborn infants enrolled in five German cities in 1990, follow-up data at age 7 years were available for 939 children (72%). Assessments included repeated measurements of specific IgE to food and inhalant allergens, measurement of indoor allergen exposure at 6 months, 18 months and 3 years of age and yearly interviews by a paediatrician. At age 7 years, pulmonary function was tested and bronchial responsiveness was determined in 645 children. At age 7, the prevalence of wheezing in the past 12 months was 10% (94 out of 938), and 6.1% (57 out of 939) parents reported a doctor's diagnosis of asthma in their children. Sensitisation to indoor allergens was associated with asthma, wheeze and increased bronchial responsiveness. However, no relationship between early indoor allergen exposure and the prevalence of asthma, wheeze and bronchial responsiveness was seen. During the first 3 years of life, intra-uterine tobacco and consistent ETS exposure have an adjuvant effect on allergic sensitisation that is transient and restricted to children with a genetic predisposition for allergy. Children sensitised to any allergen early in life and sensitised to inhalant allergens by the age of 7 years were at a significantly increased risk of being asthmatic at this age (odds ratio (OR) = 10.12; 95% confidence interval (CI) = 3.81-26.88). Children with repeated episodes (> or =2) of runny nose before the age of 1 year were less likely to develop asthma by the age of 7 years (OR = 0.52; 95% CI = 0.29-0.92). Our data do not support the hypothesis that exposure to environmental allergens directly causes asthma in childhood but that induction of specific IgE responses and the development of childhood asthma are determined by independent factors. Indoor allergen avoidance is recommended as first line treatment in secondary and tertiary prevention; however, conclusions should be drawn with caution about the possible effect of primary preventative measures. Since allergic asthma seems to be a Th2-disease, immunomodulating factors such as early childhood infections, LPS-exposure or other factors influencing gene-environment interaction and individual susceptibility seem to be relevant for the development of childhood asthma.

Acetazolamide treatment for infantile central sleep apnea

Central sleep apnea is a common respiratory pattern in healthy neonates. Nevertheless, frequent central sleep apnea associated with drops in oxygen saturation may contribute to infantile morbidity. Recently, low-dose acetazolamide was shown to reduce symptomatic central sleep apnea in adults. We treated 12 infants, median conceptional age 42 weeks (range, 40-44 weeks), with central sleep apnea. In all cases, the central apnea index was >40/h total sleeping time (apnea > or = 3 sec). The cumulative duration of drops in oxygen saturation below 90% was more than 3 min/h total sleeping time. All individuals received acetazolamide 7 mg/kg/day (orally, divided in three doses) for 11 weeks. Polysomnography was begun 10 hours before the first dose and continued for 10 hours after the third dose. Polysomnography was repeated after 6 weeks of treatment and 1 week after acetazolamide therapy was discontinued. Comparison of the respiratory patterns before and after treatment (10-hour recording after the third dose) showed a decrease in the median central apnea index from 74/h (range, 42-152/h) to 13/h (range, 6-49/h). The median of the cumulative duration of drops in oxygen saturation below 90% decreased from 3.6 min/h (range, 3.1-9.2 min/h) to 0.07 min/h (range, 0-0.5 min/h). Basal oxygen saturation increased from 95 (92-97%) to 98% (96-99%). This improvement was maintained in the final polysomnography (12 weeks after therapy was begun and 1 week after completion of the 11-week course). No adverse effects were noted. We conclude that low-dose acetazolamide treatment may be useful for the treatment of central infantile sleep apnea associated with hypoxemia.

Male homosexuality

In 1961 a research team of the Society of Medical Psychoanalysts completed a nine year study of male homosexuality in which 77 of its members each filled out a detailed questionnaire that tapped information on a sample of 106 male homosexuals and a comparison group of 100 male heterosexuals in psychoanalytic treatment.

Since then, the authors have seen well over 1000 male homosexuals and about 100 pairs of their parents in direct, psychoanalytically focused interviews. In all regards, the data obtained are in accord with the research findings, thus strengthening its validity and reliability.

The developmental picture and family background of homosexuals have the following salient characteristics: The parents generally have an unsatisfactory relationship with each other but the mother forms an overly close bond with her homosexual son. She tends to dominate and restrict him and she discourages his assertiveness. Though there are variations in the pattern, most such mothers are close, binding and intimate (CBI), sometimes in sexually inappropriate ways. This son is usually her favourite whom she openly prefers to her husband. Within the family system, the CBI mother and son form a romantically tinged dyad, while the father and other siblings remain on the periphery. The son develops a profound dependency on the mother who often remains the most beloved person and focus of his life.

The father-son relationship is strikingly different. The fathers are hostile, competitive and do nothing to neutralize deleterious maternal influences. Patients’ reports of their father are almost always negative. He is virtually non-existent, rejecting, hostile, harsh or brutal. The fathers show neither love nor respect for this son. The authors have repeatedly noted that constructive, affectionate fathers preclude the development of homosexuality, though, conversely, hostile fathers do not necessarily produce homosexual sons. Boys who become homosexual, leave childhood with a profound fear and hatred of the father, yet retain a deep longing for paternal affection and acceptance — a central determinant of a homosexual orientation.

Relationships with siblings also tend to be disturbed. The siblings’ intense jealousy of the mother's favourite is more corrosive among other sons than daughters and it results in marked rivalry and hostility. Closely similar are the difficulties with same-sex peer groups. Prehomosexual boys are so traumatized by a hostile father and brothers, that they cannot cope with the aggressive, combative behaviour of young boys at play, hence are deprived of the needed ancillary opportunities for masculine identification and support. Often, the first meaningful contact with peers occurs in adolescence when the combativeness of the earlier years has abated.

The widely held theory that homosexuals fear women is not supported. They fear only a sexual relationship with a woman, a fear stemming from expectations of retaliation from aggressive men. The bisexual theory, also, is not supported. It asserts that humans are by nature bisexual and that homosexuals, unlike sexually balanced, normal people, have a preponderance of femininity. Homosexuals are physiologically normal. They become oriented to homosexuality as a substitute for heterosexuality because women are psychologically beyond reach.

Homosexuality offers complex defensive and reparative mechanisms for coping with fear of aggressive, rejecting men. Sexual arousal cues offer insights into the dynamics of such mechanisms. In a study by I. Bieber, three categories of stimulae were delineated: 1. the displacement of the heterosexual stimulus to a homosexual object; 2. the eroticization of the feared object; 3. arousal associated with affection shown by men.

Recent work in sexual identity, gender identity and gender role behaviour emphasizes the view that effeminate homosexuals and transvestites have, in early life, identified with the mother leading, in adult life, to an identification with women. According to the Bieber studies, homosexuals have a basically masculine identification but have a sense of impaired masculinity. This distinction not only influences psychotherapeutic strategy but may extend to decisions involving transsexual change.

The authors’ method of treatment is cognitive psychoanalysis, a process which delineates and evaluates irrational beliefs and irrational belief systems associated with fears of threat and injury. For those patients who might derive benefit from a group experience, T. Bieber offers individual sessions in combination with group sessions. The all-male homosexual group is preferred to the heterogeneous group. It has a less threatening, more familiar atmosphere, it facilitates verbalization and affective responses and offers an important peer group support system.

Reversal estimates now range from 30% to an optimistic 50%. A shift to heterosexuality does not mean that the potential for homosexual arousal has been totally extinguished, though in some cases this does occur. Should a post-analytic patient be faced with a recurrence of homosexual interest, he may short-circuit it by identifying the situation that has triggered anxiety about heterosexuality. By thoughtfully working out the dynamics by himself or with the analyst in a session or two, homosexual obsessions and other symptoms may be dissipated.

The view that homosexuality is but an alternate way of loving and that the psychopathology is a consequence of social discrimination and prejudice is not supported. Societal bias may add to feelings of anguish and unacceptability but as demonstrated in the homosexuality study and other publications, it is the destructive family relationships and other deleterious interpersonal influences that induce a homosexual adaptation.