A eficácia da terapia manual em indivíduos cefaleicos portadores e não-portadores de degeneração cervical: análise de seis casos / The effectiveness of manual therapy in indiv iduals with headaches, with and without cervical degeneration: analysis of six cases

CONTEXTUALIZAÇÃO: As cefaléias do tipo tensional (CTT) geralmente são tratadas com fármacos que possuem ações profiláticas. No que se refere ao tratamento fisioterapêutico, vários tipos de procedimentos são relatados e vão desde a eletroterapia e acupuntura até técnicas de tração cervical, de mobilizações vertebrais, alongamentos e relaxamentos. OBJETIVO: Examinar a evolução de seis pacientes com diagnóstico de cefaléia do tipo tensional, submetidos a um protocolo de tratamento fisioterapêutico de terapia manual. MATERIAL E MÉTODO: Foram acompanhados seis indivíduos, três com alterações vertebrais associadas (indivíduos portadores - IP) e três sem alterações vertebrais (indivíduos não-portadores - INP), sendo cinco mulheres e um homem, submetidos a um tratamento constituído por dez sessões de tração cervical manual, alongamentos, mobilização vertebral e massagem. FORAM MEDIDOS: a intensidade da dor por meio da escala visual analógica (EVA) e o limiar de dor por pressão (LDP) no músculo trapézio superior, por meio do algômetro de pressão analógico (PDT - Pain, Diagnostic & Treatment). Os dados, para análise, foram dispostos em um sistema de linha de base múltipla associado a um seguimento. RESULTADOS: Embora o tratamento tenha apresentado resultados eficazes em todos os casos, em relação à intensidade da dor, verificou-se maior dificuldade na remissão completa dos sintomas por parte dos indivíduos não-portadores de alterações vertebrais e, em relação ao LDP, verificou-se que os indivíduos portadores apresentaram melhora acentuada.

BACKGROUND: Tension-type headaches (TTH) are generally treated with prophylactic medication. With regard to Physical Therapy treatment, many types of procedures have been reported, ranging from electrotherapy and acupuncture to techniques such as cervical traction, vertebral mobilization, stretching and relaxation. OBJECTIVE: To examine the evolution of six patients diagnosed with TTH who underwent a Physical Therapy treatment protocol consisting of manual therapy. METHOD: Six individuals were followed up (three with associated vertebral abnormalities and three with no abnormalities). Five participants were women and one was a man. They underwent treatment consisting of ten sessions of manual cervical traction, stretching, vertebral mobilization and massage. Pain intensity was assessed using a visual analog scale (VAS) and the pain threshold for pressure on the upper trapezius muscle was measured using an analog pressure algometer (PDT; pain detection threshold). The data were graphically displayed in a multiple baseline system and during a follow-up period. RESULTS: Even though this treatment showed positive results in all cases, in relation to pain intensity, greater difficulty in completely relieving the symptoms was found among the individuals who did not have vertebral abnormalities. With regard to PDT, it was found that individuals with cervical degeneration presented greater improvement.

Unsuspected sporotrichosis in childhood.

We report 10 prepubertal girls with sporotrichosis who were misdiagnosed because they had solitary ulcerative skin nodules, rather than a "sporotrichoid" pattern of multiple linear nodules. All had positive cultures for Sporothrix schenckii. We urge clinicians to consider sporotrichosis in the differential diagnosis of a solitary skin nodule.

Pigmentary disorders: update on neurofibromatosis-1 and tuberous sclerosis.

Pigmentary disorders are a common finding in primary care pediatric practice. Tuberous sclerosis and neurofibromatosis type 1 are two pigmentary disorders that have had many changes in their diagnostic and therapeutic approach. This review focuses on the significant advances in the past few years in the genetics and diagnostic criteria of these disorders. A review of the clinical presentation of neurofibromatosis is provided along with the revised diagnostic criteria for tuberous sclerosis. A logical approach to testing the tuberous sclerosis patient and his or her family is included.

Childhood pernio and cryoproteins.

Childhood pernio is an uncommon condition described mainly through isolated case reports. We examined the cutaneous spectrum, clinical associations, presence of cryoproteins, and evolution of the condition in children, and performed a retrospective case series evaluation of children with pernio seen at a single ambulatory care university center over a 10-year period. Cases were drawn from a population of 3.2 million. Follow-up was at least 3 years. We found four boys and four girls with pernio. Distribution of skin lesions was on the fingers, toes, and ears. Four children had cryoglobulins or cold agglutinins, two had a positive rheumatoid factor, and none had a positive ANA or ANA profile. All eight cleared within 3 months and did not recur over at least a 3-year period. We concluded that childhood pernio is uncommon and may be associated with the presence of cryoproteins.

Does sensitization to contact allergens begin in infancy?

OBJECTIVE: Because previous studies have found allergic contact sensitization common in children by 5 years of age, our aim was to determine the prevalence of positive epicutaneous test results in children <5 years of age and to determine whether sensitization to contact allergens was as common in infancy. METHODS: We recruited 95 asymptomatic children 6 months to 5 years of age from well-child visits at Denver area pediatric practices for epicutaneous patch testing using the T.R.U.E. Test system. Allergens were placed on the skin for 48 hours, and at a later follow-up visit, positive reactions were evaluated. RESULTS: A total of 85 patients completed the study. Of these, 20 (24.5%) had 1 or more positive reactions to the tested allergens. Positive reactors ranged from 6 to 65.5 months of age, with an average of 30.4 months of age. Of the children, 16 reacted to 1 allergen, and 4 reacted to 2. Eleven positive reactions were observed to nickel, followed by 8 to thimerosal. Other positive reactions were to neomycin, cobalt, and kathon CG. CONCLUSIONS: Children as young as 6 months of age may be sensitized to contact allergens. Within this pediatric population, the prevalence of sensitization is 24.5%. Sensitization to contact allergens may occur in infants.

Steroid rosacea in prepubertal children.

OBJECTIVE: To examine clinical associations, family history of rosacea, and response to treatment in prepubertal children with steroid rosacea. DESIGN: Retrospective case-series evaluation of children younger than 13 years with steroid rosacea seen over an 8-year period (1991-1998). SETTING: Ambulatory care university hospital. PATIENTS: Referral patients from pediatricians serving a population of 3.4 million. INTERVENTIONS: Abrupt cessation of topical corticosteroid use and initiation of treatment with oral erythromycin stearate for 4 weeks. MAIN OUTCOME MEASURES: Age at onset, class of topical corticosteroid used, family history of rosacea, location of lesions, treatment, and weeks to clearing. RESULTS: We evaluated 106 (46 boys and 60 girls) who developed steroid rosacea. Preceding steroids used were predominantly (54% of children) class 7 agents including 1% hydrocortisone and over-the-counter hydrocortisone preparations. Only 3% of children had used superpotent (class 1) topical corticosteroids. The mean age at onset was 7.04 years (range, 6 months to 13 years). Twenty-nine children were younger than 3 years. A family history of rosacea was found for 20% of the children. After abruptly stopping topical steroid use and starting treatment with oral erythromycin, 86% of children had complete clearing within 4 weeks and 100% by 8 weeks. Clearing within 3 weeks was observed in 22% of children. CONCLUSIONS: Abrupt discontinuation of topical corticosteroids and institution of oral antibiotics resulted in clearing within 4 weeks. This finding does not support the concept that prepubertal children with steroid rosacea need to continue low-strength steroids in a gradual withdrawal strategy. This conclusion is supported by the finding that 54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children. Susceptibility may be genetic as 20% of children had a first-degree relative with rosacea.

"Block the sun, not the fun": evaluation of a skin cancer prevention program for child care centers.

INTRODUCTION: This paper describes the evaluation of a skin cancer prevention program for preschools and daycare centers. The intervention was targeted primarily at staff of child care centers, with the aim of increasing use of sun protection practices for young children while attending these centers. Secondary target groups included parents and the children themselves. The intervention, which adopted the slogan, "Block the Sun, Not the Fun," included workshops for child care center staff, and information/activity packets for parents. METHODS: Twenty-seven preschools and daycare centers were randomly assigned to an intervention or wait-list control group. The intervention group received the intervention during the spring of 1994; the wait-list control group received the intervention during the spring of 1995. Evaluation consisted of interviews with center directors, observations of practices, and review of written policies before the intervention (in summer, 1993) and after the intervention (in summer, 1994). A survey of 201 parents was conducted during late summer 1994. RESULTS: While the intervention did not appear to change the sun protection attitudes or practices of parents, or use of clothing and shade at child care centers, results suggested significant changes in the sun protection knowledge/attitudes of center directors and the use of sunscreen at child care centers. Additionally, parents with children attending centers in the intervention group were more likely to be satisfied with sun protection practices at their centers. CONCLUSION: This low-intensity intervention appears to be effective at changing sun protection attitudes and sunscreen use at child care centers, and can be easily replicated. However, high staff turnover at child care centers would suggest that "boosters" will be necessary to sustain the impact. More intensive efforts directed at social norms are likely to be necessary to change clothing and outdoor play practices.

Overexpression of mutant ras in human melanoma increases invasiveness, proliferation and anchorage-independent growth in vitro and induces tumour formation and cachexia in vivo.

Malignant melanoma is the deadliest form of skin cancer. Previous studies have shown that the incidence of ras mutation increases with progression of melanoma, but that such mutations may not be present in the earliest radial growth phase melanomas. Recently it has been proposed that introduction of ras mutations into cells deficient in tumour suppressor genes such as p16 (INK4a) is sufficient to induce characteristics of cellular transformation such as anchorage-independent growth and tumour formation in vivo. To test this hypothesis in human melanoma, mutant N-ras, mutant H-ras or wild-type H-ras genes were transfected by electroporation into WM35 cells, a p16-deficient human melanoma cell line of low invasive potential. Increased expression of mutant ras p21 enhanced anchorage-dependent cell growth on tissue culture plastic. In addition, overexpression of mutant N-ras and H-ras, but not of wild-type H-ras, increased the experimental invasive potential, inducing anchorage-independent growth in soft agar, increasing cell motility measured by time-lapse video microscopy, and increasing invasiveness through reconstituted basement membranes. Finally, overexpression of mutant H-ras in melanoma cells was shown to increase tumorigenicity and to induce cachexia when H-ras transfected cell lines were injected subcutaneously in severe combined immunodeficiency (SCID) mice. Thus the addition of activating ras mutations to a melanoma cell line already deficient in p16 leads to enhanced proliferation, survival and migration in vitro and to enhanced subcutaneous tumour formation in vivo. This phenotype is typical of the behaviour of vertical growth phase (VGP) melanoma, and we propose that activation of the ras signalling pathway in the presence of deletions in p16 or related tumour suppressors can induce the VGP melanoma phenotype.

Childhood immunobullous disease following a second organ transplant.

Immunobullous diseases are quite unusual in children. We report two children who developed immunobullous disease shortly after a second solid organ transplantation. One child had IgA pemphigus vegetans, the other bullous pemphigoid. We hypothesize that the repeat organ transplantation served as a "booster" immunization for autoantibody production. Both children developed their immunobullous condition while being treated with immunosuppressive drugs that are used to treat immunobullous disorders.

The clinical spectrum of anti-Ro-positive cutaneous neonatal lupus erythematosus.

BACKGROUND: Cutaneous neonatal lupus erythematosus (NLE) is an uncommon disease described mainly through isolated case reports. OBJECTIVE: Our purpose was to examine the cutaneous spectrum, clinical associations, and course of disease in babies with anti-Ro-positive NLE. METHODS: This is a retrospective case series evaluation of newborns with anti-Ro-positive NLE seen at a single ambulatory care university center over a 20-year period. Cases were drawn from a population of 3.2 million. Follow-up was at least 3 years. RESULTS: Four boys and 14 girls were included in our evaluation. Distribution of skin lesions in 18 babies was as follows: face, 17; periorbital "owl-eye" or "eye mask" facial rash, 14; scalp, 15; arms and legs, 13; trunk and groin, 6. Crusted lesions were predominant in 3. Photosensitivity was seen in 12, and features of cutis marmorata telangiectasia congenita were observed in 4. In 17 neonatal lupus was not suspected until the dermatology consultation. Noncutaneous manifestations included thrombocytopenia in 4, cholestatic hepatitis in 3, and congenital heart block in 3. Four patients had residual telangiectasia that persisted for 3 or more years but eventually cleared in 2 patients. Three babies had dyspigmentation that spontaneously cleared within 22 months. None had atrophy or scarring. CONCLUSION: Periorbital, scalp, and extremity lesions are common in cutaneous NLE. Crusted lesions predominated in male infants. In children selected by cutaneous involvement, thrombocytopenia and hepatic disease were present as frequently as cardiac disease and occurred more frequently in male babies with crusted skin lesions. Children with cutaneous NLE should be evaluated for hematologic and hepatic as well as cardiac involvement.

Fixed drug eruptions in children.

To determine the anatomic location and offending drug in fixed drug eruptions (FDE) in children, we performed a 5-year retrospective analysis. Thirty-five children with FDE were evaluated. The most common cause of FDE was the combination drug trimethoprim-sulfamethoxazole.

Newly recognized infectious exanthems.

An exanthem is defined as any rash which is associated with an infectious agent. During the past 6 years, molecular techniques have produced a revolution in clinical dermatology including the exanthems. The infectious agents responsible for many exanthems of previously unknown causes have been uncovered. Included in this review is an update of the rapidly changing spectrum of exanthems, and 10 examples of new viral etiologies of exanthems and two new bacterial exanthems that were recognized during the past 5 years.

Use of lasers in pediatric dermatology.

Since the elucidation of the principles of selective photothermolysis, lasers have revolutionized the treatment of many types of vascular and pigmented lesions seen in children. Although laser treatment is not perfect, it is extremely safe and allows for improvement or in some instances complete removal of previously untreatable childhood abnormalities. Children with any of the types of lesions discussed in this paper should be referred to an experienced laser surgeon for early evaluation and treatment if appropriate.

Facial port wine stains in childhood: prediction of the rate of improvement as a function of the age of the patient, size and location of the port wine stain and the number of treatments with the pulsed dye (585 nm) laser.

In this study we examined the rate of decrease in size of facial port wine stains (PWS) as a function of number of treatments, lesion size, lesion location and patients' age. This study was performed at the University of Colorado Hospital Outpatient Dermatology Center, Denver, U.S.A. A consecutive sample of 91 patients 18 years of age or younger with facial PWS in which the entire lesion was treated at each visit were studied. Included were all patients who had a minimum of five treatments or complete clearance of their lesion in fewer than five treatments. Patients were evaluated following one, five and 10 treatments with the pulsed (450 s) dye (585 nm) laser. Improvement was defined as the percentage decrease in the size of the PWS. For all patients, the first five treatments resulted in a mean decrease in size of 55% while the second five treatments (38 patients) only improved the mean decrease in size by 18%. Grouped by location, the mean decreases in size from the first five and the second five treatments were as follows: central forehead = 100%, 0%; peripheral face = 58%, 28%; central face = 48%, 14%; and mixed (combination of peripheral and central face) = 21%, 9%. All central forehead PWS completely cleared within five treatments while none of the mixed PWS did so even with an average of 14 treatments. Grouped by size, mean decrease in size was highest for small lesions; < 20 cm2 = 67%, 21%; 20 to < 40 cm2 = 45%, 8%; and > 40 cm2 = 23%, 29%. Grouped by age, mean decrease in size was highest for young children: < 1-year-old = 63%, 33%; 1 to < 6 years = 48%, 15%; and older than 6 years = 54%, 10%. For all patients studied, maximal improvement was obtained in the first five treatments. Major determinants of treatment response in order of decreasing importance are PWS location, size and patients' age. The most successful responses are seen in young patients (less than 1 year old) with small PWS (under 20 cm2) that are located over bony areas of the face such as the central forehead. These three determinants may be useful tools to guide patient expectations and to predict the rate of improvement of PWS to pulsed dye laser treatment.

Inflammatory nevus comedonicus in children.

More than 100 years has passed since the first report of a nevus comedonicus. The earliest reports emphasized the inflammatory aspect of the nevus comedonicus as being the most significant problem. In the past 30 years, publications have ignored the inflammatory aspect of nevus comedonicus while emphasizing a variety of associated malformations. In this review, we describe five prepubertal children with prominent and persistent inflammatory changes limited to areas within a nevus comedonicus. In our experience, inflammation can be severe and resistant to treatment. Ultimately, surgical removal of the involved skin was required in two children.