Ahead of Print
Dilemmas of Chronic Sclerosing Sialadenitis: A Case Report and Literature ReviewAbstract
We report a case of chronic sclerosing sialoadenitis focusing on clinical, laboratory and histological aspects and perform a review of literature with discussion of multidisciplinary clinical approach to this pathology. Chronic sclerosing sialoadenitis is an uncommon, chronic inflammatory disease that has been recently included in the IgG4-associated diseases spectrum. This pathology simulates cervical neoplastic pathology, and its definitive diagnosis is difficult. Its etiology, treatment and evolution remain topics of scientific debate.Date: 2023-11-29
Smoking Cessation for Light Smokers: ReviewAbstract
Over half a million Portuguese citizens are light smokers, smoking up to ten cigarettes daily, with associated nicotine dependence and an increased risk of smoking-related diseases. With this in consideration, we performed a review of existing evidence regarding the treatment in smoking cessation in light smokers, through a systematic research of studies evaluating and comparing pharmacologic treatment and/or brief intervention in attaining smoking cessation. Six randomized controlled trials were included, which showed that bupropion and nicotine replacement therapy are not more effective than isolated brief intervention, but varenicline is more effective than isolated brief intervention in attaining and maintaining smoking cessation in light smokers for at least six months, so its use can be beneficial in light smokers without contraindications for this drug, with a B-level SORT strength of recommendation.Date: 2023-11-29
Hipurato de Metenamina na Prevenção de Infeções do Trato Urinário de Repetição: Uma Revisão Baseada na Evidência
Methenamine Hippurate for the Prevention of Recurrent Urinary Tract Infections: An Evidence-Based ReviewAbstract
INTRODUCTION: Antibiotic prophylaxis is used to prevent the recurrence of urinary tract infections (UTIs), however, the growing problematic of antibiotic resistance over the last few years has led to the search for a viable alternative to antibiotics. The main goal of this review was to evaluate the evidence available regarding the effectiveness of methenamine hippurate
as an alternative to antibiotic therapy in the prophylaxis of recurrent UTIs.
METHODS: the data sources were The Cochrane Library, MEDLINE/PubMed, DARE, TRIP Medical Database, Canadian Medical Association Practice Guidelines Infobase and National Guideline Clearinghouse. Research of meta-analyses, randomized controlled trials, observational studies and guidelines written in English or Portuguese published between January 2012 and May 2022, using the MeSH terms “methenamine” and “urinary tract infections”. The level of evidence and strength of recommendation were assessed by applying the American Family Physician’s Strength of Recommendation Taxonomy (SORT) scale.
RESULTS: Of the 106 results obtained initially, 2 randomized controlled clinical trials and 1 retrospective observational study were selected. The evidence found in these studies revealed that methenamine hippurate is comparable to antibiotic prophylaxis in preventing recurrent UTIs.
CONCLUSION: This review allows us to conclude that methenamine hippurate appears as a possible, viable and safe alternative to antibiotic prophylaxis, demonstrating its non-inferiority.Date: 2023-11-23
HEADS-ED: Tradução e Adaptação de uma Escala de Rastreio de Patologia Mental em Adolescentes Portugueses
HEADS-ED: Translation and Adaptation of a Mental Health Pathology Screening Scale in Portuguese AdolescentsAbstract
INTRODUCTION: HEADS-ED (Home; Education; Activities and Peers; Drugs and Alcohol; Suicidality; Emotions, Behaviors and Thought Disturbance; Discharge Resource) scale was created in Canada, to detect mental pathology in the pediatric emergency department. In Portugal, a validated scale with this intention still does not exist. The objective was to create a Portuguese instrument to triage psychological, behavioral and social problems in adolescents hospitalized.
METHODS: Prospective, transversal, non-randomized study developed in the pediatric ward of a level II hospital. It comprised 4 phases: 1) Translation and adaptation of HEADS-ED scale to Portuguese; 2) Pilot study to validate the scale to Portuguese population; 3) Systematic interview to adolescents and their specialized referral according to their needs; 4) Statistical analysis.
RESULTS: Ninety-six interviews were realized, 55% feminine sex, average age of 15 years old, 45% with a chronical illness. Thirteen patients had punctuation ?5. Referral was established in 19.8% of the adolescents: 6.3% to psychology/ psychiatry appointment, 8.3% to NHACJR, in 5.2% previous follow-up was improved. There was statistically significant relation between higher age and higher total points (p-value=0.004) and between feminine gender and higher total points (p-value=0.005).
CONCLUSION: HEADS-ED scale adapted to Portuguese intends to screen mental pathology in adolescent, having potential to improve their follow-up and future life quality.Date: 2023-11-23
Atypical Intracerebral Haemorrhage as an Extrahepatic Manifestation of Hepatitis CDate: 2023-11-23
Quisto Ganglionar do Ligamento Longitudinal Anterior: Uma Causa Rara de Abaulamento FaríngeoDate: 2023-11-15
Behind a Low Back Pain: A Case ReportAbstract
Low back pain is one of the most frequent causes of human suffering next to the common cold. It is a frequent reason for medical consultation in General Practice and a relevant public health problem due to the morbidity and socio-economic costs it entails. Only a small percentage of cases correspond to a specific etiology, requiring a differentiated diagnostic and therapeutic approach. The authors describe a case of a 53-year-old man with history of degenerative lumbar pathology with mechanical low back pain without relief with analgesic treatment; lumbar computed tomography showed a suspicious finding of neoplastic lesion versus spondylodiscitis and was referred for neurosurgical consultation. The bone biopsy showed that it was an infection with Mycobaterium tuberculosis and he was oriented to the pulmonary disease center. The treatment lasted 12 months.Date: 2023-11-10
Music to Your Ears: A Case of Idiopathic Musical HallucinosisAbstract
Musical hallucinosis is a disease with a poorly understood pathophysiology, in which hearing loss and mood disorders can be triggering factors. Although there is no consensual approach, psychoeducation plays a central role.
We present the clinical case of an 84-year-old woman with hearing loss and depressive disorder reactive to her husband’s role as a caregiver. Four days after the introduction of antidepressant medication she developed auditory musical hallucinosis, where she listened to songs from her childhood continuously throughout the day. These complaints remained despite the interruption of the antidepressant and the prescription of antipsychotics.
After screening for organic pathologies, psychoeducation was initiated, focusing on increasing social activity and auditory stimuli and optimizing co-morbid pathologies. The patient had a favorable evolution and almost complete resolution of the complaints.Date: 2023-11-10
Nicho Uterino: Uma Patologia a ConsiderarAbstract
Uterine niche is a recess located in the anterior wall of the uterine isthmus, over the cesarean section scar. This condition is often asymptomatic, but it can be associated with symptoms such as abnormal uterine bleeding, pelvic pain and secondary infertility. Endovaginal ultrasound is the first-line diagnostic method. Treatment includes hormonal methods or surgery, and surgical treatment seems to be the most effective in resolving symptoms. We describe the case of a 37-year-old woman, with an obstetric history of a pregnancy with cesarean delivery, who complained of pelvic pain and menstrual irregularity. An endovaginal ultrasound was requested, which reported the presence of a “… echogenic oval formation with well-defined limits measuring 28x17 mm in the topography of the cesarean scar.” After a clinical discussion with a doctor specializing in Gynecology, the patient was referred to a hospital consultation in this specialty for investigation. The diagnosis of uterine niche was confirmed, and the treatment consisted of the placement of an intrauterine system.Date: 2023-11-10
A Sharp Case: A Report of a PneumothoraxAbstract
Acupuncture is a therapy that is over 2000 years old, having recently become popular as a practice in Western culture. This therapy consists of inserting fine needles to alleviate symptoms such as pain or nausea. This article focuses on a pneumothorax secondary to acupuncture case. A 20-year-old man came to the Emergency Department with pleuritic pain in the right scapular region. The pain appeared after an acupuncture session performed for low back pain. On physical examination, a eupneic patient was observed, but with some difficulty in completing sentences, with O2 saturation of 98% in room air, with a slight decrease in vesicular murmur on auscultation of the upper right hemithorax and hypertympanism on percussion of the same area, with notorious pain facies, pain on right intercostal palpation and two dorsal punctiform wounds compatible with the insertion of needles.
Chest X-ray revealed a right pneumothorax, so a chest drain was placed. After resolution, the user was discharged with indication for control in primary health care.Date: 2023-11-10
Oropharyngeal Gonorrhea: A Diagnosis to be ConsideredAbstract
Gonorrhea is a sexually transmitted disease (STD) with multiple clinical presentations. This is a case report about a young man with gonococcal pharyngitis. A 27-year-old male seeks medical attention because of three days of symptoms compatible with pharyngitis, having already been medicated with ibuprofen, 600 mg, twice a day, with no improvement. The patient was worried with the possibility of this being an STD because his boyfriend had been diagnosed with a urinary tract infection the day before. Culture of pharyngeal swab was requested, which confirmed the diagnosis of pharyngeal gonorrhea. Diagnosis of pharyngeal gonorrhea demands a high level of clinical suspicion, which arises during the clinical interview. Guidance on situations like this should be comprehensive, providing not only treatment but also counseling on how to stop ongoing transmission.Date: 2023-11-10
Doença de Behçet nos Cuidados de Saúde Primários: Um Diagnóstico Difícil numa Consulta de 10 Minutos
Behçet’s Disease in Primary Health Care: A Difficult Diagnosis in a 10-Minute ConsultationAbstract
Behçet’s disease is a rare autoimmune disease that can affect all blood vessels, and is therefore considered a panvasculitis. It is characterized by recurrent aphthous stomatitis, genital aphthosis and systemic manifestations that may affect the skin, central nervous system, eye, joints, digestive system and vascular system. Manifestations such as erythema nodosum, arthritis, uveitis, digestive ulcers or vascular aneurysms are frequent. In this article, a patient goes to a patient with Behçet’s disease, who reports to the consultation of an acute situation, a diagnosis that meets the limited time of consultation and the complexity of his disease, constituting a challenge for us.Date: 2023-11-10
Dropped Head Syndrome: Rare Manifestation of Myasthenia GravisAbstract
Myasthenia gravis is an autoimmune disease of the neuromuscular junction that is characterized by muscle weakness and fatigue. Dropped head syndrome is a rare complication of myasthenia gravis and is manifested by a head drop resulting from progressive weakness of the flexor and extensor muscles of the neck. Targeted treatment of myasthenia gravis is associated with a recovery of neck strength, thus reducing the negative impact on daily life caused by this disease. It is essential that all healthcare professionals recognize the association between these two entities. We present the clinical case of a 68-year-old female initially evaluated in primary health care for head drop. The diagnosis of myasthenia gravis was only made one month after the initial appointment when other symptoms such as hypophonia and dysphagia were already present. Treatment with intravenous immunoglobulin allowed the recovery of strength in the extensor muscles of the neck.Date: 2023-11-08
Back Pain and Eyelid Drooling: A Rare Case of Horner SyndromeAbstract
A compression or interruption of the oculosympathetic pathway is generally the cause of Horner syndrome. Different etiologies are usually considered, either in the central or in the peripheral nervous system. Horner syndrome due to a herniated cervical or dorsal disc seems to be an excedingly rare event, which is the diagnosis of the presented case. The patient is a 59-year-old woman with sudden onset of dorsal pain and right unilateral ptosis and slight miosis, along with numbness in the third, fourth and fifth fingers of the right hand, due to a D1-D2 herniated disc with associated spinal nerve root compression. An extensive investigation ruled out other possible etiologies. In conclusion, the differential diagnosis of patients presenting with Horner syndrome should include upper thoracic disk herniation.Date: 2023-11-08
Montelukast and Neuropsychiatric Events in Children: What is the Evidence?Abstract
Childhood asthma is a prevalent chronic illness, and the medication montelukast is frequently used as treatment. However, this drug has been linked to neuropsychiatric events that have potentially fatal outcomes. The objective of this review paper was to evaluate the available evidence on this association between montelukast and neuropsychiatric events in children. From an analysis of 17 articles and 1 clinical guidance standard identified by a bibliographic search method, only 5 fulfilled the previously defined inclusion criteria. These selected studies provide support for the existence of possible occurrences of montelukast-induced neuropsychiatric symptoms among asthmatic pediatric patients administered with the medication. Therefore, healthcare providers need to be informed about these risks while making prescribing decisions for young patients who are taking montelukast or undergoing follow-up care subsequently. More multicenter studies are needed, with robust samples, longer follow-up period and well-defined methodology, to clarify the association of montelukast with neuropsychiatric events in children.Date: 2023-11-08
Lipoma Ileal: Uma Causa Rara de Intussusceção em AdultosAbstract
Bowel intussusception is a rare entity in adults. Symptoms are nonspecific and most of diagnoses are made by computed tomography scan. We report the case of an adult with bowel obstruction due to an ileoileal intussusception caused by a lipoma.
A 44-year-old male patient with colicky epigastric pain since the day before, bilious vomiting, abdominal distension and epigastrium tenderness. Plain abdominal radiography revealed dilation of small bowel with gas-fluid levels and computed tomography scan suggested an ileoileal intussusception. We performed bowel resection comprising the lesion, removal of the regional lymph nodes and a primary anastomosis. The histopathology report revealed a lipoma. Patient was discharged on the fifth postoperative day.
A lipoma is a rare cause of intussusception, with a challenging diagnosis, because of nonspecific symptoms. An early computed tomography scan is essential for the diagnosis and prompt surgical resection is recommended.Date: 2023-11-07
When Grief May Not Be Normal: Approach in Primary HealthcareAbstract
Grief is the natural response to the loss of a loved one, which affects the population universally. Acute grief reactions are normal and expected and should not be diagnosed as a disease. In more complex situations, complications may occur that prevent or delay the adaptation to the loss, leading to the development of prolonged grief. This entity can only be diagnosed at least six months after the loss, but the family physician, due to established proximity, can identify earlier and more accurately individuals at risk.
The aim of this work is to create a screening tool to assess the risk of developing long-term grief disorder before six months after the loss.
A search for scientific articles published in Medline/PubMed, using the terms “Grief”, “Bereavement”, “Risk assessment” and “Primary care”, and clinical guidelines, in English and Portuguese, in the last 10 years, was performed. Their selection was based on the relevance of the title, reading the abstract and full text.
Diagnostic tools for prolonged grief disorder, validated for the Portuguese population, should be applied only after six months of the loss, but immutable risk factors, present since the loss, may be identified early. Therefore, a pilot screening tool is proposed in this work, to be applied in the first 6 months after the loss, guiding the need for reassessment or referral to specialized care.
In the future, it is intended that this tool can be disseminated, applied and ideally validated in primary health care, with prognostic benefit for bereaved individuals.Date: 2023-11-07
When the Legs Speak: A Case ReportAbstract
Peripheral neuropathy is a vast entity that encompasses several differential diagnoses, namely meralgia paresthetica, which reflects a lesion of the lateral cutaneous femoral nerve. In this article, the authors describe a case of meralgia paresthetica addressed in the primary healthcare. This case highlights the importance of knowing this entity for a timely diagnosis and, consequently, reduction of the patients’ suffering.Date: 2023-09-07
Autoantibodies in Type 1 Diabetes: A Retrospective Study of Children Diagnosed Under Ten Years of Age
Autoanticorpos na Diabetes Tipo 1: Estudo Retrospetivo em Crianças com Diagnóstico Inaugural em Idade Inferior a 10 AnosAbstract
INTRODUCTION: Type 1 diabetes is a chronic disease characterized by a selective loss of pancreatic ?-cells with a disproportionate recent increase at ages under 5-years old. Its etiology is multifactorial, to which immune factors contribute through pancreatic autoantibodies. Our main aim is to assess whether the type of pancreatic autoantibody influence the clinical symptoms, glycated hemoglobin and glycemia at diagnosis of type 1 diabetes in children diagnosed under ten-years of age.
METHODS: Observational, retrospective and analytical study carried out with a total of 95 patients included. We compared two groups (aged ?60 months and >60 months) and each type of autoantibody (positive/negative) regarding demographic, immune, clinical and laboratory characteristics. The autoantibodies studied were islet cell autoantibodies (against cytoplasmic proteins in the ?-cell), antibodies to glutamic acid decarboxylase, anti-insulin and anti-zinc transporter 8. The impact of autoimmunity, glycated hemoglobin, gender and age on clinical and laboratory parameters of these children was analyzed.
RESULTS: Children diagnosed over 60 months had a higher glycated hemoglobin value (p=0.005) and this laboratory parameter was the only one that showed an impact on the initial presentation as diabetic ketoacidosis (CI95%: OR=1.66;p=0.001). The value of glycemia at admission showed to be influenced negatively by age (?=--0.25;p=0.022) and positively by glycated hemoglobin (?=0.35;p=0.001). None of the autoantibodies evaluated seemed to interfere in the clinical and laboratory manifestations of type 1 diabetes.
CONCLUSION: Demographic, clinical and laboratory characteristics showed no statistically significant differences between two groups of positive/negative pancreatic autoantibodies analyzed. It is crucial to develop further studies in the scope of autoimmunity that allow to structure potential immune phenotypes and assist in the discovery of new therapeutic targets.Date: 2023-09-06
Penile Neoplasm: Diagnosis Masked by SGLT2 InhibitorsAbstract
Penile cancer is a rare neoplasm that can present with a wide range of symptoms. When diagnosed early, it has an excellent prognosis, however, it worsens dramatically in the presence of metastases. A 69-year-old male patient with a personal history of diabetes mellitus. After prescription of empagliflozin, the patient develops an erythematous lesion in the foreskin. He was progressively medicated with clotrimazole cream, valaciclovir, azithromycin, tinidazole, fluconazole, amoxicillin + clavulanic acid and hydrocortisone without improvement. Diagnosed with squamous cell carcinoma of the penis after biopsy in a Dermatology consultation. This is a case of penile cancer with non-specific symptoms in a patient with risk factors for genital infections, making clinical suspicion difficult and promoting the adoption of measures aimed at the treatment of genital infection. The role of the family doctor is essential for an early referral of patients with clinical signs suggestive of penile cancer.Date: 2023-09-06
A Bizarre SunburnAbstract
Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, complex, potentially life-threatening, drug – induced hypersensitivity reaction that often includes skin eruption, hematologic abnormalities, lymphadenopathy and organ involvement. The authors present a clinical case of a 79-year-old Caucasian man presented to the emergency department due to a burn-in chest and abdomen after vacation and solar exposure without sunscreen protection. He has been taking the following medication for the past two years: perindopril + amlodipine, simvastatin and allopurinol. He had also an itchy maculopapular erythema on his back and confluent erythematous eruption on the lower limbs, similar to purpuric lesions. Laboratory data demonstrated a lymphopenia and elevated liver enzymes. According to RegiSCAR score, this case is classified as probable DRESS syndrome. Allopurinol was discontinued immediately, and the patient started prednisolone. He was observed one month later, with progressive improvement of the lesions. Diagnosing DRESS syndrome can be challenging but should be suspected in a patient who receives a high-risk medication and presents with characteristic symptoms. Supportive therapy and prompt withdrawal of the culprit drug is the primary treatment. In the case presented, the patient complained of a burn but had a toxiderma caused by allopurinol which bizarrely manifested itself.Date: 2023-07-20
Métodos Contracetivos e Função Sexual Feminina: Revisão de LiteraturaAbstract
Contraceptives can affect libido, and method choice should consider possible effects on female sexual function. This review aims at identifying the role of different contraceptive methods on female sexual function, thus allowing for better clinical counseling. This review, performed in August/2022, included 13 reviews and 32 clinical trials. The levonorgestrel intrauterine system, vaginal ring, and transdermal patch showed mainly positive or neutral effects. The subcutaneous implant and combined oral contraceptives led to mixed results. The progestogen-only oral contraceptive and the DMPA intramuscular injection were associated with mainly negative sexual effects. The copper uterine device had no impact on female sexual function. Sterilization had mixed psychological effects. Adequate counseling, replacement of the contraceptive method, and, in specific cases, pharmacologic treatment may improve contraceptive-associated female sexual dysfunction. More large-scale studies are needed to allow for specific recommendations regarding each contraceptive method and the production of clinical guidelines for these situations.Date: 2023-07-20