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Febre durante a erupção dentária primária − Há evidência?
No full textIntroduction: There is no consensus on the causal relationship between primary dental eruption and both systemic and local signs and symptoms. Fever, an important sign, is often reported. Such lack of evidence hampers clinical reasoning and may contribute to delayed diagnosis of important conditions.
Objective: To review existing evidence underlying the association between primary tooth eruption and fever.
Methods: A review of the evidence on English, Portuguese and Spanish scientific publications over the last ten years was performed in the main international databases using the query “tooth eruption” and “fever” [MeSH], and in the index of Portuguese medical journals using the query “erupção dentária” and “febre” [DeCS]. SORT system of the American Family Physician was used for rating the strength of evidence.
Results: A total of 53 articles were retrieved, from which two meta-analyses and two original studies were selected, comprising a total of 5317 children. Massignan et al. (2016) meta-analysis and Memarpour et al. (2015) clinical trial found a slight temperature increase on the day of primary tooth eruption, but no fever. In Nemezio et al. (2017) meta-analysis, this association was observed in the subgroup that used the rectal method for temperature assessment. Un Lam et al. (2016) observational study reported a fever prevalence of 49.9%.
Discussion and conclusions: The present analysis had several limitations, including a significant heterogeneity amongst studies in the definition of fever, interpersonal variability during fever measurements, different fever assessment methods or absence of that information, and no exclusion of confounding factors. Given available evidence, it is not possible to establish a clear association between primary dental eruption and the occurrence of fever. A higher number of robust studies is required to confirm this hypothesis (SORT B).Introdução: Não existe consenso na literatura sobre a existência de uma relação causal entre erupção dentária primária e ocorrência de sinais e sintomas sistémicos e locais. A febre, um importante sinal clínico, é frequentemente reportada por pais e profissionais de saúde. A falta de evidência dificulta o raciocínio clínico, podendo contribuir para atrasos no diagnóstico de patologias importantes associadas a este sintoma.
Objetivo: Rever a evidência disponível acerca de uma associação entre erupção dentária primária em lactentes e o aparecimento de febre.
Métodos: Foi efetuada uma pesquisa de artigos científicos em Inglês, Português e Espanhol publicados nos últimos dez anos nas principais bases de dados médicas internacionais utilizando os termos MeSH “tooth eruption” e “fever”, e no índice de revistas médicas Portuguesas utilizando os termos DeCS “erupção dentária” e “febre”. Foi utilizada a escala SORT da American Family Physician para avaliar os níveis de evidência.
Resultados: Foram identificadas 53 publicações, das quais foram selecionados duas meta-análises e dois artigos originais, abrangendo um total de 5317 crianças. Na meta-análise de Massignan et al. (2016) e no ensaio clínico de Memarpour et al. (2015), verificou-se um ligeiro aumento da temperatura no dia da erução dentária primária, mas não foi descrita a ocorrência de febre. Na meta-análise de Nemezio et al. (2017), essa associação foi encontrada no subgrupo que utilizou o método retal para medição da temperatura. O estudo observacional de Un Lam et al. (2016) encontrou uma prevalência de febre de 49,9%.
Discussão e conclusões: A presente análise tem várias limitações: uma grande heterogeneidade entre estudos na definição de febre, variabilidade interpessoal na realização das respetivas medições, utilização de diferentes métodos de medição de febre ou ausência de referência ao mesmo, e ausência de exclusão de fatores de confundimento. Perante a evidência disponível, não é possível confirmar a existência de uma associação entre erupção dentária primária e febre, sendo necessários mais estudos robustos para avaliar esta hipótese (SORT B)
An unusual finding on the anterior fontanelle exam
No full textIntrodução: A palpação da fontanela anterior permite avaliar o volume e pressão intracranianos. Uma fontanela tensa numa criança tranquila e observada em posição vertical sugere hipertensão intracraniana, que pode ter várias etiologias, nomeadamente processos neoformativos.
Caso clínico: Uma lactente do sexo feminino, de dois meses de idade, recorreu a consulta na sua Unidade de Saúde Familiar por tumefação na fontanela anterior. Objetivou-se a presença de tumefação nodular, de consistência mole, com cerca de 1 cm de maior diâmetro. A ecografia transfontanelar revelou um provável quisto epidermoide. A lactente foi referenciada para Cirurgia Pediátrica, tendo realizado ecografia de controlo após dois meses, que revelou crescimento da lesão, motivo pelo qual foi referenciada para Neurocirurgia. Efetuou ressonância magnética encefálica, que confirmou o diagnóstico ecográfico e excluiu comunicação da lesão com estruturas endocranianas. A lactente manteve seguimento por Neurocirurgia e foi decidido manter vigilância até a fontanela encerrar para realização da cirurgia de exérese. O exame histológico confirmou o diagnóstico de quisto dermoide.
Discussão:A vigilância clínica e os achados dos exames imagiológicos demonstraram o carácter benigno da lesão, permitindo adiar a intervenção cirúrgica.Introduction: Palpation of the anterior fontanelle allows to investigate intracranial pressure and volume. Swelling of anterior fontanelle in a quiet baby examined in a supine position indicates high intracranial pressure, which may have distinctive causes, namely neoplasms.
Case report: A female infant, two months old, attended an emergency consultation at the Family Health Unit due to swelling in the anterior fontanelle. A soft nodular swelling with approximately one centimeter in diameter was observed at the fontanelle. Transfontanellar ultrasound revealed a potential epidermal cyst. The infant was referred to the Pediatric Surgery Department. Ultrasound was repeated two months later and revealed lesion growth. The infant was referred to the Neurosurgery Department, and a brain magnetic resonance imaging was performed. Absence of communication with endocranial structures was confirmed. Surveillance was maintained until fontanelle closure, aiming at later excision. Histological examination confirmed the diagnosis of dermoid cyst.
Discussion: Regular clinical follow-up supported by imaging studies revealed the benign nature of the lesion, allowing to postpone surgery
Hipotonia e dificuldades alimentares no recém-nascido: um caso de distrofia miotónica tipo 1 congénita
No full textIntroduction: Congenital myotonic dystrophy type 1 (DM1) is characterized by hypotonia and severe general weakness at birth, often with respiratory distress and even death.
Clinical report:A newborn male with prenatal diagnosis of ventriculomegaly and polyhydramnios was born at 39 weeks of gestation with no immediate occurrences and a maternal family history of two cases with unspecified neuromuscular conditions. The newborn was admitted in the second day of life due to feeding problems and desaturation episodes, presenting with hypotonia, non-vigorous crying, facial diplegia, and arthrogryposis of the lower limbs. A genetic study for myotonic dystrophy was requested, which revealed cytosine thiamine and guanine (CTG) expansion in the DMPK gene (1100−1400 repeats), confirming diagnosis of congenital DM1.
Discussion and conclusions: Despite the presence of congenital DM1, this newborn presents with a milder phenotype than expected for the condition. Symptom recognition, combined with family history, allowed an early diagnosis and adequate follow-up.Introdução: A distrofia miotónica tipo 1 (DM1) congénita caracteriza-se por hipotonia e fraqueza generalizada grave ao nascimento. Frequentemente, apresenta-se com insuficiência respiratória, podendo ser fatal.
Caso Clínico: Um recém-nascido do sexo masculino, com diagnóstico pré-natal de ventriculomegalia e polihidrâmnio, nasceu às 39 semanas sem intercorrências. Dos antecedentes familiares, destacam-se dois elementos da linhagem materna com doença neuromuscular não esclarecida. O recém-nascido foi internado no segundo dia de vida devido a dificuldades alimentares e episódios de dessaturação, apresentando hipotonia, choro pouco vigoroso, diplegia facial e artrogripose dos membros inferiores. Foi solicitado estudo genético de distrofia miotónica, que revelou expansão de citosina, tiamina e guanina (CTG) no gene DMPK (1100−1400 repetições), confirmando o diagnóstico de DM1 congénita.
Discussão e conclusões: Apesar de se tratar de um caso de DM1 congénita, este recém-nascido apresenta um quadro menos grave do que o expectável. O reconhecimento da sintomatologia, aliado à história familiar, permitiu estabelecer um diagnóstico atempado e um plano de seguimento adequado
Um caso raro de volvo intestinal causado pela persistência de um quisto onfalomesentérico
No full textA persistent omphalomesenteric duct is one possible cause of small-bowel volvulus, a rare cause of acute abdomen in children. A four-year-old child was admitted to the Emergency Department with abdominal pain and incoercible vomiting, with neither abdominal guarding nor relevant abnormalities revealed in complementary diagnostic exams. Due to a significant clinical deterioration over a 48-hour observation period, the child was transferred to a tertiary hospital with pediatric surgery. An abdominal ultrasound revealing severe bowel distension and increased abdominal free fluid warranted an exploratory surgery, which identified a voluminous omphalomesenteric duct cyst. When symptomatic, treatment of this condition is consensual and consists of surgical excision of the anatomical abnormality, either by laparoscopy or conventional surgery. The latter was performed.
Conclusion: A persistent omphalomesenteric duct is a rare condition that generally requires a high level of clinical suspicion for diagnosis to be made, being most commonly detected during surgery. Associated complications and mortality rates are high, and a timely intervention is key, since surgical removal is the only treatment option.A persistência do ducto onfalomesentérico pode ser responsável pela formação de um volvo intestinal na porção do intestino delgado, uma causa rara de abdómen agudo em crianças. Uma criança de quatro anos de idade foi admitida no Serviço de Urgência por dor abdominal e vómitos incoercíveis, sem defesa abdominal nem alterações significativas nos exames auxiliares de diagnóstico. Devido a um agravamento clínico significativo no período de 48 horas em que esteve sob observação, foi transferida para um hospital terciário, com acesso a cirurgia pediátrica. Uma nova avaliação ecográfica abdominal, que demonstrou extensa distensão abdominal e presença de líquido livre, levou a exploração cirúrgica, tendo sido identificado e removido um volumoso quisto do canal onfalomesentérico. Quando sintomática, a orientação terapêutica desta patologia é consensual, consistindo na excisão cirúrgica do defeito anatómico, que foi efetuada. Conclusão: A persistência do ducto do canal onfalomesentérico é uma condição rara, cujo diagnóstico exige um elevado nível de suspeição, sendo muitas vezes detetado apenas durante a cirurgia. A taxa de complicações e mortalidade é elevada e uma intervenção atempada é essencial, dado que a remoção cirúrgica constitui a única opção de tratamento
Aspergillus Species and Antifungals Susceptibility in Clinical Setting in the North of Portugal: Cryptic Species and Emerging Azoles Resistance in A. fumigatus
Get PDFAspergillus spp. are agents of a broad-spectrum of diseases among humans. Their growing resistance to azoles, the cornerstone in the management of human aspergillosis, is a worrisome problem around the world. Considering lack of data from Portugal on this topic, particularly from the northern region, a retrospective surveillance study was planned to assess frequency of cryptic Aspergillus species and azoles resistance. A total of 227 clinical isolates, mainly from the respiratory tract (92.1%), collected from three hospitals serving a population of about three million people, were studied for their epidemiology and antifungal susceptibility patterns determined by the E.DEF.9.3 protocol of EUCAST. Employing molecular methods, seven Aspergillus complexes were identified; Aspergillus fumigatus sensu stricto was the most frequent isolate (86.7%). A 7.5% prevalence of cryptic species was found; A. welwitschiae (A. niger complex-3.1%) and A. lentulus (A. fumigatus complex-2.2%) were the most frequent. Amongst cryptic species, it was found a percentage of resistance to voriconazole, posaconazole and isavuconazole of 47.1, 82.4, and 100%, respectively. Five A. fumigatus sensu stricto showed pan-azole resistance. Sequencing their cyp51A gene revealed the presence of one isolate with TR46/Y121F/T289A mutation and two isolates with TR34/L98H mutation. This study emphasizes the need to identify strains to the species level and to evaluate their antifungal susceptibility in all human originated Aspergillus spp. isolates, particularly those from invasive aspergillosis.This work was supported by Grant IN-PT-131-1755 from Gilead Sciences.info:eu-repo/semantics/publishedVersio
Photo Rounds: Rapid-onset rash in child
No full textOur patient's pruritic rash was spreading throughout his trunk and arms. An acute infection 10 days earlier shed light on the diagnosis.info:eu-repo/semantics/publishedVersio
Comparison between modified Dunn procedure and in situ fixation for severe stable slipped capital femoral epiphysis
Get PDFBackground and purpose - The best treatment option for severe slipped capital femoral epiphysis (SCFE) is still controversial. We compared clinical and radiographic outcomes of modified Dunn procedure (D) and in situ fixation (S) in severe SCFE. Patients and methods - We retrospectively compared D and S, used for severe stable SCFE (posterior sloping angle (PSA) > 50°) in 29 patients (15 D; 14 S). Propensity analysis and inverse probability of treatment weights (IPTW) to adjust for baseline differences were performed. Patients were followed for 2-7 years. Results - Avascular necrosis (AVN) occurred in 3 patients out of 15, after D, causing conversion to total hip replacement (THR) in 2 cases. In S, 1 hip developed chondrolysis, requiring THR 3 years after surgery. 3 symptomatic femoroacetabular impingements (FAI) occurred after S, requiring corrective osteotomy in 1 hip, and osteochondroplasty in another case. The risk of early re-operation was similar between the groups. The slippage was corrected more accurately and reliably by D. The Nonarthritic Hip Score was similar between groups, after adjusting for preoperative and postoperative variables. Interpretation - Although D was superior to S in restoring the proximal femoral anatomy, without increasing the risk of early re-operation, some concern remains regarding the potential risk of AVN in group D.info:eu-repo/semantics/publishedVersio
Epigenome-wide DNA methylation profiling of periprostatic adipose tissue in prostate cancer patients with excess adiposity-a pilot study
Get PDFBackground:
Periprostatic adipose tissue (PPAT) has been recognized to associate with prostate cancer (PCa) aggressiveness and progression. Here, we sought to investigate whether excess adiposity modulates the methylome of PPAT in PCa patients. DNA methylation profiling was performed in PPAT from obese/overweight (OB/OW, BMI > 25 kg m-2) and normal weight (NW, BMI < 25 kg m-2) PCa patients. Significant differences in methylated CpGs between OB/OW and NW groups were inferred by statistical modeling.
Results:
Five thousand five hundred twenty-six differentially methylated CpGs were identified between OB/OW and NW PCa patients with 90.2% hypermethylated. Four hundred eighty-three of these CpGs were found to be located at both promoters and CpG islands, whereas the representing 412 genes were found to be involved in pluripotency of stem cells, fatty acid metabolism, and many other biological processes; 14 of these genes, particularly FADS1, MOGAT1, and PCYT2, with promoter hypermethylation presented with significantly decreased gene expression in matched samples. Additionally, 38 genes were correlated with antigen processing and presentation of endogenous antigen via MHC class I, which might result in fatty acid accumulation in PPAT and tumor immune evasion.
Conclusions:
Results showed that the whole epigenome methylation profiles of PPAT were significantly different in OB/OW compared to normal weight PCa patients. The epigenetic variation associated with excess adiposity likely resulted in altered lipid metabolism and immune dysregulation, contributing towards unfavorable PCa microenvironment, thus warranting further validation studies in larger samples.This work was supported in part by the Natural Sciences and Engineering Research Council of Canada, Manitoba Research Health Council, University of Manitoba, and China Scholarship Councilinfo:eu-repo/semantics/publishedVersio
Long-term trends in mortality and AIDS-defining events after combination ART initiation among children and adolescents with perinatal HIV infection in 17 middle- and high-income countries in Europe and Thailand: A cohort study
Get PDFBackground: Published estimates of mortality and progression to AIDS as children with HIV approach adulthood are limited. We describe rates and risk factors for death and AIDS-defining events in children and adolescents after initiation of combination antiretroviral therapy (cART) in 17 middle- and high-income countries, including some in Western and Central Europe (W&CE), Eastern Europe (Russia and Ukraine), and Thailand.
Methods and findings: Children with perinatal HIV aged 6 months of cART) death and progression to AIDS were assessed. Of 3,526 children included, 32% were from the United Kingdom or Ireland, 30% from elsewhere in W&CE, 18% from Russia or Ukraine, and 20% from Thailand. At cART initiation, median age was 5.2 (IQR 1.4-9.3) years; 35% of children aged 400 c/mL predicted late death. Predictors of early and late progression to AIDS were similar. Study limitations include incomplete recording of US Centers for Disease Control (CDC) disease stage B events and serious adverse events in some countries; events that were distributed over a long time period, and that we lacked power to analyse trends in patterns and causes of death over time.
Conclusions: In our study, 3,526 children and adolescents with perinatal HIV infection initiated antiretroviral therapy (ART) in countries in Europe and Thailand. We observed that over 40% of deaths occurred ≤6 months after cART initiation. Greater early mortality risk in infants, as compared to older children, and in Russia, Ukraine, or Thailand as compared to W&CE, raises concern. Current severe immune suppression, being underweight, and unsuppressed viral load were associated with a higher risk of death at >6 months after initiation of cART.info:eu-repo/semantics/publishedVersio
Desfechos psicológicos em longo prazo após alta da terapia intensiva
Get PDFObjective:
To investigate the longterm psychological outcome in survivors of critical illness after intensive care unit discharge.
Methods:
A prospective cohort of survivors admitted to a mixed intensive care unit between January and September 2010 was evaluated six months and five years after hospital discharge. The Dementia Rating Scale-2, the Hospital Anxiety and Depression Scale, the Posttraumatic stress syndrome 14-questions inventory, the Euro Quality of Life 5 Dimensions (EQ-5-D), and the Visual Analogue Scale (EQ VAS) were assessed at both follow-up periods.
Results:
Of 267 patients, 25 patients were evaluated at 6 months after discharge (62 ± 16 years); 12 (48%) presented cognitive impairment, 6 (24%) anxiety, 4 (16%) depression, and 4 (16%) post-traumatic stress disorder. Among those re-evaluated five years after discharge (n = 17; 65 ± 15 years), the frequency of cognitive impairment dropped from 8 (47%) to 3 (18%) (p = 0.063), due to improvement in these patients over time, and other patients did not acquire any dysfunction after discharge. At five years after discharge, only two patients (12%) reported anxiety, and none had depression or post-traumatic stress disorder. No differences were found between the six-month and five-year follow-ups regarding EQ-5-D and EQ VAS.
Conclusion:
Survivors do not show a progressive decline in cognitive function or quality of life within five years after intensive care unit discharge. Psychopathological symptoms tend to decrease with time.Objetivo:
Investigar o desfecho psicológico em longo prazo em sobreviventes de doenças críticas, após alta da unidade de terapia intensiva.
Métodos:
Avaliou-se coorte prospectiva de pacientes sobreviventes após admissão a uma unidade de terapia intensiva mista entre janeiro e setembro de 2010, 6 meses e 5 anos após a alta hospitalar. Aplicaram-se em todos os momentos as seguintes escalas: Dementia Rating Scale-2, Hospital Anxiety and Depression Scale, Post-Traumatic Stress Syndrome 14-Questions Inventory, Euro Quality of Life 5 Dimensions (EQ-5-D) e Visual Analogue Scale (EQ VAS).
Resultados:
Dentre 267 pacientes, 25 foram avaliados após 6 meses (idade: 62 ± 16 anos). Aos 6 meses, 48% apresentavam comprometimento cognitivo; 24% ansiedade, 16% depressão e 16% transtorno de estresse pós-traumático. Foram reavaliados 5 anos após a alta 17 pacientes, com idade: 65 ± 15 anos. Dentre eles, a frequência de comprometimento cognitivo caiu de 47% para 18% (p = 0,063), em razão da melhora destes pacientes ao longo do tempo e do não surgimento desta condição em outros pacientes após a alta. Ainda após 5 anos, apenas 12% da amostra relatou ansiedade, e nenhum tinha depressão ou transtorno de estresse pós-traumático. Não se encontraram diferenças em termos das escalas EQ-5-D e EQ VAS entre as avaliações após 6 meses e 5 anos.
Conclusão:
Os sobreviventes não apresentaram declínio progressivo da função cognitiva ou da qualidade de vida dentro de 5 anos após a alta da unidade de terapia intensiva. Os sintomas psicopatológicos tenderam a diminuir com o tempo.info:eu-repo/semantics/publishedVersio