Attention-deficit/hyperactivity disorder (ADHD) is among the most prevalent neurodevelopmental disorders in children. Psychostimulants, particularly methylphenidate, are first-line pharmacological agents with robust evidence of efficacy and a favorable safety profile. However, abrupt offset of pharmacodynamic effect may precipitate a rebound phenomenon, characterized by transient exacerbation of irritability, hyperactivity, and behavioral dysregulation. This phenomenon is rarely documented in scientific literature and likely underdiagnosed.
An eight-year-old boy with unremarkable past medical and family history presented with longstanding inattention, increased motor activity, and academic underachievement. Other comorbid conditions were excluded.
Diagnosis of ADHD was established. Treatment was initiated with extended-release methylphenidate. Daily late-afternoon episodes of marked irritability and increased motor restlessness emerged, consistent with methylphenidate rebound. Add-on administration of immediate-release methylphenidate in the afternoon resulted in effective mitigation of rebound symptoms.
This case study aims to review the semiological characteristics of the rebound effect induced by methylphenidate and the respective therapeutic approach.

Introduction: The association of speech therapy (ST) with phonosurgery can improve vocal quality. Preoperative ST enhances treatment adherence and addresses factors contributing to vocal fold injury. Postoperative ST promotes healing and helps manage potential compensatory muscle tension.
Methods: Development of an intervention protocol between Otorhinolaryngology (ORL) and ST in the pre and postoperative management of phonotraumatic laryngeal pathology, based on a literature review and the experience of a Tertiary Hospital.
Results: The ORL assessment includes clinical history and audioperceptive evaluation - pitch, loudness and GRBAS (Grade/Roughness/Breathiness/Asthenia/Strain) scale. Objective examination is complemented by videostroboscopy, assessing vocal fold vibration, mucosal wave propagation, and the presence of lesions or signs of supraglottic hyperfunction. In the preoperative ST consultation, the impact of dysphonia is assessed using the Voice Handicap Index-10; aerodynamic assessment - maximum phonation time and S/Z ratio - and acoustic analysis - fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio - are also obtained. Patients receive vocal hygiene recommendations, semi-occluded vocal tract and relaxation exercises, and guidance on appropriate breathing techniques. Postoperatively, 3-5 days of voice rest are recommended, and patients are reassessed by ORL and ST. ORL repeats the audioperceptive assessment and videostroboscopy to assess healing. ST follow-up includes reinforcement of vocal hygiene recommendations, posture control exercises, postural and vibratory relaxation techniques, costodiaphragmatic breathing, and coordination of respiration and phonation. Conclusion: This protocol underscores the importance of coordinated ORL and ST intervention in the pre and postoperative periods to optimize surgical outcomes in patients with phonotraumatic laryngeal pathology.

The overlap of primary biliary cholangitis with systemic sclerosis is referred to as Reynolds syndrome and is infrequent. We present the case of a 54-year-old woman with a nodular lesion on the second finger of her left hand. She exhibited fatigue, generalized pruritus, and a laboratory pattern of cholestasis, leading to a directed study that confirmed the diagnosis of primary biliary cholangitis, with compatible serology and histology. Raynaud’s phenomenon was also identified, and a biopsy of the cutaneous lesion revealed calcinosis cutis, raising the suspicion of an overlap with systemic sclerosis. Additionally, interstitial lung disease with positive anti-Ro52 was present. Three years after the initial presentation, she developed skin thickening of the limbs and face. A diagnosis of Reynolds syndrome was established.

Henoch-Schönlein purpura (HSP) is a rare vasculitis in adults, requiring a high index of suspicion. This case highlights the role of Primary Healthcare and a comprehensive assessment in early recognition.
A healthy 27-year-old female presented to the Emergency Department (ED) with abdominal pain and vomiting and was discharged with suspected gastroenteritis. Four days later, she consulted her Family Doctor for persistent symptoms. A thorough review revealed arthralgia, rectal bleeding and palpable purpura on both lower limbs. She was promptly referred back to the ED. Laboratory results and abdominal ultrasound had no major alterations and abdominal computed tomography (CT) suggested inflammatory enteritis.
She was admitted for a diagnostic skin biopsy and initiated on corticosteroid therapy for suspected HSP. The patient showed a favorable clinical response to prednisolone, with stable renal function and blood pressure throughout hospitalization.
This case reinforces the value of Primary Health Care in ensuring comprehensive evaluation and facilitating early diagnosis to prevent complications.

Introduction: Chronic kidney disease (CKD) affects approximately 9.8% of the Portuguese population. As it is a progressive condition and often asymptomatic in its early stages, screening and early diagnosis are essential. One of the main pillars is the estimation of the glomerular filtration rate (GFR), whose determination varies according to the equation used. We aimed to evaluate differences in CKD staging using validated equations for GFR calculation.
Methods: Observational, cross-sectional, retrospective, and analytical study conducted at USF Lethes (February 2025). Individuals aged ?18 years with a recorded serum creatinine value in SClínico® were included. Those without a recorded body weight were excluded. Sociodemographic, clinical, and anthropometric data were collected through the MIM@UF® platform and analyzed using LibreOffice®.
Results: Among 8 900 individuals, significant variations in CKD classification were observed depending on the equation used. The Cockcroft–Gault (CG) equation identified more cases (12%) than CKD-EPI 2009 (7.5%) and CKD-EPI 2021 (6.1%). CKD-EPI 2021 classified more individuals in the early stages (G1 and G2), whereas CG assigned a higher number to moderate stages (G3a and G3b). Greater agreement was found between CKD-EPI 2009 and 2021, particularly in transitions between stages.
Conclusion: The CG equation demonstrated higher sensitivity, while CKD-EPI 2021 showed greater specificity but a lower ability to detect early and moderate stages. These divergences in GFR estimation influence the diagnosis and staging of CKD, with a direct impact on clinical monitoring, treatment, and referral to Nephrology. Uniform adoption of CKD-EPI 2009, without a race factor, may improve diagnostic accuracy in primary health care in Portugal.

Glycogen storage disease type IXa (GSD IXa) is a congenital disorder of glycogen metabolism caused by pathogenic variants of the PHKA2 gene, which encodes the ?-subunit of liver phosphorylase kinase. This study presents six cases of boys with hemizygous variants in the PHKA2 gene. At presentation, manifestations included recurrent ketotic hypoglycemia (n= 4), hepatomegaly (n= 3), hypertriglyceridemia (n= 3) and elevated aminotransferases (n= 2), with evidence of mild liver fibrosis in two cases. Supplementation with glucose polymers and proteins, alongside the avoidance of prolonged fasting, led to clinical improvement and normalization of laboratory results. These cases demonstrate the phenotypic variability of GSD IXa, which makes differential diagnosis with other causes of recurrent ketotic hypoglycemia. The data reinforce the value of detecting hypoglycemia with simultaneous determination of ketonemia. Corroboration of the diagnosis through genetic testing is useful for guiding treatment and enabling family counselling.

Subacute thyroiditis (De Quervain's thyroiditis) is a rare cause of thyrotoxicosis, typically preceded by viral infection. It is characterized by thyroid inflammation that leads to a transient thyrotoxic phase, resulting from follicular cell destruction. Clinically presented with anterior neck pain, fever, and fatigue; laboratory findings psoinclude low or suppressed TSH and elevated free T3/T4 levels; ultrasound can show a hypoechoic gland, and scintigraphy reveals reduced radionuclide uptake. We report the case of a 53-year-old woman with anterior neck pain and palpitations. Her history included anxiety and family history of thyroid disease. Physical examination revealed enlarged and tender thyroid. Ibuprofen was initiated, and further investigations confirmed the diagnosis. Due to persistent symptoms, propranolol and oral prednisolone were introduced, leading to clinical and biochemical improvement within two months. This case underscores the importance of recognizing subacute thyroiditis in primary care, avoiding unnecessary referrals, and highlights the family physician’s role in diagnosis and follow-up.

We describe the case of a 49-year-old man, treated with disulfiram 500 mg/day and with simultaneous alcohol intake, who, after approximately one month of cumulative exposure to the drug, developed progressive tetraparesis, preventing him from walking independently. Neurological examination revealed tetraparesis with greater severity in the lower limbs, abolished Achilles reflexes, and stocking and glove hypoesthesia. Electroneuromyography identified axonal sensory-motor polyneuropathy with a distal-proximal gradient and very severe severity in the distal segments of the lower limbs. Progressive clinical and electrophysiological improvement was observed after discontinuation of disulfiram and implementation of a rehabilitation program. The authors seek to draw attention to a neurological complication associated with a drug that is relatively common in national clinical practice.

Drug interactions are a frequent cause of Emergency Department (ED) visits and may pose a significant threat to patients, leading to reduced therapeutic efficacy or drug toxicity. Early recognition of these interactions is essential to prevent adverse clinical outcomes. A 66-year-old man with a history of hypertension, smoking and epilepsy, treated with olmesartan, levetiracetam, and carbamazepine. Following a diagnosis of Helicobacter pylori infection, he was started on an eradication regimen including esomeprazole, amoxicillin, metronidazole and clarithromycin. On the fifth day of treatment, he developed gait imbalance, slurred speech, dizziness and motor incoordination. Due to suspicion of acute ischemic stroke, he was referred to the ED. Cranial computed tomography was normal, while laboratory tests revealed toxic serum levels of carbamazepine. Clarithromycin acts as a potent inhibitor of the CYP3A4 isoenzyme, reducing the hepatic metabolism of carbamazepine and increasing its serum levels. This combination can cause neurological toxicity with a presentation similar to a stroke, and should therefore be avoided.

Orbital abscess is a frequent complication of pediatric acute sinusitis requiring surgical drainage combined with FESS. The preseptal transconjunctival approach provides safe orbital access, enabling effective drainage while preserving ocular function and avoiding facial scarring. We aimed to describe the case of a child with an orbital abscess treated with preseptal transconjunctival drai-nage combined with ESS. A 9-year-old boy presented with fever, purulent rhinorrhea, and left periorbital swelling. Computed tomograph showed left maxillary and ethmoidal sinusitis with an 8mm extraconal intraorbital abscess. After no improvement with intravenous antibiotics, he underwent FESS combined with preseptal transconjunctival abscess drainage. By postoperative day 7, complete resolution of infection and full recovery of ocular function were achieved. This case highlights timely surgical intervention in pediatric orbital complications of acute sinusitis. The combi-ned FESS and preseptal transconjunctival approach achieved infection control, preserved ocular function, and avoided scarring, supporting transorbital approaches in infectious orbital pathology.

Introduction: Pain is a very common symptom in Palliative Care, and a multidimensional approach is important. Currently, there are several scales that allow the assessment of isolated components of pain, but no tool for assessing total pain, resulting in a gap in this area. This study aimed to develop a total pain assessment protocol and subsequently assess its prevalence.
Methodology: Development of a total pain assessment protocol, applied to patients present in the Palliative Care Unit between January and February 2022. Formulation of a self-completion questionnaire, based on six validated scales (numerical pain scale, faces scale, McGill scale, HADS scale, FACIT-PAL scale and FACIT-SP-12 scale), with the aim of evaluating the presence of total pain (physical, emotional, social and spiritual). The presence of each of the aforementioned domains was assessed using descriptive statistics, medians, interquartile ranges and Spearman's correlation coefficient.
Conclusion: The presence of physical pain was verified in 100% of users on the numerical scale and in 91.7% on the face scale. According to the McGill scale, everyone indicated some degree of physical pain, and 83.3% some degree of psychological pain. Using the HADS scale, it can be seen that 75% had psychological pain. According to the FACIT-PAl and FACIT-Sp-12 scales, everyone presented some degree of social and spiritual pain. Finally, considering the presence of total pain in the presence of some degree of all types of pain, this was observed in the majority. This protocol represents a useful tool in clinical practice and for future studies.

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma. In approximately 40% of cases, it presents in extranodal sites, particularly in the gastrointestinal tract. Its clinical presentation may mimic inflammatory bowel diseases, infectious conditions, or neoplasms, making early diagnosis challenging. We report the case of a 35-year-old man presenting with mechanical low back pain of several months duration and constitutional symptoms, initially managed under the suspicion of Crohn’s disease. Following an extensive multidisciplinary workup, a definitive diagnosis of anaplastic variant DLBCL, stage IV-B with intestinal involvement, was established. This case highlights the diagnostic complexity and underscores the importance of clinical follow-up, reconsideration of diagnostic hypotheses, and coordinated collaboration between primary care and hospital-based healthcare services.

Introduction: Arterial hypertension (HTN) is the most prevalent chronic disease in Portugal, affecting 36% of adults aged 25 to 74. It is a major risk factor for cardiovascular (CV) events, which remain the leading cause of morbidity and mortality worldwide. The World Health Organization estimates that approximately 600 million people have hypertension, accounting for over 7 million deaths annually. We aimed to characterize hypertensive patients with non-fatal major cardiovascular events followed in a local primary care unit over 10 years, assessing SCORE/SCORE2/OP risk factors, comorbidities, medical history, and pre-event pharmacological treatment.
Methods: A retrospective study was conducted using electronic health records (MIM@UF, SClínico, and RSE), including patients with HTN and major CV events between 2014 and 2024. Pregnant women, patients under 18 years old, and non-hypertensive individuals were excluded. Statistical analysis was performed using IBM SPSS®.
Results: A total of 185 patients were included (67% male), with a mean age of 72.7 years. The most prevalent comorbidities were dyslipidemia (87.6%), obesity (39.9%), and type 2 diabetes mellitus (39.5%). Stroke was the most frequent event (42.7%), followed by ischemic heart disease with angina (26.5%). Only 15.1% of patients with dyslipidemia had LDL levels within the target, despite 82.7% being on statins. Regarding HTN, 18.9% were untreated and 51.4% were on ?2 antihypertensive drugs, yet many remained uncontrolled.
Conclusion: Significant gaps persist in the control of HTN and dyslipidemia. Systematic risk stratification and therapeutic education are essential to prevent CV event recurrence in this high-risk population.

Dieulafoy’s lesion is a rare but potentially fatal cause of gastrointestinal bleeding, typically located in the stomach, with even rarer extragastric locations, as in the colon. Although endoscopy is the gold standard for diagnosis, it can be challenging due to the lesion’s small size, intermittent bleeding, or inaccessible location. In such cases, contrast-enhanced computed tomography has demonstrated a key role in identifying the source of bleeding and localizing the lesion, enabling prompt and effective endoscopic treatment, as illustrated in the present case. The diagnosis of Dieulafoy’s lesion remains challenging and requires high suspicion and close multidisciplinary collaboration.

This perspective highlights the value of international clinical experiences in Adolescent Medicine, drawing from the author’s residency training in Portugal and subsequent fellowship at Boston Children’s Hospital. Immersing in a new healthcare system provided a deeper appreciation of both shared global challenges and distinct cultural approaches to adolescent care. The article reflects on how international exchange fosters clinical growth through openness, vulnerability, and curiosity - qualities we ask of our adolescent patients and should also embrace as providers. Key topics explored include transitional care, adolescent autonomy, mental health screening, digital media use, and healthcare accessibility. Real-world examples, such as strengths-based communication, confidential care models, and virtual visit innovations, demonstrate how contrasting practices can inspire reimagined, more inclusive care standards. Programs supporting marginalized adolescents, particularly those living with HIV, underscore the urgency of equitable access. Ultimately, international experiences allow clinicians to exchange ideas, challenge assumptions, and build more responsive models of care. This piece invites pediatric providers to seek global learning opportunities and reminds us that, despite geographic and systemic differences, we are united by a shared goal: empowering adolescents to thrive.

Community-acquired pneumonia (CAP) remains a significant cause of morbidity and mortality in adults. Microorganisms classified as atypical, because they cannot be identified by traditional microbiological methods, represent a substantial diagnostic and therapeutic challenge. This review aims to synthesize the most recent evidence on the etiology, diagnosis, and therapeutic implications of atypical pneumonias in adults, integrating data from meta-analyses and current international recommendations. The main bacterial and viral agents are discussed, with an emphasis on suggestive clinical criteria, available diagnostic methods, and options for empirical therapy, addressing antimicrobial resistance and the rational use of antibiotic therapy, and offering a practical perspective for the management of CAP with suspected atypical pathogens.

Introduction: The pregnancy period and the first few months of life are a critical time for a child’s development. On the other hand, the transition to fatherhood represents a life event that increases the vulnerability to men-tal disorders in parents. Paternal postpartum depression (PPD) and its effects have received less attention than maternal postpartum depression (MPD), for which the impact on child development has already been described. This review article aims to synthesize the impact of PPD on child development.
Methods: A bibliographic search was conducted in June 2024 for meta-analyses, systematic reviews and rando-mized clinical trials published in the last 20 years, in Portuguese or English, in the databases PubMed, Cochrane Library, Database of Abstracts of Reviews of Effects, and BMJ Evidence-Based Medicine, using the terms “de-pression,” “father,” “infant,” and “development.” The Strength of Recommendation Taxonomy from the American Family Physician was used to assign levels of evidence and strength of recommendation.
Results: Of the 743 articles obtained, three met the selection criteria. These articles suggest that, like MPD, PPD negatively affects cognitive and language development in children up to 24 months of age.
Conclusion: Given the scientific evidence presented, the authors consider it relevant to create strategies and measures aimed at preventing mental illness in fathers.

Introduction: Gambling disorder, classified in the DSM-5 as a non-substance-related addictive disorder, is charac-terized by persistent and problematic gambling behavior that has a significant clinical impact. The World Health Organization (WHO) estimates that between 0.1% and 6% of the global population may develop this disorder. We aimed to characterize the risk of gambling disorder among the adult population in Portugal.
Methods: A cross-sectional study, using a convenience sample of adults recruited via social media and health units, was conducted using an online questionnaire with sociodemographic data, substance use, health status, and the Portuguese version of the South Oaks Gambling Screen (SOGS-PV).
Results: A total of 595 responses were included (mean age 39.2 years, 67.1% female). 10.9% (95% CI: 8.7–13.7) were at risk for gambling disorder. The most popular games are scratch cards (41.5%), lottery games (34.7%), and online games (22%). Contributing factors to gambling disorder included male gender (OR: 3.57; 95% CI: 1.99–6.52), tobacco use (OR: 2.60; 95% CI: 1.34–4.95) and having a mother (OR: 12.1; 95% CI: 0.534–138.2), friend (OR: 2.349; 95% CI: 0.948–5.423) or family member (OR: 2.85; 95% CI: 1.165–6.481) with gambling di-sorder. Only 1.7% reported discussing this topic with their family physician.
Conclusion: The risk of gambling disorder among Portuguese adults is significant. The presence of identifiable risk factors underscores the importance of opportunistic screening and preventive approaches in primary care, enhancing early detection and intervention.

Introduction: Cardiovascular diseases are the leading cause of morbidity and mortality, with hypertension (HTN) being the most prevalent risk factor. Cardiovascular risk (CVR) stratification using Systematic Coronary Risk Estimation 2 (SCORE2) is currently recommended. The objective was to increase the proportion of patients with HTN undergoing CVR assessment using SCORE2.
Methods: A quality improvement study conducted in a Family Health Unit. Patients aged 40–69 years with uncomplicated HTN were included. Data were collected before the intervention (T0) and at 3 (T1) and 7 months (T2) following an educational intervention aimed at promoting the use of SCORE2 among the medical team.
Results: A total of 304 patients were included; 150 (49.3%) were male, with a median age of 59 years (interquartile range 52–64). Among patients with documented CVR assessment, the use of SCORE2 increased from 3.9% at T0 to 69.6% at T1, and from 6,6% to 47.4% at T2 (p<0.001). A significant reclassification to higher CVR categories was observed following implementation of the tool.
Conclusion: The intervention significantly increased the use of SCORE2 and led to reclassification to higher risk levels. The reduction in utilization at T2 highlights the need for structural integration of the tool into clinical information systems to ensure sustainability.

Digital health technologies have emerged as a transformative force in modern medicine, particularly in the field of cardiovascular care. With the advent of wearable devices, mobile health applications, telemedicine platforms, and AI-driven diagnostics, the potential to significantly enhance patient outcomes and revolutionize the delivery of cardiovascular care is more significant than ever. These technologies provide real-time monitoring, personalized treatment plans, and enhanced patient engagement, all of which are crucial for effectively managing chronic cardiovascular conditions and preventing adverse events. However, despite the promising potential of digital health, integrating these technologies into routine clinical practice has been met with numerous challenges. These include disparities in access to technology, concerns about data privacy and security, the absence of standardized protocols, and the need for interdisciplinary collaboration. Additionally, the long-term implications of widespread digital health adoption, including its impact on healthcare systems, costs, and the overall quality of care, have not been fully explored. This article addresses these gaps by critically examining the barriers to implementing digital health technologies in cardiovascular care, proposing strategies to overcome these challenges, and discussing the potential long-term effects on healthcare systems and patient outcomes. By doing so, it aims to provide a roadmap for successfully integrating digital health into cardiovascular care, ultimately leading to a more predictive, preventive, and personalized healthcare model.

Introduction: We intended to assess the prevalence of sexual dysfunction in men receiving opioid substitution therapy in a Portuguese center, which domains of sexual function are affected, and which factors influence sexual dysfunction.
Methods: We conducted a self-administered form, including: sociodemographic and clinical characterization; maintenance treatment with methadone or buprenorphine; presence of anxiety/depression, assessed with Hos-pital Anxiety and Depression Scale; sexual dysfunction, assessed with Massachusetts General Hospital – Sexual Functioning Questionnaire; erectile dysfunction, assessed with International Index of Erectile Function.
Results: A total of eighty-two patients participated in the study. Of these, 80.5% were receiving methadone treat-ment, with a mean current dose of 53.5 mg, a mean duration of treatment of 12.6 years, and a mean maximum dose of 86.2 mg. Buprenorphine was used by 19.5% of participants, with a mean current dose of 5.74 mg, a mean duration of treatment of 10.4 years, and a mean maximum dose of 8.07 mg. Antidepressants and antipsychotics were taken by 23.8% and 14.8% of participants, respectively. Anxiety and depression were present in 43.5% and 46.2% of cases, respectively. The Massachusetts General Hospital – Sexual Functioning Questionnaire revealed that 42.1% had sexual dysfunction and the item with the lowest score was general satisfaction. The International Index of Erectile Function revealed that 67.9% had erectile dysfunction and the item with the lowest score was achieving and maintaining an erection. There were no statistically significant differences between patients treated with methadone or buprenorphine, regarding the presence of sexual dysfunction and erectile dysfunction. The Factors significantly correlated with sexual dysfunction were: age, professional status, maximum methadone dose used by the patient, anxiety, and depression. The factors significantly correlated with erectile dysfunction were: age; marital status; maximum methadone dose used by the patient, tobacco, anxiety and depression.
Conclusion: We did not find evidence to switch from methadone to buprenorphine, if sexual dysfunction arises. Anxiety and depression seem to be the factors most correlated with sexual dysfunction and erectile dysfunction.