Search

Shoulder dislocations remain the most frequent of joint dislocations, with anterior displacement of the humeral head being the direction of dislocation seen most often (97%). Recently, the Dutch clinical guideline on shoulder dislocations has been revised on the basis of predetermined bottlenecks in clinical practice. In this paper, the guideline is translated to clinical practice by means of two fictional cases, in which the novel recommendations are incorporated. The following topics were systematically assessed based on the best available scientific evidence: primary diagnostics, reduction techniques, painmedication/ sedation surrounding reduction and the need for physiotherapy, stabilization surgery and immobilization. Also, a best practice care pathway is advocated. Since scientific evidence is often inconclusive to provide undebatable therapeutic rules, the committee graded the available evidence and additionally used expert opinion to carefully draft recommendations. The paper concludes with an overview of all the recommendations stated in the updated multidisciplinary guideline.

Group A streptococcal (GAS) infections are caused by the Gram-positive bacterium Streptococcus pyogenes. Infection can occur via droplet infection from the throat and via (in)direct contact with infected people. GAS can cause a wide variety of diseases, ranging from superficial skin infections, pharyngitis and scarlet fever, to serious invasive diseases such as puerperal sepsis, pneumonia, necrotising soft tissue infections (NSTI) (also known as necrotising fasciitis/myositis), meningitis and streptococcal toxic shock syndrome (STSS). In invasive GAS infections, the bacteria has penetrated into a sterile body compartment (such as the bloodstream, deep tissues, or the central nervous system). Invasive GAS infections are rare but serious, with high morbidity and mortality. Since March 2022, the National Institute for Public Health and the Environment (RIVM) reported a national increase in notifiable invasive GAS infections (NSTI, STSS and puerperal fever). Particularly NSTI has increased compared to the years before the SARS-CoV-2 pandemic. Remarkably, the proportion of children aged 0 to 5 years with invasive GAS-infections is higher in 2022 than in the previous years (12% compared to 4%). While seasonal peaks occur, the current elevation exceeds this variation. To promote early recognition and diagnosis of invasive GAS infections different clinical cases are presented.

Aim: To demonstrate the results of routine screening and treatment for psychiatric problems, psychosocial problems and substance use (PPS) among pregnant women in the Netherlands. This approach is advocated by the national program 'The first 1000 days', which focuses on a healthy start for (unborn) children in vulnerable situations., Design: Secondary data analysis of a routine care dataset obtained from midwifery practices and hospitals throughout the Netherlands. All practices and hospitals applied systematic screening with Mind2Care., Method: Each Mind2Care screening results in either a negative result (no risk), an alert and/or a treatment advice based on local care pathways. Anonymous data on detected risk factors and subsequent alerts/advices from 22.141 pregnant women were analyzed., Results: Of all women, 24% had at least one PPS risk factor. Accumulation of risks was present in 10% of women. Thirty-one percent of all pregnant women received at least one specific advice (15% alerts, 24% treatment advices, including overlap)., Conclusion: One in four pregnant women has psychiatric problems, psychosocial problems and/or substance use for which guideline care is available. Implementation of Mind2Care is demanding to the obstetrical system, and requires multidisciplinary care processes of medical and social caregivers. Despite the lack of a scientific evidence on the added value of systematic detection and treatment of PPS-risks in all pregnancies, this programmatic approach is increasingly acknowledged on the national attention level as the way forward to a healthy start for every child, even if born under vulnerable conditions.

Background: An umbilical infection (omphalitis) is frequent in de neonatal period. The infection usually presents as a relatively mild cellulitis. However, in rare cases omphalitis has a complicated course., Case Description: A 20-day-old infant was referred to our Emergency Department with a fever and red umbilicus. Our diagnosis was "omphalitis" and after taking cultures we started with flucloxacillin and gentamicin intravenously. Upon clinical deterioration, we added ceftazidime and performed an ultrasound of the abdomen. A urachal remnant was found. The umbilical swab was positive for Staphylococcus aureus, which we treated with flucloxacillin monotherapy until the infiltrate disappeared on ultrasound., Conclusion: A patient with an omphalitis should be referred to the pediatrician. Clinical admission, obtaining cultures and starting antibiotic treatment is necessary. A large number of health care providers are involved in the care during the neonatal period. Therefore, broad knowledge about prevention and early identification of this disease is important.

A 47-year old male presented to the emergency department with a pneumomediastinum following a small penetrating wound to the neck.

The chance of survival from a prehospital cardiac arrest has increased enormously in recent years thanks to the efforts of civilian first responders. They can start CPR and possibly defibrillate while waiting for the ambulance. These civilian first responders regularly include professional caregivers who can provide advanced life support (ALS) together with ambulance personnel. This article describes the opportunities and challenges, and discusses competence and ability, the use of expertise, and crew resource management (CRM) to ensure that the available knowledge and skills are managed in the right direction. This can further improve the quality of patient care and thus increase the chance of survival.

Background: A thoracic aortic dissection is a rare condition (2.5-3.5 per 100,000 person years) and patients can present with atypical symptoms. However, a missed diagnosis is often fatal., Case Description: A 66-years-old male presents himself at the GP's office with sharp pain and loss of strength and sensation in the right arm. Pulse and blood pressure are undetectable on the right arm. An immediate thoracoabdominal CT-angiography is ordered in the nearest hospital. It reveals an aortic dissection (Stanford type A) and the patient is swiftly transferred to a tertiary referral hospital. Upon emergency surgery, the aortic valve, -root and ascending aorta are replaced. The patient is discharged home after one month., Conclusion: Swift recognition and referral are paramount to survival in aortic dissection. Patients with a low suspicion can be referred to the closed hospital for immediate imaging. When suspicion is high, direct transfer to a thoracic surgery hospital is warranted.

Three immunocompetent children were admitted to the hospital because of varicella-related complications. The first patient developed a bacterial pneumonia secondary to a varicella infection which ultimately lead to a debridement using Video Assisted Thoracoscopic Surgery. The second patient presented with a left peripheral facial paralysis and vesicular lesions in de left auricle. Liquor investigations were positive for the varicella zoster virus and she was diagnosed with Ramsay Hunt syndrome. The last patient was referred to the emergency department with possible absence seizures. These seizures turned out to be caused by an ischemic stroke due to post-varicella arteriopathy. All patients were previously healthy and had no risk factors for varicella-related complications. We conclude that varicella-related complications should also be considered in immunocompetent children, even when the primary infection took place months ago. Patients with severe varicella-related complications need to be referred to a medical specialist where anti-viral therapy should be considered.

Background: The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives., Aim: To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding., Methods: This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire., Results: A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients >80 years (66.4%) and in patients using >10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically., Conclusions: The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

The buried bumper syndrome (BBS) is a rare complication of percutaneous endoscopic gastrostomy (PEG). Hereby the internal PEG bumper is overgrown by hypertrophic gastric mucosa and embedded into the gastric wall. Most often an endoscopic approach to remove the bumper is successful. If not, an operative removal of the plate is necessary. In this paper, we present a case of a patient in whom a BBS was diagnosed. Besides the therapeutic options to treat a BBS, in this paper we want to focus on the prevention of this complication. Consideration needs to be given as to how long after the procedure should it be loosened to prevent BBS. The distance a PEG tube is advanced and whether it should be rotated is crucial in order to prevent BBS.

For decades, a fasting lipid profile was required to predict the cardiovascular risk of patients. This was due to the assumption that if low-density lipoprotein cholesterol (LDL-C) is calculated with the Friedewald Formula, LDL-C is dependent on the triglycerides concentration, which can vary after fat consumption. However, several prospective studies show minimal differences of lipid values in fasting and non-fasting lipid profiles. There is also evidence that a non-fasting lipid profile is equally accurate in the prediction of cardiovascular risk. Only in select cases, such as non-fasting triglycerides > 8 mmol/l (708 mg/dl), it is advised to obtain a fasting lipid profile. In conclusion, it is not a necessity to obtain a fasting lipid profile for determining cardiovascular risk. This has many advantages for patients, laboratories and physicians.

This lab quiz presents some practical case studies on the correct use of D-dimer tests in patients suspected of venous thromboembolism. Elevated D-dimer levels are associated with clotting activation and fibrinolysis and can be used as indirect biomarkers of thrombosis. The D-dimer test is highly sensitive and is used to rule out the presence of venous thromboembolism (VTE) when clinical probability is low, based on Wells scores. However, sensitivity and specificity of cut-off values for D-dimer for ruling out VTE are strongly assay-dependent due to lack of standardisation. Because of low specificity, use of these cut-off values is problematic in cases of sepsis and inflammation, after recent surgery and in cases of trauma and active malignancy as well as during anticoagulant therapy and pregnancy. Agedependent cut-off values for patients > 50 years old might improve specificity and could be safely used if clinically validated assays (latex-agglutination assays) are used as described for the ADJUST-study.

Background: Palmar and axillary hyperhidrosis are defined as perspiration exceeding the body's 'normal' physiological need for thermal regulation. This condition affects about 1% of adolescents and children and may lead to psychosocial problems and poor school performance., Case Description: We carried out an endoscopic thoracic sympathectomy (ETS) with clips in a 14-year-old girl and a 16-year-old girl who suffered from debilitating palmar and axillary hyperhidrosis. They were able to quickly resume their general daily activities and both were free of symptoms during an outpatient visit after 6 weeks., Conclusion: ETS using clips is a safe, relatively simple and effective technique, which may provide a permanent solution. ETS can be an option in case of therapy-resistant debilitating hyperhidrosis. This surgical procedure should be carefully considered, possible causes should be excluded and ETS should not be offered as the first treatment option for children.

- We are learning more and more about the effects of smoking on orthopaedic conditions such as osteoporosis and osteoarthritis and on healing of fractures and tendons.- Smoking seems to have a slight protective effect on osteoarthritis.- Smokers have a higher risk of postoperative complications such as wound infection, death and prosthesis-related complications.- If smokers stop smoking preoperatively, the risk of general postoperative complications can be reduced, but this is yet to be proven for prosthesis-related complications.- Smoking patients experience slower healing of fractures and tendons and often have less favourable outcomes.- It is important to discuss the negative effects of smoking on the treatment of orthopaedic disorders with the patient.

Background: Soft tissue swelling of the leg is a relatively uncommon occurrence in children, and is often benign. In adults, 1% of malignancies originate in soft tissue, whereas for children the figure is 8%. Based on medical history and physical examination alone, it is difficult to differentiate between benign and malignant soft tissue tumours., Case Description: A 15-year-old girl presented to her GP with a swelling in the left thigh, without alarming symptoms. The GP suspected the lesion to be benign and she was asked to return if the swelling increased in size. Five months later, when the lesion was excised, it proved to be a granular cell tumour. The second case concerns a 12-year-old boy who presented to his GP with a swelling of the lateral malleolus, which had developed after impact against a door five years ago. The boy was referred to the surgical department where after excision it was shown to be a dermatofibrosarcoma protuberans., Conclusion: In paediatric cases when diagnosis is inconclusive, including cases involving possible growth of the swelling, suspicions raised during physical examination, or unusually lengthy recovery after trauma, awareness is important. Imaging diagnostics or even tissue excision with histopathology may be indicated to allow the correct diagnosis to be made.

A 63-year-old woman had a sclerotic plaque with a bulla under her left breast. Histopathological examination of a biopsy confirmed the diagnosis of bullous morphea. Bullae are rarely seen in morphea. The patient was successfully treated with mometasone ointment 0.1%. To our knowledge, the pathogenesis of bullous morphea is still under debate.

A 14-year-old boy developed a chronic painless swelling of the upper lip. Histology of a skin biopsy showed non-necrotizing tuberculoid granulomas. The diagnosis cheilitis granulomatosa was made.

Background: The differential diagnosis of nephrotic syndrome is diverse. Systemic conditions and medication such as NSAIDs can cause this syndrome., Case Description: A 33-year-old male with Crohn's disease for which he was receiving adalimumab noticed he was gaining weight and had swollen ankles. Examination revealed nephrotic syndrome without renal insufficiency. Renal biopsy showed a membranous glomerulopathy. We excluded secondary causes of membranous glomerulopathy such as diabetes mellitus, systemic lupus erythematosus, viral infection or malignancy. We treated the patient with high-dose glucocorticoids on a weaning schedule and adalimumab was discontinued. This regimen resulted in complete remission. It is likely that the nephrotic syndrome with membranous glomerulopathy was associated with adalimumab., Conclusion: In patients with nephrotic syndrome based on membranous glomerulopathy both primary and secondary causes, such as use of medication, need to be excluded.

A 65-year-old patient with rectal carcinoma underwent an 18FDG PET-CT scan. The scan showed nodular foci of 18FDG uptake against the ventral abdominal wall, possibly carcinomatous peritonitis. These abnormalities were caused by a foreign body reaction to a mesh that was placed five months earlier because of an umbilical hernia repair.

Background: Food protein-induced enterocolitis is a manifestation of non-IgE-mediated cow's milk allergy, characterized by acute vomiting and profuse diarrhoea. This reaction is often not recognized as cow's milk allergy., Case Description: We present a 6-week-old, formula-fed girl with frequent vomiting, diarrhoea and failure to thrive. These symptoms disappeared after giving cow's milk-free formula. Forty-five minutes after the last dose in a non-blinded provocation test with cow's milk, she developed profuse diarrhoea and vomiting, resulting in hypovolemic shock. No specific IgE against cow's milk was found., Conclusion: Unusual in this case is the severe but relatively late reaction to the provocation test. In an acutely ill infant with vomiting, diarrhoea and pallor - which can even result in shock - food protein-induced enterocolitis as manifestation of non-IgE-mediated allergy must be considered. These symptoms start as late as 2 to 3 hours after exposure and disappear after withdrawal of the causal product.

Background: Renal function is currently estimated using the Modification of Diet in Renal Disease (MDRD) formula, which is partly based on the serum creatinine level. Patients with impaired renal function are referred to nephrologists in accordance with the Dutch national transmural agreement for 'Chronic renal impairment'., Case Description: A 54-year-old woman without significant history was referred to analyse a coincidentally found decline in the estimated glomerular filtration rate (eGFR). The patient had no complaints and used no medication except creatine supplements. Additional diagnostic testing showed no abnormalities. After cessation of creatine supplementation, the calculated renal function normalized., Conclusion: Serum creatinine is a reflection of muscle mass. The use of creatine-containing dietary supplements, such as creatine ethyl ester, can influence serum creatinine levels and therefore the eGFR as calculated with the MDRD formula. The use of supplements deserves attention when taking the history.

A 22-year-old women visited the dermatologist with hypertrophic finger- and toenails, palmoplantar keratoderma and oral leukokeratosis since her childhood. The diagnosis 'pachyonychia congenita type 1' was made. This is a rare dermatosis with an autosomal dominant inheritance pattern. The treatment is symptomatic.

Objective: To gain insight into patient awareness of symptoms associated with a TIA or stroke and the speed at which medical help is sought., Design: Observational study., Methods: The study was conducted with patients admitted to our Stroke Care Unit after having experienced a TIA or stroke. A questionnaire was used to collect information on external factors such as the initial reaction of the patient, the presence of a bystander and knowledge about stroke. This questionnaire consisted of 18 closed questions and 2 open questions., Results: We included 105 patients who had experienced a TIA or an ischemic or haemorrhagic stroke. Mean age was 71.6 years. Overall, 54% of these patients had undertaken no action within an hour of their first symptoms. The main reasons for this were a lack of insight into the symptoms associated with stroke or the expectation that the symptoms would disappear (73%). It appeared that 35% of these patients were not able to name one or more symptoms associated with a stroke., Conclusion: Patient knowledge of stroke and the awareness of the importance of urgent medical help are insufficient. These are important factors causing delay in rapid treatment with thrombolytics. National research is needed to explore whether our results are comparable to those in other regions of the Netherlands.

This article contains our comments on the practical guideline for treating chronic hepatitis B in the Netherlands, which was published in 2008. Revision of this guideline had already become necessary in 2011 due to rapidly changing therapeutic strategies. New second-generation drugs show minimal antiviral resistance and their use should be considered more frequently. In addition, certified multidisciplinary centres of expertise should contribute to the improvement of care for patients with chronic hepatitis B. Our opinion is that the revisions make the guideline for treating chronic hepatitis B more complete and up to date.

A 54-year-old woman was referred to the radiology department for an X-ray of her shoulder because of shoulder ache. Coincidentally, the X-ray showed an abnormality in the right lung. The abnormality was confirmed on chest X-ray, and a CT-scan showed a branching tubular structure with distal air trapping. This finding is pathognomonic for congenital bronchial atresia, a rare congenital abnormality. Usually this is a coincidental finding, because it is not associated with any clinical symptoms or signs. Treatment or follow-up is not necessary.

Introduction: McArdle disease is a hereditary myopathy caused by muscle phosphorylase deficiency. Patients experience painful muscle cramps after strenuous exercise; the condition is sometimes associated with rhabdomyolysis, myoglobinuria and resulting acute renal failure., Case Description: A 12-year-old boy visited the Paediatric and Neurology outpatients' departments with symptoms of leg myalgia, occurring during the warming-up phase of soccer practice, which disappeared after a short rest. Detailed history-taking revealed that he already experienced pain while walking during early childhood. An elevated serum creatine kinase concentration in combination with the typical presentation led to the presumptive diagnosis 'McArdle disease', which was confirmed by molecular genetic analysis., Conclusion: There is no effective gene therapy; a multidisciplinary approach by a neurologist, paediatrician, physiotherapist and nutritionist is advised.

A 73-year-old man had a firm node on his right upper arm, which was caused by a Merkel cell carcinoma (MCC). The diagnosis was made on the basis of characteristic histopathological findings and a surgical excision with wide margins followed. Twenty months later a considerable swelling manifested in the right armpit due to a metastasis. During a CT scan of the thorax and abdomen, 2 suspicious abnormalities were seen in the mesenterial adipose tissue of the left lower abdomen and left perirenal adipose tissue. A tissue sample of the last abnormality taken under CT guidance confirmed this to be a metastasis of the MCC. The patient was irradiated but chose not to have chemotherapy. He died 2 years after the diagnosis. Merkel cell carcinoma is a rare and aggressive malignant skin neoplasm. Early recognition facilitates cure of the disease. Treatment is multidisciplinary, but surgery, either alone or in combination with radiotherapy, forms the basis of treating both the localised and regionalized forms of the disease. Chemotherapy may be used in case of disseminated disease and has a reasonable, albeit temporary, effect. The 10-year survival rate varies from 20-70%, dependent on the stage of the disease.

Three women aged 32, 35 and 37 years, respectively, presented with upper abdominal symptoms such as pain, nausea and vomiting. Their history revealed that an adjustable silicone gastric band had been implanted for the treatment of obesity one, four and seven years previously. Their symptoms were not immediately recognised as being possible complications of the gastric band and this caused treatment delay. In the first two patients ischaemic lesions were found at laparotomy. Their surgical treatment was successful. The third patient, however, was referred to the surgeon who had placed the gastric band, but she died in the mean time. Lack of recognition of symptoms caused by gastric banding and delay in diagnostic and therapeutic intervention may lead to very serious complications, or even death. Good diagnostic imaging and prompt therapeutic intervention can prevent the progression from herniation of the stomach through the silicone gastric band to irreversible ischaemia and eventually necrosis and perforation.

A 48-year-old woman presented with a low hemoglobin count and multiple lytic skull lesions caused by multiple myeloma.

Over the past decade considerable progress has been made in several fields relating to the diagnosis and treatment of gall bladder cancer. This literature search evaluates if these recent advances have led to improved diagnosis, treatment and survival of patients with gall bladder carcinoma. The increase in the number of cholecystectomies being carried out has resulted in more carcinomas being discovered incidentally, and at an early and treatable stage. The combination of ultrasound and MRI yields the most accurate preoperative staging. Current radiotherapy and chemotherapy in adjuvant and neoadjuvant settings have not shown any survival benefit. Surgical resection remains the only potentially curative option. For in-situ- and T1a-tumours a simple cholecystectomy can be performed resulting in favourable 10-year survival. For T1b- and T2-tumours an additional resection is indicated, resulting in 5-year survival rates of 55-90%. For T3-tumours, only those patients without metastatic disease will benefit from an additional resection.

In three women aged 53, 51, and 42 respectively, who were treated by breast-conserving surgery for mammary carcinoma, the cancer was not found in the surgical specimen. For both patient and treating physician it is rather worrying when there is no good explanation for the fact that a histologically proven breast cancer cannot be detected in the surgical specimen without neoadjuvant therapy having been given. It is important to revise the needle biopsies, to exclude mix up of patient materials, to totally include the resected specimen in the pathological examination and to perform addition imaging of the remaining breast, preferably with MRI. An explanation may be that biopsy has removed such an amount of tumour tissue that the remains are not found. If no flaws are apparent, adjuvant radiotherapy and further adjuvant therapy on indication suffices.

Two months after a normal pregnancy, a 27-year-old woman presented with a focal liver lesion, which was first interpreted on CT as 'multiple liver cell adenomas'. 2 months later, it turned out to be a metastasis of a choriocarcinoma. This rare neoplasm will often be omitted from the differential diagnosis of liver lesions found during or after pregnancy. However, it is important not to miss this diagnosis since choriocarcinoma metastasis can be successfully treated. Therefore, it is advisable when focal liver lesions are found in women of child-bearing age also to measure human chorionic gonadotropin (hCG) serum concentration.

A 38-year-old woman presented with mild abdominal pain in the right inferior quadrant. Ultrasonography and CT scan suggested intussusception in the ileocoecal region. At exploratory laparotomy an invagination ofthe appendix through the appendicial base into the coecum was found. Pathological findings were: presence of peri-appendicitis and foci ofendometriosis in the peri-appendiceal fatty and connective tissue. Intussusception of the appendix is mostly found in children, particularly in boys.

Severe hyponatraemia was observed in a 35-year-old man with progressive malaise; this was caused by hypopituitarism and secondary hypocortisolism as a result ofneurosarcoidosis. Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology which can develop in any of the body's organs or tissues. The central nervous system is affected in only 5-15% of patients with sarcoidosis. Neurosarcoidosis is a rare disorder with clinical heterogeneity. Extensive diagnostic procedures, including MRI of the cerebrum and histological investigation, and structural outpatient follow-up are mandatory in patients in whom neurosarcoidosis is suspected. Treatment consists mainly of high-dose corticosteroids, which usually have to be taken long-term. Clinical course and prognosis are variable, and depend on the accompanying symptoms.

Objective: To assess the indications, complications and mortality associated with splenectomy in a large general hospital, and to evaluate adherence to guidelines for postoperative vaccination and prophylactic antibiotics., Design: Retrospective, descriptive., Method: Data were collected on 106 patients who underwent splenectomy between 1999 and 2004. Indications for surgery, complications, duration of hospitalisation, and vaccination status were investigated retrospectively. Patients were contacted by telephone for a structured interview regarding vaccination and antibiotic prophylaxis., Results: Of the 95 patients with sufficient data for analysis, 41 underwent elective surgery and 54 underwent non-elective surgery, including 37 who required splenectomy due to iatrogenic injury. Posteroperative complications arose in 45 patients, including 23 who developed serious complications. 10 patients died due to complications, including 7 who died within one month after the procedure. Vaccination coverage for the entire group was 58%., Conclusion: In this large general hospital, splenectomy was often performed due to iatrogenic injury and was associated with a relatively high complication rate. Adherence to guidelines on vaccination and prophylactic antibiotics could be improved.

The Dutch College of General Practitioners (NHG) revised their practice guideline on vaginal discharge. From a gynaecological point of view, relocation of cervix problems from this guideline to the NHG guideline 'The STD consultation' is not practical. Moreover, the role of simple, but effective diagnosis with a microscope in the primary-care setting cannot be overemphasized. The reluctance to oral treatment is rather inopportune, because once-only ingestion has the advantage of promoting compliance. As physical examination is not always necessary in a recurrent Candida infection, treatment performed by the patient with imidazole compounds is a possibility that does not always result in abuse or increased resistance.

In a 76-year-old man bilateral leg oedema was caused by compression of the V. cava inferior by a large abdominal aortic aneurysm. The oedema resolved after an aortobiiliac prosthesis was placed.

Recently, echo-guided compression sclerotherapy (ECST) using foam was introduced as an efficient and patient-friendly therapy for the treatment of varicose veins. ECST enables operation under either spinal or general anaesthetic to be avoided. Foam for phlebological use is a volatile mixture of a gas, usually air, and a small quantity of liquid with the characteristics of a detergent or soap, such as polidocanol. The product that is injected has deterging properties. It reduces the surface tension of endothelial cells resulting in the destruction of the vascular wall. The treated vessel is subsequently reduced to a fibrous cord. For small calibre varicose veins, sclerosing fluids are used. In The Netherlands, until relatively recently branch varicosities of the long and short saphenous veins were treated surgically, but ECST using foam can be successfully used to treat wide calibre varicosities. Caution is advised in treating patients who are known to have a history of open foramen ovale because of the higher risk of the occurrence of scotoma and transient cerebral ischaemia.

A 26-year-old male amateur cyclist, with no risk factors for vascular disease or previous trauma, presented with left-calf claudication. Physical and additional examination revealed an occlusion of the external iliac artery. During the operation, the cause was found to be an endofibrotic lesion of the external iliac artery, probably due to mechanical trauma as a result of the non-physiological aerodynamic position held on the bicycle during many hours of training. An endarterectomy was performed and the tendon of the psoas-minor muscle was cut because of its strong impression on the psoas-major muscle, which resulted in kinking of the external iliac artery. There followed two episodes of re-occlusion which were treated with a venous interposition graft and a dacron interposition graft, respectively. Thereafter the patient was able to train without pain. Intermittent claudication of the legs in young athletes should not be underestimated; occlusive vascular disease caused by arterial endofibrosis should be considered.

In a 13-year-old girl sudden pain in the right hip after playing soccer was caused by anterior inferior iliac spine avulsion.

A 42-year-old man was referred because of a pigmented dermatofibrosarcoma protuberans, a so-called Bednar tumour, on his left buttock. It was radically excised.

Two girls aged 1.5 and 3 years, presented with a skin rash, loss of proximal muscle power and malaise. The younger girl recovered quickly after a short course of corticosteroids but the elder girl proved more difficult to treat effectively with corticosteroids, methotrexate, ciclosporin, intravenous immunoglobulins and hydroxychloroquine. This combination of symptoms should make one consider the diagnosis of juvenile dermatomyositis (JDM). To make the diagnosis of JDM, a characteristic skin rash, proximal muscle weakness, elevated muscle enzymes and, possibly, an abnormal EMG or muscle biopsy should be present. Treatment consists, of steroids and, if necessary, immunosuppressive agents or intravenous immunoglobulins. If cutaneous lesions are serious or persistent, hydroxychloroquine may also be prescribed.

A 36-year-old man presented with acute abdominal pain due to occlusion of the superior mesenteric artery associated with intestinal rotation caused by an upper abdominal postoperative adhesion.

Two women, 33 and 31 years of age, were referred to a surgeon for the removal of a previously implanted hormonal contraceptive after the general practitioner had attempted this without success. However, no foreign body could be detected in either patient by surgery, echography and MRI and by X-ray, echography and MRI, respectively. They were then referred to a gynaecologist. In the first patient, a low level of etonogestrel confirmed that there was no contraceptive in her body. Subcutaneous contraceptives are sometimes implanted incorrectly. If the rod is not palpable at the site of insertion, then the etonogestrel level should be determined first of all. If the hormone level indicates that a rod is indeed present, then echography or MRI may be considered to localise it before resorting to surgical exploration. Many problems can be prevented by proper implantation.

A neonate was born prematurely with polyhydramnios and yellow amniotic fluid. He developed gastric retention and bilious vomiting. Abdominal röntgenography showed jejunum atresia.

A 46-year-old man presented with a swelling of the proximal phalanx of the right index finger, due to a giant cell tumour of the tendon sheath.

A 25-year-old man underwent periodic coloscopy due to the occurrence of colon carcinoma in the family. At the age of 41, a mutation in the MSH2-gene was detected. More than a year after resection of the sigmoid for recurrent diverticulitis, he developed ileus in the small intestine; in the resected specimen of a non-viable portion of small intestine an adenocarcinoma was found. One year after a wide repeat resection, the patient is doing well. The prevalence of small-bowel tumours in patients with hereditary non-polyposis colorectal carcinoma (HNPCC) is relatively high, but low in absolute terms. There are no good options for screening patients for small-bowel tumours. HNPCC patients presenting with complaints that could be due to obstruction should undergo gastroduodenoscopy, coloscopy or, if these yield negative results, wireless capsule endoscopy to reveal obstruction. In case of iron deficiency anaemia or symptoms that cannot immediately be related to an obstruction, one should be careful with a diagnostic laparotomy. In any other case the threshold for a diagnostic laparotomy should be quite low.

In a 73-year-old man with a non-tender palpable mass in the right part of the upper abdomen and soft stool a porcelain gallbladder was observed at radiological examination.