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Although no less than 78 Medieval manuscripts of Vitruvius's De Architectura Libri X (25 B.C.) have been preserved, very little is known of the needs felt in copying the text. Contemporary comments are scarce and generally do not show much more than a philological curiosity, the ars architecturae in itself being held in a rather ambivalent esteem, either as a 'free' or 'liberal' discipline, or, perhaps more often, as a modest, 'mechanical' one. In addition, and in a Vitruvian tradition, we have some typical Early Medieval 'recipes' for constructional problems, partly being copied from Late Roman sources; it is unclear whether these prescriptions were really being put into practice. On the other hand, some ten German manuals in a Late Gothic tradition present us with a coherent set of rules and guidelines for building and design. Representing the actual procedures, they may well be characterised as sound theory, reflecting at least the days from Villard to Dürer (XIII-XVI c.). Probably due to the fundamental formal differences between Classical and Medieval architecture, no attempt has as yet been made at thoroughly comparing Vitruvian design theory with the more modestly formulated 'recipes' by the Gothic architects. In doing so, the familiarity in drawing to scale, in applying a so-called 'practical' geometry, and in choosing design measurements becomes surprisingly obvious. So, if one cannot prove an actual influence of De Architectura because textual sources referring to it are failing, we may well knit the eyebrows at the ostentatiously declared 'rediscovery' of Vitruvius by the Florentine humanist - and writer of farces - Poggio Bracciolini in the year 1416. The least we may assume is, that a limited but growing group of Medieval church founders, intellectuals and architects were left with enough insight - and practice - in their own days to be able to grasp not all of Vitruvius' technical vocabulary, but certainly the foremost principles of building he once cared so much to offer us in writing.

Recent research shows that the functional outcome after an acute Achilles tendon rupture is comparable after conservative versus operative treatment. It is therefore recommended to treat patients conservatively, but strong reasons for surgical treatment exist. In principle, no additional radiographic diagnostic exams are indicated for the diagnosis. An appropriate anamnesis, palpable gap and positive Thompson test have an excellent sensitivity. In case of doubt, an ultrasound should be performed as the first step. A shared decision process should be pursued for establishing treatment plan. However, it is recommended that patients be treated conservatively unless strong arguments for surgical intervention are present. It is important to properly inform patients, and thus manage expectations about the expected rehabilitation process. If there is an increased risk of re-rupture, such as in athletes or during physically demanding work, surgical treatment can be considered. Then a surgical technique in which expertise and experience has been gained should be used as no difference in outcome have been found after open versus minimal invasive techniques.

The antisynthetase syndrome (AS) is a rare auto-immune disease characterised by inflammatory myopathies, interstitial lung disease, inflammatory arthritis, Mechanic's Hands and Raynaud phenomenon. AS infrequently presents with life-threatening lung disease as its primary or sole manifestation. By means of two clinical case reports, an overview is given of recent advances in diagnosis and treatment of AS-related interstitial lung disease. We emphasise the importance of considering AS as a differential diagnosis if lung disease does not respond to standard treatment in a relatively young patient, certainly if there is even a mild suggestion of myopathy, arthritis or cutaneous involvement.

Background: In case of a ruptured bladder with urine leakage into the peritoneal cavity 'reversed autodialysis' can occur, in which urea and creatinine diffuse back into the bloodstream via the peritoneum. This causes clinical signs of pseudorenal failure, with raised concentrations of creatinine and urea. The urea/creatinine ratio does not change., Case Description: A 34-year-old female patient experienced increasing abdominal pain 3 days after laparoscopic myomectomy. Acute renal failure was suspected because of increased serum concentrations of creatinine and urea, but no cause could be found. There was a build-up of fluid in the abdominal cavity, which proved to be urine originating from an iatrogenic rupture of the bladder. Serum levels normalised following repair of the rupture., Conclusion: If serum creatinine levels rise rapidly following abdominal surgery or blunt abdominal trauma the bladder should be examined for possible perforation, particularly if the abdominal dimension increases. A ruptured bladder leading to pseudorenal failure is an indication for rapid surgical intervention.

This article discusses the case history of an 87-year old woman with loss of consciousness following accidental CO intoxication. A few weeks later, the patient's cognitive abilities progressively deteriorated. This is hence a case of Delayed Neurological Symptoms after CO intoxication. This condition occurs in 40% of patients with CO intoxication and manifests itself 3-240 days after apparent recovery. Symptoms can linger for a long time and are in some cases even permanent. Treatment of CO intoxication usually consists of administering normobaric oxygen and in certain cases hyperbaric oxygen. The role of treatment with hyberbaric oxygen in delayed neurological symptoms after CO intoxication remains controversial, however.

A 29-year-old man presented with a painless soft mass that was hanging on a string of skin on his upper leg. Physical examination revealed a 5 cm broad, elastic, stalked skin toned mass. On microscopic examination the diagnosis fibrolipoma was objectified.

Background: Variant angina, or vasospastic angina, is a form of angina caused by vasospasm of the coronary arteries, probably caused by endothelial dysfunction. This form of angina is provoked by non-classical risk factors such as stress, alcohol use, use of sympathomimetics and low environmental temperatures, but also by smoking. Treatment is based on elimination of risk factors and vasodilator therapy with nitrates and long-acting calcium antagonists., Case Description: We present a 68-year-old woman with recurring thoracalgia at rest and during exercise, suggestive of severe variant angina in more than one coronary artery. Despite elimination of risk factors and administration of vasodilatory therapy the treatment was initially insufficient. It eventually emerged that the probable cause was frequent use of a vasoconstrictive nasal spray, although this was not described in literature, and not originally mentioned by the patient., Conclusion: A thorough case history is of vital importance in a patient presenting with a history suggestive of variant angina. Even undescribed and apparently less important risk factors can be responsible for persistence of symptoms, and can lead to an applied treatment not producing the desired result.

The rising costs and potential harms of medical care are matters of growing concern. In a recent article from the USA, Sirovich et al. examined the association between the intensity of the training environment and clinical-management decisions made by recent graduates. They found that, regardless of overall medical knowledge, internists trained at programmes in hospital referral regions with lower-intensity medical practice are more likely to recognise situations in which conservative management is appropriate. These internists remain capable of choosing a more active approach when indicated. This study suggests that residents adopt the practice style experienced in their training environment. Sometimes less healthcare can actually result in better health. In contrast, an aggressive practice style may waste resources and harm patients through inappropriate intervention. The training environment appears to have a considerable impact on the wisdom of medical decision making.

Mallet finger is a very common injury, but there is still much discussion about the best treatment. Mallet finger should be operated on if a fracture is larger than 1/3 of the articular surface or in volar subluxation, because otherwise the fracture may remain unstable or there may be loss of function. However, we believe that most mallet fingers can be treated conservatively. Consideration of the relevant literature from PubMed shows that nearly all cases of mallet finger can be treated conservatively with a splint, without significant differences in function, deformity or pain versus surgical treatment. Although there is no significant difference in complications between splinting and surgery, the complications of an operation may be far more serious. In spite of the current operation indication, we should be more reluctant to operate on mallet finger.

Objective: To determine the effect of cold ischaemia time (CIT) on the outcome of cadaveric renal transplantation in the Netherlands., Design: Retrospective, comparative., Methods: We studied data from the Netherlands organ transplant registry of cadaveric renal transplants from 1990-2007., Results: 6322 cadaveric renal transplant recipients were studied, of whom 5306 were from heart-beating donors (HBD) and 1016 from non-heart-beating donors (NHBD). The mean CIT was 24.0 h in the HBD group and 21.6 h in the NHBD group. The rate of delayed graft function (DGF) was 12.3% in the HBD group and 50.4% in the NHBD group. Multivariate analysis showed that prolonged CIT was an independent risk factor for graft failure. Prolonged CIT was also associated with the more frequent occurrence of DGF and primary non-function (PNF). Recipients of renal allografts from HBD with CIT

This pilot study was designed to examine prevalence, circumstances and consequences of falls among 131 community-dwelling elderly (mean age = 76.7 y.; SD = 5.4; response = 29.8%). Based on a retrospective analysis, 39.7% of our study population had experienced one (65.4%) or more (34.6%) falls in the preceding year. Falls appeared to occur predominantly while getting up from the bed, chair or bath (18%), cycling (14%), walking on an uneven surface (14%) and during household work (14%). Fall-related injuries were reported in 67.3% of the fallers, fractures in 17.4%. Additionally, a majority of fallers (63.5%) experienced a mild to serious form of anxiety, 48.1% consulted a general practitioner after the fall and 34.6% was hospitalised. In line with data reported in the literature, falls are a common problem in Flanders and are associated with a negative impact on the physical and psychosocial well being of the elderly population. We conclude that there is an urgent need to develop and implement preventive measures as well as multidisciplinary strategies to identify, assess and target high-risk persons for falling.