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Ingrown toenails (also called unguis incarnatus) are a common problem in the general population. In early 2020, the medical specialists' guideline "Ingrown toenail" was published in which the various treatment options are compared. Conservative treatment can be considered for stage I ingrown toenails. In stage II-III ingrown toenails and failing conservative treatment, operative treatment is recommended consisting of partial nail extraction from the ingrown nail edge in combination with destruction of the corresponding part of the matrix. There doesn't seem to be any reason to deviate from the advice in the case of a recurring ingrown toenail or an ingrown toenail in a patient with expected wound healing problems. A detailed elaboration of the guideline, which also contains a step-by-step operative approach, can be found on the Guidelines database (https://richtlijnendatabase.nl/).

In 2018 the first Dutch guideline on necrotizing soft tissue infections (NSTIs) was drafted. Its aim is to standardize the care of this disease in order to reduce variation, and thereby improve the quality of care. This guideline is a benchmark for all healthcare providers who deal with this devastating disease; it focuses on diagnostics, treatment options and organization of care. Given the low incidence, the complexity and the fulminant course of NSTIs, it is important to ensure continuous specialized care. Therefore it is recommended to make regional agreements about referral to specialized centres. Surgical exploration remains the gold standard for diagnosis. The empirical antibiotic regimen depends on if the onset of disease is community or nosocomial, and if its aetiology is a monomicrobial (type I) or a polymicrobial (type II). The guideline recommends that intravenous immunoglobulin (IVIg) therapy be started if gram staining reveals streptococci. IVIg must be discontinued if group-A streptococcus is excluded as a causative agent.

Fracture-related infection (FRI) is a serious complication after fracture care and can lead to severe morbidity with loss of quality of life, a significant increase in medical expenses and loss of participation in work and social life. Early recognition, adequate surgical debridement, deep uncontaminated tissue cultures with (if indicated) soft tissue reconstruction and fracture stabilization followed by antibiotic therapy are the cornerstones of the successful management of FRI. Recently, in 2018, the AO/EBJIS consensus definition for FRI was published and both national and international working groups are being assembled and provide guidelines and tools for the care of patients with FRI. This paper is a synopsis of the Dutch guideline on FRI (2018), illustrated by a clinical case, and is aiming to provide an overview of the current knowledge on diagnosis and treatment of this disease.

Necrotising soft tissue infections require early consultation of an experienced surgeon, regardless of what time of day they occur. Delays in diagnosis and treatment should not occur. Necrotectomy should be skin-sparing when possible. A low threshold for consultation with a tertiary referral center is recommended.

Gaining more insight into any differences in care expenses between minimum and higher income groups.Cross-sectional study among 6,709 citizens of Amsterdam aged 19 years and over.Data on declared health care expenses from 2012 were linked to personal income and to public health survey data. Through weighted logistic regression analysis, differences in expenses for primary care, hospital care, mental health care and other care were compared for minimum and higher income groups, controlling for demographic characteristics, educational level and health status.Minimum income groups claimed more often for mental health care costs (11%) than higher income groups (7%). However, after controlling for demographic characteristics, educational level and health status this difference was not significant. Further, minimum income groups claimed fewer expenses for hospital care, but this difference was not significant. The number of claims for other care did not differ. The size of the expenses differed between income groups. Expenses for primary care among minimum income groups were lower versus those for higher earners. Expenses for hospital care, mental health care and other care were higher, but not to a statistically significant level.Minimum income groups claim lower costs for primary care. On the other hand, the number of claims for mental health care, hospital care and other care is equal or higher than that of higher income citizens, as is the size of the claimed expenses.

Eosinophilic otitis media (EOM) is a rare middle ear disease that may closely resemble therapy-resistant otitis media with effusion (OME). The diagnosis is made if eosinophil-rich fluid is present with two or more of the following minor criteria: (a) history of nasal polyps or, (b) bronchial asthma, with (c) viscous fluid in the middle-ear, or (d) conventional otitis media treatment has no effect.A 70-year-old male with a history of the ASA triad (bronchial asthma, nasal/ethmoidal polyposis and aspirin intolerance) presented with progressive mixed hearing loss. Otoscopy showed bilateral otitis media with effusion (OME). Conventional treatment of this had no effect. Myringotomy resulted in the evacuation of highly viscous middle-ear effusion containing abundant eosinophils. After treatment with oral corticosteroids his symptoms improved considerably. Following later optimisation of his asthma treatment, corticosteroid treatment was stopped and his hearing remained stable.The adequate recognition and treatment of EOM will result in the prevention of permanent hearing loss.

Necrotising soft-tissue infections occur in the soft tissue compartment consisting of the dermis, subcutaneous tissue, superficial fascia (fascia of Scarpa), deep fascia and muscle. Although this severe and acutely life-threatening infection has a low incidence, both GPs and specialists will see a necrotizing soft-tissue infection more than once during their career. The mortality related to necrotising soft-tissue infections has been halved during the past 15 years from nearly 40 to 20% due to adequate treatment. Laboratory examination and X-ray findings could be of added value, but the gold standard remains biopsy of the fascia and Gram staining. Treatment consists of prompt volume resuscitation in case of sepsis, administration of broad spectrum antibiotics and surgical debridement; this debridement should be as skin-sparing as possible. The use of hyperbaric oxygen therapy has remained a controversial issue, unless a patient has gas gangrene, caused by Clostridium species. A multidisciplinary treatment and admission to a tertiary intensive care unit are indispensable for the treatment of a septic patient with necrotizing soft-tissue infection.

Frostbite injuries rarely occur in healthy Dutch persons. However, as the number of people engaging in winter and outdoor activities and travelling to high altitudes increases, the risk of frostbite also increases. Frostbite is a cold-induced injury which results from two processes: freezing and microvascular occlusion. Adequate first aid, which focuses on the prevention of refreezing and mechanical injury, and rapid rewarming together with the administration of ibuprofen, are of the greatest importance for limiting eventual tissue damage. Iloprost infusion and possibly (r)tPA are indicated if a patient presents within 24 hours after the tissue has thawed and the injury is such that severe morbidity can be expected. If the patient presents after this time period, hyperbaric oxygen therapy may be considered; however, the evidence available on this type of treatment is limited.

A 85-year-old woman suffered persisting pain in her left hip after a fall. On X-ray no fracture was seen. Her infection parameters were high and she developed a delirium and a painful swelling on her left hip. Examination with ultrasound showed free gas in the soft tissue of the left hip. A CT-scan of the abdomen and left upper leg showed a ruptured abscess in the left kidney with free gas, spreading through the M. iliopsoas into the upper left leg. On request of the patient and her family no treatment was given.

We present three patients, a 55-year-old man, a 69-year-old woman and a 25-year-old man, with a seatbelt sign following a car accident. All 3 patients exhibited various injuries that may occur in the case of a blunt trauma, for example rib fractures. In one patient, however, symptoms of internal abdominal injury occurred several days after the accident. The presence of a seatbelt sign is associated with an increased risk of internal abdominal injury. We therefore advise a CT scan of the abdomen in patients who present with a seatbelt sign, even if abdominal ultrasound does not reveal signs of injury.

Hypospadias is a congenital defect of the penis in which the urethral orifice is located on the ventral aspect of the glans penis or, more proximally, on the shaft or scrotum. Some type of hypospadias occurs in approximately 1 in 200 boys. The defect can be minimal or so severe that the sex of the newborn is difficult to determine. Many boys with hypospadias also have a congenital curvature of the penis that needs correction. Corrective surgery is done preferably between the ages of 6 and 12 months. The aim of surgery is to obtain a functionally and cosmetically normal penis while limiting the psychological burden on the child as much as possible. The common surgical procedures include: meatal advancement and glanuloplasty (MAGPI), the tubularised incised plate (TIP) technique according to Snodgrass, and vascularised foreskin flap-plasty. Urethral surgery for hypospadias is accompanied by a relatively high number of complications and should therefore be carried out by surgeons with sufficient experience.

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

A 10-year-old Turkish boy with consanguineous parents was presented with a disproportionately short stature and a nephrotic syndrome. The mild form of Schimke's immuno-osseous dysplasia was diagnosed as the common cause. This rare, autosomal recessive osteochondrodysplasia is characterised by spondyloepiphyseal dysplasia, facial dysmorphism, T-cell immunodeficiency and progressive renal failure due to focal segmental glomerulosclerosis. In Schimke's immuno-osseous dysplasia, a severe early-onset form and a milder later-onset form can be distinguished on the basis of the clinical course. The patient was treated by fluid and salt restriction, enalapril and later also losartan, which led to a decrease in the proteinuria and an increase in serum albumin concentration. Two years later, the renal function was still normal.

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.

Primary open-angle glaucoma (POAG) is a group of multifactorial diseases that affects 1.5% of the population. If untreated, the disease leads to irreversible damage to the visual system. The clinical features of POAG are excavation of the optic disc and visual field defects, probably due to degeneration of retinal ganglion cells. Important risk factors for POAG are older age, elevated intraocular pressure, the presence of POAG in relatives, and still largely unknown molecular genetic factors. The clinical, genetic and pathological heterogeneity most likely reflects the complex heterogeneous situation at the molecular level. The three genes known to be involved in POAG (MYOC, CYP1B1 and OPTN) account for up to 18% of the POAG cases. These findings result in new possibilities for the presymptomatic molecular diagnosis of POAG.

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.

A 62-year-old man suffering from long-standing ankylosing spondylitis had a 5-year history of progressive difficulty of defecation, micturition and erection, due to complication by a cauda equina syndrome.

To assess the prevalence of psychiatric disorders and help-seeking behaviour of Afghan refugees with a residence status in the province of Drenthe, the Netherlands.Cross-sectional prevalence study.By means of a modified multiflex snowball sampling with 3 primary informants, 55 Afghan households in 16 towns and villages in Drenthe were selected. After informed consent had been obtained, 51 adults completed a sociodemographic questionnaire and a culturally validated shortened 'Composite international diagnostic interview' (CIDI), DSM-IV version. Help-seeking behaviour was recorded.Half of the sample had resided in the Netherlands for at least 3 years. There was a high level of education, an unemployment level of 88% and moderate to poor language skills in 92% of the respondents. The prevalence of psychiatric disorders was 65% (95% CI: 52-78); depressive disorder occurred in 57% and posttraumatic stress disorder in 35%. Psychopathological findings were related to poor language skills, a lower level of education and unemployment. A total of 56% received treatment from a general practitioner and 4% were under psychiatric treatment.The prevalence of psychiatric disorders among adult Afghan refugees in Drenthe with a residence status was considerably higher than among the general population in the Netherlands.

A 47-year-old woman suffering from chronic abdominal pain developed erythema ab igne (reticular hyperpigmentation of the skin caused by exposure to heat). Histological examination revealed premalignant changes in two specimens of affected skin. The incidence of erythema ab igne is declining since fewer people use open fires for heating. Nowadays it is found mostly in patients suffering from chronic pain using hot water bottles, infrared lamps or heating pads. The disease is an important clinical indication for underlying chronic diseases. The affected skin runs a higher risk of development of actinic keratoses. Bowen's disease and squamous cell carcinomas. Dysplastic features of keratinocytes can be found histologically in lesions which are clinically not under suspicion.

The case is described of a neonate who suffered from withdrawal symptoms within 24 hours after birth as a result of the use of clomipramine by the mother during pregnancy. The symptoms consisted of increased irritability, alternating hyper- en hypotonia, hyperreflexia, cyanosis and hypothermia. He was treated with clonazepam with good result. Prescription of clomipramine during pregnancy should be restricted to specific cases and the doses should be kept as low as possible. Because the symptoms are withdrawal symptoms, phenobarbital should not be used as treatment, as it increases drug metabolism by the liver causing an even faster decrease of plasma concentrations of clomipramine. Clonazepam is the drug of choice.

Two out of 20 patients treated for metastatic or non-metastatic breast cancer with tamoxifen (20 mg 2 dd) developed bilateral secondary tapetoretinal degeneration. In one patient in whom the medication was stopped there was still slight progression of degeneration afterwards. In the other patient tamoxifen was continued under strict ophthalmological control. The total doses have been 7.3 g and 43.8 g respectively.