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Multiple sclerosis is a chronic inflammatory disease of the central nervous system, caused by an autoimmune reaction. Treatment options have largely increased over the years. In this article, we present two clinical cases. Patient A has a classic relapsing remitting course of multiple sclerosis with satisfactory effect on second line therapy. Patient B had a stable disease course until a new relapse occurred after the initiation of TNF-alpha blocking therapy because of Crohn's disease. The co-occurrence of multiple auto-immune diseases creates challenges, but also opportunities in choosing the right treatment strategy.

The prevalence of disorders related to the movement apparatus such as osteoarthritis and neck/back complaints is increasing, thereby compromising the accessibility and affordability of movement care. Besides, these complaints cause high burden of disease, high sick leave and decreased self-sustainability. These developments demand an integral multidisciplinary and line transcending approach. Within the field of movement care several initiatives are already developed such as the Beweeghuis Network, Network Osteoarthritis, One-and-a-half line outpatient clinic Zuyderland. If healthcare evaluation of these initiatives show positive effects, these examples of network medicine can give answer and substance to the challenges and assignments discussed in the Integral Care Act. An important condition for upscaling on a national level is a new funding model in which prevention of care is being rewarded as well.

Tinnitus is a common condition with great variability in the intensity of symptomatology. In recent years, more and more insights have been gained into the mechanism of tinnitus and its relationship with hearing loss and other factors such as stress. Depending on the symptoms and clinical findings, a patient may be referred to an ENT specialist or audiologist. For the majority of patients, re-assurance and providing good information is sufficient. For others improving hearing and possibly cognitive behavioral therapy remains the most important pillars for treatment of tinnitus. A number of experimental treatments are currently underway which offer hope for the future.

In this article, the new Dutch pediatric guideline Brief Resolved Unexplained Event is discussed, which replaces the old guideline Apparent Life Threatening Event. The main goal of the new guideline is identification of a group of low-risk infants who need not be admitted to the hospital and in which only limited diagnostic workup is indicated. Three fictional cases are presented to highlight the major changes in management of infants who present with an unexplained event. Application of the new guideline will likely result in less clinical admissions and diagnostic testing in these patients.

A considerable percentage of the Dutch population has primary hypothyroidism and is therefore lifelong treated with levothyroxine. Recently, Dutch healthcare insurance companies made plans to change their reimbursement policies with regard to levothyroxine. This policy change implies that the healthcare insurer will only reimburse one specific brand of levothyroxine usually the most inexpensive brand with the aim of reducing healthcare costs. The more expensive brands will no longer be reimbursed, forcing patients to switch between brands. However, clinical experience and previous research reveal that substitution between levothyroxine brands can lead to symptoms both with and without changes of serum thyroxine levels. Do the advantages of levothyroxine substitution even outweigh the disadvantages?

A59-year-old patient reports back to general practice with a burning sensation at the ankle a few hours after a partial nail extraction with phenolization of the nail bed. There is a chemical burn caused by a drop of phenol spilt during the procedure.

One-size-fits-all breast cancer screening no longer reflects the current state of knowledge and technology. 8% of the participants in the Dutch Breastcancer Screening Program have extremely dense breasts, which is coupled to a strongly increased risk of breast cancer. In addition, for this group of approximately 80,000 women per year, mammography is only 60% sensitive. The DENSE trial showed that supplemental MRI after a negative mammogram reduced the number of interval cancers by more than 80%. The Dutch Health Council however subsequently recommended to consider contrast-enhanced mammography (CEM) as a screening tool. At the request of the Ministry of Health-Welfare and Sport, simultaneous research is being set up to study both CEM and the introduction of CEM and "accelerated" (abbreviated) MRI. This article explains the differences between the two techniques and discusses the role both could play in screening this large group of women when politicians give green light.

Objective: Hospitalization for corona virus disease 2019 (COVID-19) may be followed by complications after discharge. We aimed to evaluate mortality, readmission rate, and readmission characteristics after hospitalization with COVID-19., Design: A retrospective cohort study METHODS: Inclusion of all patients hospitalized for COVID-19 between March 1, 2020, and June 1, 2020 in Zuyderland Medical Centre, The Netherlands. Main outcome measures were mortality and readmission after hospitalization. Univariate and multivariate regression analysis were performed to identify risk factors for death and readmission., Results: A total of 769 patients hospitalized with COVID-19 (mean age 70 ± 14 years; 39% female) were included in the study. In-hospital mortality was 22.4% , as such 596 patients were discharged alive and followed after discharge with a median of 80 days (IQR 66-91). Total mortality after discharge was 6.4% (n=38) and readmission rate was 11.7% (n=70). Main reasons for readmission were respiratory insufficiency (31%), arterial and venous thrombotic events (16%) or related to a chronic comorbidity (14%). Mortality rates were higher in older patients and patients who experienced delirium during hospital stay. Risk factors for readmission were male sex, discharge to a long-term care facility and COPD., Conclusion: 1 out of 6 COVID-19 positive patients died or was readmitted after discharge. This shows an ongoing vulnerability of COVID-19 patients. Physicians and policy makers should consider this high rate when making decisions on discharge, hospital-capacity planning, and patient monitoring after discharge.

Background: In times of coronavirus, a patient with respiratory symptoms whose chest CT scan reveals ground-glass opacities, COVID-19 may seem an obvious diagnosis., Case Description: At the (currently assumed) peak of the coronavirus crisis, a 12-year-old boy was admitted to the hospital twice for severe respiratory symptoms. A chest CT scan revealed ground-glass opacities.COVID-19 pneumonia was initially thought of. However, it turned out to be a rare interstitial pulmonary disease., Conclusion: Due to the increased awareness about COVID-19, tunnel vision is lurking. Even during a health crisis, doctors should remain alert to alternative diagnoses.

Pectus excavatum is the most common deformity of the anterior chest wall. Nevertheless, awareness amongst physicians is lacking and consequences of the diagnosis are often underestimated. Symptoms include cardiopulmonary symptoms such as palpitations, fatigue and exercise intolerance. Moreover, patients often have psychosocial problems and suffer from poor body image and lower quality of life. A multidisciplinary approach is recommended for diagnostic work-up and treatment, involving dedicated paediatricians, cardiologists and surgeons. Treatment can be non-surgical or surgical. Conservative options include physiotherapy and vacuum bell therapy. In symptomatic patients, surgical treatment is warranted from the age of 12-14 years. Minimally invasive repair with the Nuss bar technique is considered the gold standard for adolescents. Patients who are unsuitable for minimally invasive repair can be treated with open surgical correction, for example, via a modified Ravitch procedure. Early referral to a specialised centre is recommended.

A 62-year old male patient was seen four days after total knee arthroplasty with pain, itchy erythema and blistering surrounding the wound. European Standard Series and wound dressing patch testing was performed. This confirmed the diagnosis allergic contact dermatitis, with the wound dressing as the offending allergen.

Objective: Consultations between general practitioners (GPs) and hospital specialists are traditionally conducted by phone. A conversation by phone where a GP seeks advice regarding a patient, who is unknown to the specialist, can have limitations. An e-consultation service for internal medicine allows GPs to consult an internal medicine specialist for clinical queries. In this study we evaluated GP use of internal medicine e-consultations., Design: Observational study., Method: Eligible patients were all those for whom the GP used an internal medicine e-consultation, provided by Zuyderland Medical Centre, location Sittard-Geleen, the Netherlands, in the period 2017-2018. Data on patient demographics, content of the GP clinical query, and any preceding diagnostics were collated. Furthermore, the internal medicine specialist response was categorised, including the presence of any patient referral advice., Results: 136 (88.6%) of all 154 GPs in the region used an e-consultation at least once, and the clinical queries covered all areas of internal medicine. A total of 1047 eligible patients were discussed by GPs in an e-consultation; 19.6% of them attended the internal medicine out-patient clinic within three months of the index episode. The use of e-consultations by GPs led to a 70% reduction in referrals when compared to the situation where e-consultations were not available., Conclusion: GPs used internal medicine e-consultations for a wide range of questions covering all areas of internal medicine. In more than 80% of cases, the GP continued to manage the patient, resulting in a reduction of the actual number of patient referrals to the internal medicine out-patient clinic.

Background: The occurrence of acute ischaemia or myocardial infarction in a patient experiencing an allergic reaction is known as allergic acute coronary syndrome or Kounis syndrome., Case Description: A 63-year-old male had a postoperative anaphylactic reaction to an intravenous dose of diclofenac. Myocardial ischaemia occurred during treatment of the anaphylaxis, caused by spasm of the right coronary artery followed by occlusion of the left anterior descending artery (the ramus interventricularis anterior). Despite percutaneous coronary intervention, he suffered an infarct of the anterior myocardium, resulting in reduced left ventricular function., Conclusion: In patients with Kounis syndrome therapy should focus on both the allergy and the acute coronary syndrome. Early recognition and intervention have a great effect on prognosis.

A 51 years old woman came to the emergency room with acute onset abdominal hematomas. She complained of vague abdominal pain without preceding trauma. Two large hematomas were present, one in the infra-umbilical region and one in the right flank, corresponding to Cullen's and Grey Turner's sign, respectively. Laboratory analysis and CT confirmed the diagnosis of necrotising pancreatitis.

Background: Glucose transporter type 1 (GLUT1) enables glucose to pass through the blood-brain barrier. A hereditary deficiency of this protein may lead to clinical symptoms when blood glucose levels are decreasing., Case Description: A 7-year-old girl with therapy-resistant childhood absence epilepsy presented with an exercise and fasting induced dystonic and atactic movement pattern. The movement pattern disappears postprandial. Based on a reduced glucose in the liquor, and also a reduced liquor glucose/serum glucose ratio, the diagnosis of GLUT1 deficiency syndrome was considered. Through genetic diagnostics a mutation of the SLC2A1 gene was identified, thereby confirming the initial diagnosis. The patient was referred to a tertiary centre for advice on following a ketogenic diet. After initiation of this treatment she no longer experienced absence epilepsy or paroxysmal dyskinesia episodes., Conclusion: GLUT1 deficiency syndrome is a relatively underdiagnosed disease. The recommended therapy is adherence to a ketogenic diet. With this diet the symptoms are treated, yet at the same time the further development of the brain is stimulated.

Objective: To investigate to what extent parents of infants are following national safe sleep advice given for the prevention of Sudden Infant Death Syndrome (SIDS) and to study the reasons for not adhering to recommendations on sleep position (always on the back) and location (parents and infant not sleeping in the same bed)., Design: Quantitative and qualitative cross-sectional study., Method: Online survey among parents of 0-11 month old children via well-baby clinics and online media., Results: Of the 1,209 respondents, 72.4% indicated that their child was usually placed on the back, and 34.1% indicated that their child slept in the same room as its parent(s), but not in the same bed. Of children aged 0-2 and 3-4 months 6.3% and 8.2% respectively slept with their parents in one bed. Parents of children of 0-6 months old (n = 199) who are not adhering to advice on sleeping position most often indicated that the child sleeps better (35%), that there is a preferred position or flat head syndrome (13%) or a desire to prevent it (16%, 29% combined). Reasons most frequently mentioned by parents for not following the recommendation not to sleep with their child in the same bed were: ease of breastfeeding (50%; n = 24) and better sleep of the child (40%; n = 19); this was for children of 0-6 months old., Conclusion: Parents do not automatically follow safe sleep recommendations for their child. Prevention may be improved by talking to parents about their reasons for not adhering to recommendations and determining together how to create a safe sleeping environment for the baby.

A 7-year-old boy was referred to the paediatric clinic with a swollen cheek since one day. Intraoral examination revealed erythematous and swollen gingivae in the right upper quadrant. The consulted maxillofacial surgeon diagnosed him with a canine fossa abscess. The patient recovered quickly after incision and drainage, followed by antibiotic therapy.

A 38-year-old male with a history of laparoscopic cholecystectomy and successfully treated Hodgkin lymphoma had a follow-up CT-scan which showed four nodular densities behind the bladder. Additional investigations demonstrated spilled gallstones instead of a relapse of Hodgkin lymphoma. Spillage of gallstones is relatively common and may mimic malignant diseases.

Background: Neuralgic amyotrophy is characterised by pain in the neck or shoulder region, followed by neuropathy of both motor and sensory nerves of the brachial plexus. The incidence of this condition is estimated at 1/1000 per year. In a rare variant of the syndrome, involvement of both phrenic nerves can occur, leading to diaphragmatic paralysis and severe orthopnoea., Case Description: A 67-year-old woman was referred to us with acute orthopnoea. Imaging studies showed bilateral diaphragmatic paralysis, and electromyography (EMG) confirmed neuropathy of both phrenic nerves. The diagnosis was bilateral neuralgic amyotrophy. The patient received nocturnal ventilation support via nasal high flow oxygen therapy. This symptomatic treatment had a positive effect., Conclusion: Isolated phrenic nerve neuropathy is a rare variant of neuralgic amyotrophy, leading to orthopnoea. Recovery is slow and frequently incomplete. Supportive treatment with non-invasive ventilation support is necessary to improve the patient's quality of life.

A 19-year-old soccer player presented with instability of his left knee after a rotation trauma. Congenital absence of the anterior cruciate ligament was suspected because of leg length discrepancy and specific MRI findings. He regained stability after an anterior cruciate reconstruction.

Myotonic dystrophy type 1 is an autosomal dominant disease, which affects multiple organ systems. Clinical symptoms in young children are non-specific, and include learning disabilities, behavioural problems and fatigue. Myotonic dystrophy type 1 is characterised by the phenomenon "anticipation": the occurrence of increasing severity of disease and lower age of onset in successive generations. Early diagnosis and treatment of early-onset symptoms in the patient and in family members is essential. Genetic counselling of all family members regarding hereditary risks is important. This article provides insight into the diagnosis of myotonic dystrophy in childhood.

An 11-year-old girl was seen with painless, bilateral periorbital edema, that had appeared a week before presentation. Additional symptoms included fever, headache and malaise. Serological tests performed three days later showed an active Epstein-Barr virus infection, which provided the diagnosis 'Pfeiffer's disease'. Bilateral periorbital edema can be the presenting manifestation of Epstein-Barr virus infection and should therefore be included in its differential diagnosis.

Sarcopenia, the decrease in muscle mass and function, may lead to various negative health outcomes, including loss of physical performance and loss of the ability to perform the activities of daily living. The exact mechanisms of sarcopenia are not yet fully understood, but it is obvious that besides ageing, metabolic alterations, diseases, nutrition, and physical exercise play a major role. In the Netherlands, screening ofsarcopenia is not yet performed in daily practice. Evidence exists that training of muscle strength, whether or not combined with a dietary intervention, has a positive effect on the loss of muscle mass and function.

An electronic health record (EHR) should provide 4 key functionalities: (a) documenting patient data; (b) facilitating computerised provider order entry; (c) displaying the results of diagnostic research; and (d) providing support for healthcare providers in the clinical decision-making process.- Computerised provider order entry into the EHR enables the electronic receipt and transfer of orders to ancillary departments, which can take the place of handwritten orders.- By classifying the computer provider order entries according to disorders, digital care pathways can be created. Such care pathways could result in faster and improved diagnostics.- Communicating by means of an electronic instruction document that is linked to a computerised provider order entry facilitates the provision of healthcare in a safer, more efficient and auditable manner.- The implementation of a full-scale EHR has been delayed as a result of economic, technical and legal barriers, as well as some resistance by physicians.

A 74-year-old woman presented with a nonreducible, painful bulge of 10 cm in the right groin-region, which had been present for 5 days. She was not feeling ill. During the CT-scan the patient performed a Valsalva maneuver. The scan demonstrated a right femoral hernia with incarcerated peritoneal fat, infiltrate and an inflamed appendix. Peroperative findings confirmed the diagnosis "hernia De Garengeot".

A 5-year-old girl presented with increasing erythroderma since one day in combination with impetigo vulgaris. As exfoliative lesions and bullae developed within hours, the patient was diagnosed with staphylococcal scalded skin syndrome. She was successfully treated with flucloxacillin.

Background: The use of antipsychotics can lead to the development of obesity, dyslipidemia, hypertension and hyperglycemia, risk factors for diabetes mellitus type 2 and cardiovascular diseases., Aim: To find out whether patients suffering from psychoses and schizophrenia and taking antipsychotics should be monitored systematically and periodically for the risk factors for and complications of the above-mentioned diseases., Method: A written survey was conducted among the relatives of users of antipsychotics, relatives being members of the Ypsilon association in the Limburg region., Results: Seventy-eight relatives (27%) returned the forms. Compared to the Dutch population, the risk factor for high blood pressure was remarkably common in the 20-30 age group. In the group of persons aged 30-40 obesity occurred surprisingly frequently; remarkably frequent too was diabetes in the 40-50 age group. At each monitoring session 27% of the users were checked on all parameters. Only 59% of the users were checked periodically., Conclusion: Apparently, systematic and regular monitoring of risk factors and somatic complications is currently inadequate. The regional survey therefore needs to be extended so that it covers the entire country.

The 'Individueel functioneren medisch specialisten' (Individual Functioning of Medical Specialists, IFMS) programme is a formative evaluation tool.- The aim of the IFMS programme is to consolidate good practices and to ameliorate those less desirable. - It is an integral system that takes the complexity of the medical profession, the physician as an individual and the expectations and demands from the individual's surroundings into account. - The IFMS programme uses the physician's intrinsic motivation and individual responsibility as its starting points. - The programme's features include maintaining a portfolio and acquiring feedback from the surroundings which are then used as a foundation for a personal discussion with a trained communicator.- The outcome of this method results in a physician who is and remains conscious of the need to deliver high-quality care, taking his or her personal aspirations and demands of the work setting into account.

Background: The Morel-Lavallée lesion is a post-traumatic collection of fluid arising after a 'closed degloving injury' has caused the separation of the skin and subcutis from the underlying muscular fascia. It usually occurs in the trochanteric region or proximal thigh., Case Description: A 36-year-old obese man was referred to the emergency department by his general practitioner for fever and pain in the right lower abdominal quadrant. Blood testing revealed elevated infection parameters. As appendicitis was suspected, a CT scan of the abdomen was performed. This revealed a Morel-Lavallée lesion, which he had sustained 9 months earlier when he had been hit by a car while riding his bicycle. A rapid recovery ensued after ultrasound-guided percutaneous drainage and treatment with antibiotics., Conclusion: A Morel-Lavallée lesion, which could manifest even months later, should be considered after any traumatic injury. Ultrasound, CT and MRI are useful tools for proper diagnosis. There is no consensus about treatment in either the acute or the chronic phase to date.

The new guideline on irritable bowel syndrome (IBS) advocates distinguishing IBS patients who predominantly suffer from constipation from those who mainly suffer from diarrhoea or from alternating bouts of diarrhoea and constipation. In the latter two groups, coeliac disease should be excluded, as should lactose intolerance if at all possible. Since there is no gold standard for the treatment of IBS a thorough explanation of the condition to patients is recommended.

We present a neonate with transient neonatal pustular melanosis, a benign skin rash seen in 0.2-2.2% of white neonates and in 4-5% of black neonates. Vesicopustular lesions are present at birth, the lesions rupture in 24-48 hours leaving hyperpigmented macules. These slowly fade in 3-10 weeks.

A primary aortoduodenal fistula is a life-threatening cause of haematemesis. Early recognition is essential for the prevention of complications and death. We describe the case of an 82-year-old man with acute haematemesis and melaena resulting from this condition. The diagnostic procedures included a gastroduodenoscopy and computed tomography angiography (CTA). The fistula was surgically removed, with neighbouring parts of the duodenum and aorta. The duodenum was closed by a simple anastomosis; the aorta by the introduction of a Dacron graft. The postoperative course was uneventful. Surgical intervention is the treatment of choice in patients with an aortoduodenal fistula.

A 49-year-old man complained of headache, dysarthria and difficulty in swallowing following a motorcycle accident. He had a tongue deviation to the right due to a traumatic lesion of the right hypoglossal nerve which was caused by a right occipital condyle fracture.

A 68-year-old female with an extensive history of unexplained problems presented at the Department of Internal Medicine for an analysis of painful cutaneous abnormalities of the lower legs. A systemic cause could not be found. Later on the general practitioner noted haematoma and petechiae and subsequently a hypovitaminosis C. The patient received active vitamin C supplement for this. The cutaneous abnormalities on the legs had significantly improved after 3 weeks. This patient was found to have symptomatic hypovitaminosis C, also known as scurvy, as a complication of an psychiatric disorder. Although scurvy might appear to be a disease of the past that rarely occurs nowadays, it should nevertheless be given due consideration. This requires a good history taking.

A newborn was seen on the suspicion of neonatal schisis. From the upper lip to the right nostril a tiny line was visible, without any other anomalies. The mother had a cheilognathopalatoschisis. The patient had a congenital healed cleft lip, a rare presentation with unknown origin.

Working "hard" is a matter of definition, therefore we are talking about quantity and not quality: The number of productive working hours and not the "hours of attendance" (i.e. unproductive hours). The problem of the current generation is their sense of working hard. This article describes the factors contributing to this feeling.

A 72-year-old man presented with chronic coughing due to an infection with Mycobacterium avium complex: Lady Windermere syndrome.

There are new insights into the pathogenesis of cot death ('sudden infant death syndrome'; SIDS). Based on these new insights, the Dutch Paediatric Association and the Dutch Child and Youth Health Care Physicians have drawn up a new guideline 'Prevention of cot death', which replaces the consensus statement of 1996. The 2 major differences from the old guideline are that co-sleeping of young infants in the same bed with the parents is now actively discouraged under the age of 4 months, and that the supine sleeping position is recommended from birth on. The recommendation that lying on one side can be used during the first 2 weeks of life has now been withdrawn.

A 41-year-old man underwent skeletal scintigraphy due to chronic pain in the left foot and polyarthralgia. He was taking medication for gout and had previously had sarcoidosis, for which he had received corticosteroids and other therapy that was discontinued 4 years ago. Scintigraphy revealed a mass in the shaft of the left humerus that, according to biopsy, was an asymptomatic osteomyelitis caused by Mycobacterium avium. The shaft of the left humerus is an uncommon site for tuberculous osteomyelitis. A viable fistula remained after the biopsy that persisted despite pharmacologic treatment with ethambutol, rifabutin and clarithromycin. Four months later, sequestrectomy was performed with insertion of gentamicin-impregnated beads, which resulted in rapid resolution. The foot pain resolved spontaneously. The incidence of bone tuberculosis has increased over the last 2 decades. The most commonly affected sites are the spine and large joints. Infection with M. avium is sometimes involved. Because of the increasing incidence it is important to include mycobacterial infections in the differential diagnosis of focal bone lesions, especially when standard cultures are initially negative.

A 38-year-old man presented with severe methanol intoxication after inhaling methanol over a period of 36 hours in a poorly-ventilated laboratory. He complained of visual disturbances, mild photophobia, hyperventilation and nausea. Laboratory results showed severe metabolic acidosis with a toxic serum-methanol level. He was treated by acute haemodialysis and ethanol infusions. After 9 hours of haemodialysis the serum-methanol value fell below toxic levels. Therapy resulted in the complete disappearance of symptoms and he was able to leave the intensive-care unit 24 hours after presentation. Often, late presentation is a cause of serious morbidity and even mortality in severe methanol intoxication, so early recognition is essential. This is the first published case of methanol intoxication due to inhalation, which is as serious and requires the same treatment as ingestion of methanol.

A 49-year-old woman suffered from vulval and vaginal ulcera and from oral mucosal lesions and uveitis due to Behçet's disease.

Background: A new line of research into psychomotor retardation in patients with a major depressive disorder began about ten years ago. The purpose of the research was twofold: to obtain a clearer understanding of psychomotor retardation in patients with a major depressive disorder and to assess the importance of psychomotor retardation for the diagnosis and treatment., Aim: To present an overview of the results of these studies in which psychomotor retardation of these patients was investigated., Method: The patients had to perform visuomotor tasks involving pen movements. The psychomotor retardation was measured by recording their pen movements objectively and accurately by means of a computer and digitiser., Results: Patients with major depressive disorder showed pronounced psychomotor retardation in the visuomotor tasks. The psychomotor retardation appeared to be of both a cognitive and motor nature. The treatment study which examined the effect of fluoxetine on psychomotor retardation revealed that the cognitive retardation disappeared but the motor retardation remained. It was particularly the more retarded patient who responded well to fluoxetine. The research that compared the psychomotor retardation in various subtypes of depression revealed that patients with major depressive disorder showed pronounced retardation but dysthymic patients did not show any retardation. Psychomotor retardation was more severe in patients with major depressive disorder with melancholic features., Conclusion: Psychomotor retardation can play an important role in the diagnosis and treatment of depressive disorders.

Bálint's syndrome consists of simultanagnosia, ocular apraxia and optical ataxia. Although various disorders may underlie this syndrome, the most frequent is Alzheimer's disease in its early stages. Because so few people are familiar with this syndrome the first reaction is often to attribute it to underlying problems that are primarily of a psychological nature. As a result treatment and support may be inadequate or given too late. The case study reported here concerns a female patient with Bálint's syndrome. The case is supported by comparable symptoms found in three other patients.

Two 37-year-old men, both drug addicts, and a 32-year-old homeless woman presented themselves with a painful arm. Except for the first patient, there was a delay in diagnosing the compartment syndrome of the arm. In the first patient emergency fasciotomy led to a good functional recovery, however kidney function was lost despite proper treatment, possibly due to combined heroine use and muscle breakdown. In the second patient prolonged immobility and altered consciousness by drug use should have increased clinical suspicion. Poor arm function remained even after fasciotomy. In the third patient inadequate clinical examination delayed surgery. Major early symptoms of compartment syndrome are progressive disproportional pain and sensory loss, not relieved by analgesia. If left untreated, the ischaemic tissue damage is potentially limb and even life threatening. The acute compartment syndrome is a clinical diagnosis and a low threshold for surgical exploration and fasciotomy is advocated.

The function and survival time of unicompartmental knee prostheses for patients with severe gonarthrosis have been improved the past few years by developments in their design, the instrumentarium and the surgical technique. A medial unicompartmental knee prosthesis may be indicated in patients with arthrosis of the medial tibiofemoral compartment. The prerequisites are an intact anterior cruciate ligament, an intact lateral compartment, a correctable varus axis and sufficient flexion in the knee. Contraindications are inflammatory arthropathies and a recent episode of septic arthritis. Relative contraindications are: old age, excess body weight, patellofemoral arthrosis and chondrocalcinosis. A unicompartmental knee prosthesis can be placed via a small parapatellar incision. The postoperative recovery is more rapid than following the classical open approach, while the knee function after 5 years is comparable. The knee function also seems better following a medial unicompartmental knee prosthesis than after valgusising tibial head osteotomy. The latter is still preferred for young active patients. Medial unicompartmental knee prostheses fail in 6-8% of patients. Revision to a total knee prosthesis is then the treatment of choice. In the long term, unicompartmental prostheses with a mobile bearing become loose less often than comparable prostheses with a fixed bearing.