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Orbital cellulitis is a rare disease usually caused by sinusitis. Generally, the prognosis of both preseptal cellulitis and orbital cellulitis is favourable. Radiological distinction should be made between an orbital abscess and subperiosteal empyema. Theoretically, empyema is more accessible to antibiotics and, as it arises in a pre-existing anatomical space, it needs less aggressive treatment than an abscess. In contrast, the wall of an abscess created by the bacteria is scarcely permeable to antibiotics. Indications for surgical drainage should be based on clinical findings and not on Chandler's classification. Loss of vision, an unresponsive pupil or a densely packed orbit are indications for immediate surgical drainage. Drainage of an orbital abscess may speed up recovery.

Recently, the CanMEDS model, which forms the basis for competency-based learning in both undergraduate and postgraduate training, has been renewed by the introduction of CanMEDS 2015. The most prominent change is the emphasis on leadership skills, which is also reflected by the name change for the role of 'manager' to 'leader'. The addition of milestones provides clearly defined targets for learning and assessment, which facilitates the monitoring of the progression in competence. Furthermore, CanMEDS 2015 strongly focusses on the overall coherence of the separate competencies. CanMEDS, designed as a model that helps to train young doctors to become good doctors, also helps us - the trainers - to become better doctors ourselves.

The Dutch Minister of Health, Welfare and Sportintends to implement Human papillomavirus (HPV) vaccination for 12-year-old girls and catch-up vaccination for 13- 16-year-old girls, as part of the National Immunisation Programme from September 2009 onwards. However, due to a well-organised screening programme, cervical cancer is not an important public health problem in the Netherlands any more, which limits the possible impact of HPV vaccination. Vaccine trials thus far have involved a relatively small number ofparticipants with limited follow-up, so the efficacy of the vaccine in preventing cervical cancer is not yet known. There are no data on frequency and severity of possible adverse events and the vaccine has not yet been tested in the intention-to-vaccinate group of 12-year-old girls. Even when we assume that HPV16/18-related cervical cancer is prevented on a lifelong basis, the cost-effectiveness ratio of HPV vaccination is estimated not to be favourable. In conclusion, HPV vaccination does not seem to be urgent in the Netherlands. Therefore we advise studying the safety in 12-year-old girls first while at the same time waiting for the longer follow-up results of ongoing trials.

Tamoxifen has both agonistic and antagonistic effects on the female genital tract, depending on the ambient oestradiol concentration and the menopausal status of the patient. In postmenopausal women tamoxifen has an oestrogen agonistic effect on the vaginal epithelium, the uterine myometrium and the endometrium. It may induce benign cystic hyperplasia of the endometrial stroma and cause an increase in poly formation. The risk of endometrial cancer increases 2-3-fold after an exposure of up to 5 years. In asymptomatic tamoxifen users, gynaecological surveillance is not recommended. However, if there is postmenopausal bleeding, then transvaginal ultrasonography and histology of the endometrium are indicated. Tamoxifen can aggravate hot flushes and have a negative effect on sexual function. In premenopausal women, tamoxifen may induce ovarian cysts resulting in high serum-oestradiol levels. Oligomenorrhoea and amenorrhoea will occur in half of the patients. Tamoxifen has an antagonistic effect on the endometrium in premenopausal women and is associated with hot flushes and impaired sexual functioning. Teratogenic effects on the foetus have been described. Despite its gynaecological side effects, the benefits of tamoxifen in breast-cancer treatment outweigh the risks. Patients need to be informed about these side effects. Irregular or postmenopausal blood loss must always be reported to the treating physician.

Objective: To assess the results of lacrimal duct probing in young children with epiphora, due to a congenital nasolacrimal duct obstruction., Design: Retrospective, descriptive., Method: Data were collected from medical dossiers on the results of lacrimal duct probing in children (0-48 months) with epiphora that was done in the period from January 1, 1997 to December 31, 2001 at the University Medical Centre in Utrecht, the Netherlands. The percentage of eyes that showed complete resolution of symptoms three months after the final probing was calculated., Results: Of the 89 children who had undergone lacrimal duct probing, seven were excluded and in three children (six eyes) the data could not be retrieved. In 96 of the remaining 116 eyes (83%), the symptoms disappeared: this included 96% of the age group 0-12 months (n = 25), 85% of the 13-24 months-olds (n = 55), 77% of the 25-36 months-olds (n = 22) and 57% of the 37-48 months-olds (n = 14). No complications of probing were seen., Conclusion: In most children in the various age groups, epiphora disappeared. Thus, children do not need to be probed in the first year of life out of fear of failure at an older age. Whether or not probing shortens the duration of epiphora cannot be determined on the basis of either this study or the literature.

Objective: To determine the long-term outcome in patients with a lesion of a single lacrimal canaliculus without surgical correction., Design: Prospective., Method: In the period August 1995-August 1999 16 patients were seen with a monocanalicular trauma. No attempt was made to reconstruct the canaliculus; only the superficial layers were closed (skin and M. orbicularis oculi). At follow-up the patients were asked about epiphora (score of Munk) and the test of Anel and the fluorescein dye disappearance test were carried out., Results: At follow-up a mean of 13.7 months (range: 3-33) after the trauma the injured canaliculus was totally blocked in all patients. In spite of this, none of the patients experienced epiphora either indoors or outdoors. Tear drainage of the ipsilateral unharmed canaliculus was functioning normally in such a way that epiphora was prevented., Conclusion: In patients with a monocanalicular lesion repair of only the superficial layers of the eyelid without reanastomosis of the torn ends of the canaliculus is sufficient to maintain normal tear drainage. This procedure is safe and simple.