Souvenaid (Nutricia, Zoetermeer, the Netherlands) is a medical food for the dietary management of early Alzheimer's disease. The mix of nutrients in this drink is suggested to have a beneficial effect on cognitive function; such implicit health claims for medical foods are not checked by government agencies. Souvenaid has been investigated in three clinical trials. The first trial showed that Souvenaid produced a significant improvement in delayed verbal recall, but not in other psychological tests. The second and largest trial showed no effect on any outcome. The third trial showed no significant effect at 12 or 24 weeks, but a significant difference in the 24-week time course of the composite memory score. None of these outcomes was clearly specified as a primary outcome at trial registration. In conclusion, there is no convincing proof that Souvenaid benefits cognitive function. Better scrutiny of the efficacy of medical foods is warranted.

In most patients, infection with a non-typhoid Salmonella species usually results in self-limiting gastroenteritis. Severe complications such as bacteraemia and extra-abdominal infections are most often attributed to typhoid subspecies like S. typhi and S. paratyphi. In this article, we present the case of a healthy patient with non-typhoid salmonellosis who nevertheless developed severe complications.A 63-year-old man with an unremarkable medical history presented at the emergency department with abdominal complaints suggestive of gastroenteritis. Cultures of faeces and blood yielded S. typhimurium. The infection was complicated by many intra-abdominal abscesses, abdominal sepsis and an intestinal perforation requiring multiple interventions. The patient has been symptom-free for half a year now.Severe complications related to infection with non-typhoid S. typhimurium are rare. The incidence of salmonellosis has risen over the past few years, however; the risk of severe complications has therefore also increased.

In addition to causing nasal septum perforation, cocaine abuse can cause extensive destruction of the osteocartilaginous structures of the nose. The clinical picture can mimic other diseases, such as vasculitis and lymphoma. Here we describe 3 patients with nasal deformities. One patient, a 39-year-old woman, had a large cocaine-related septum perforation, which caused a saddle-nose deformity. This deformity was corrected via external-approach rhinoplasty. The second patient, a 58-year-old man with limited granulomatosis with polyangiitis, presented with recurrent nose bleeds. He was treated with prednisolone for an exacerbation of symptoms. His nasal defects are now stable. The third patient, a 41-year-old man, had extensive deformities and tissue defects of the nose and palate. He was treated surgically, but this was followed by a relapse of the tissue defects due to persistent cocaine abuse. In patients with destruction of the nasal skeleton, the possibility of cocaine abuse should always be considered.

- Various guidelines are available for the diagnosis and treatment of ADHD in adults, but not for patients with ADHD and a comorbid substance use disorder (SUD).- In 2010, the Addiction Medicine Working Party, a division of the VAD (Verenigingvoor Alcohol- en andere Drugproblemen / Association for Alcohol and other Drug Problems) developed a practice guideline on how, when and by whom ADHD can be diagnosed in patients with an addiction, and how these patients should be treated.- Given the high prevalence of ADHD in treatment-seeking SUD patients and the availability of valid screening instruments, all SUD patients should be screened for ADHD as soon as their drug use has stabilized. - Acquiring information from external sources as well as clinical observation and questionnaires are important tools for the establishment of the diagnosis of ADHD. - Integrated treatment primarily includes psycho-education, coaching and cognitive behavioural therapy in addition to pharmacotherapy.- Evidence-based treatments for addiction may also be effective in patients with concomitant ADHD, provided the methods are adapted to the limitations that are associated with this condition.

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'.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.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 risk factor has a causal effect on a disease when the disease would not have occurred in the absence of the risk factor. Analogous reasoning applies to the effect of a particular therapy. - Thinking in terms of contrasts is fundamental to causal reasoning in medicine. The contrast determines the content of the causal claim; the most important assumption here is that the prognosis between groups is comparable. - Causal effects of risk factors are not always the same as the causal effect of an intervention: removal of a risk factor (e.g. smoking) for a disease does not necessarily mean that the risk will subsequently normalize. - A second problem is that risk factors cannot always easily be translated into interventions. This applies to factors that cannot be changed (e.g. gender) or that can have multiple causes themselves (e.g. obesity).

Hallucinogen persisting perception disorder (HPPD) is a relatively unknown complication of ecstasy use. As a result, the diagnosis is often missed. The prevalence of HPPD is probably low. Few patients seek medical help; HPPD is however widely discussed by drug users on internet fora.We describe a 23-year-old male with HPPD after ecstasy use. Besides visual complaints, including seeing little spots ('visual snow'), the patient suffered from anxiety and depressive symptoms. We treated him with citalopram with good results.In patients with HPPD combined with anxiety or depressive complaints, citalopram could be a good treatment option. Further research into treatment is necessary.

- Gonococcal resistance to antibiotics is increasing worldwide.- In patients tested in Dutch STI clinics in 2009, gonococcal resistance to ciprofloxacin was over 50%.- Ceftriaxone, a third-generation cephalosporin, has been the first-choice medication since 2004.- General practitioners treated 25% of their gonorrhoea patients with ciprofloxacin in 2010.- There is a need for up-to-the-minute, dynamic guidelines for treating gonorrhoea as well as the more systematic use of an up-to-date digital prescription system.

- Spinal instability in patients with spinal metastatic disease plays a role in the selection of surgical intervention.- The classic 'three-column model' used in traumatology to assess the stability of the spinal column is not always applicable to spinal metastatic disease. - The recently introduced Spinal Instability Neoplastic Score (SINS) is the first instrument that can be used to classify instability in spinal metastatic disease.- Utilisation of the SINS by the medical community could lead to more uniformity, which could prevent a delay in the treatment of patients with spinal instability.- Only a select group of patients with spinal instability due to metastatic disease is eligible for spinal surgery. Other patients are often prescribed bed rest or other conservative treatment. The usefulness of such treatments, however, has not been adequately substantiated.

A recent Danish study showed that instructor feedback significantly reduced the duration of training time needed for acquiring laparoscopic skills. While there is a clear advantage to trainees reaching a predetermined expert level of performance more rapidly, this does not necessarily imply that the skills were also acquired more efficiently. Experiencing continual feedback while undergoing a training task could reduce the level of difficulty in performing it; the presence of an instructor can also heighten emotional tension. Both of these factors can impair the learning process. For this reason, we recommend self-directed feedback during training on complex laparoscopic skills.