[Headache in adults; article for education and training purposes]. / Hoofdpijn bij volwassenen.

Headache is one of the most common complaints for which patients request help from the general practitioner (GP). Anxiety and fear of serious illness are the most common reasons for consulting the GP, but a request for medication and worries about daily functioning can also prompt the consultation. In this educational article we describe a practical approach to the symptom 'headache' in adults on the basis of a number of questions. Our aim is to enable the general practitioner to: recognise alarm signals; identify the type of primary headache correctly; discuss, implement and evaluate the appropriate treatment; and reassure the patient.

Biological and environmental drivers of trophic ecology in marine fishes - a global perspective.

Dietary niche width and trophic position are key functional traits describing a consumer's trophic ecology and the role it plays in a community. However, our understanding of the environmental and biological drivers of both traits is predominantly derived from theory or geographically restricted studies and lacks a broad empirical evaluation. We calculated the dietary niche width and trophic position of 2,938 marine fishes and examined the relationship of both traits with species' maximum length and geographic range, in addition to species richness, productivity, seasonality and water temperature within their geographic range. We used Generalized Additive Models to assess these relationships across seven distinct marine habitat types. Fishes in reef associated habitats typically had a smaller dietary niche width and foraged at a lower trophic position than those in pelagic or demersal regions. Species richness was negatively related to dietary niche width in each habitat. Species range and maximum length both displayed positive associations with dietary niche width. Trophic position was primarily related to species maximum length but also displayed a non-linear relationship with dietary niche width, whereby species of an intermediate trophic position (3-4) had a higher dietary niche width than obligate herbivores or piscivores. Our results indicate that trophic ecology of fishes is driven by several interlinked factors. Although size is a strong predictor of trophic position and the diversity of preys a species can consume, dietary niche width of fishes is also related to prey and competitor richness suggesting that, at a local level, consumer trophic ecology is determined by a trade-off between environmental drivers and biological traits.

Contribution of CSF cytology in the diagnostic work-up of breast cancer patients with neurological symptoms: a retrospective analysis over two decades.

The aim of this study was to evaluate the contribution of cytological analysis of cerebrospinal fluid (CSF) in the diagnostic work-up of breast cancer patients who present with neurological symptoms suspected for central nervous system (CNS) metastases. In the period 1989-2009, a total of 81 patients with breast cancer underwent CSF cytological examination. Relevant tumour characteristics, clinical presentation and radiological findings were scored. The CSF cytological diagnosis was classified according to the 1996 NCI-sponsored conference approach as malignant, suspicious for malignancy, atypical, benign or inadequate. During the course of 20 years, 145 CSF cytological examinations were performed. Relatively common neurological symptoms resulting in cytological CSF examination were headache (n = 25), nausea and vomiting (n = 19), sensory disturbances (n = 16), and cranial nerve dysfunction (n = 16). Of these, headache and nausea/vomiting were most often associated with malignant cells in the CSF (CSF(+)) (in 48 and 53% of the cases, respectively). The 4 patients with both headache and confusion/altered mental status all had CSF(+). In 10 patients, CSF(+) was found despite the absence of radiological evidence for metastasis in/around the CNS. In our series, repeated CSF analysis appeared to have limited additional value, and CSF(+) was strongly correlated with shorter survival. A substantial number of patients with neurological symptoms but without radiological abnormalities can have CSF(+). In our series, the additional value of repeated cytological examination of CSF was limited. Our study underscores the value of CSF cytology as a tool for the unequivocal diagnosis of metastatic spread of breast cancer to the CNS, and confirms that CSF(+) is a strong predictor of poor survival.

Metastatic medulloblastoma in an adult; treatment with temozolomide.

Medulloblastoma is a malignant brain tumour most frequently seen in children. Treatment of this tumour type usually consists of surgery followed by radiotherapy. Relapses of medulloblastoma are sensitive to chemotherapy and treatment with chemotherapeutics in children has increased the survival rates. A medulloblastoma at adult age is extremely rare, and there is no overall accepted treatment, especially not in the case of a relapse. Recently improvement of survival was reported in patients with glioblastoma treated with a combination of radiotherapy and concomitant temozolomide. This observation encouraged us to decide to treat an adult patient with a recurrent medulloblastoma with temozolomide. This female patient showed a recurrence of a medulloblastoma 7 years after the initial presentation with metastatic spread along the neuraxis and progressive neurological deterioration. Treatment with temozolomide resulted in relief of clinical symptoms and stabilization of tumour growth for 8 months.