[A man with limescale splashes]. / Een man met kalkspatten.

A 79-year-old man visits his general practitioner due to white spots on his hands and feet. Upon examination, numerous white papules are observed, leading to a diagnosis of stucco keratosis. Stucco keratosis is typically asymptomatic and is identified by benign keratotic papules. Treatment is challenging because of the large quantities.

[How to ensure the accessibility of primary care]. / Hoe houden we de huisartsenzorg toegankelijk?

The accessibility of primary care is under pressure, because more and more responsibilities and tasks are being shifted to general practitioners. Changes will have to take place to safeguard the core values of primary care: person-oriented, medical-generalistic and continuous. The increase in chronic diseases and multimorbidity forces general practitioners to delve deeper into complex care and maintain their management role in healthcare. Because of their guiding function, general practitioners must orientate themselves on problem areas that were previously discussed less prominently, such as questions related to gender identity and diversity. The time required for this may become available through the disposal and delegation of tasks and through further digitization. Digital interdisciplinary consultation in particular may improve the efficiency and quality of care. Finally, patients must be better informed about the nature of their complaints and the indications for an assessment by the GP.

[A toddler with a lump on his penis]. / Een peuter met een zwelling op de penis.

A father consulted his general practitioner with his 3-years-old son who had swelling on his penis for several months. He experienced no miction problems. The swelling appeared to be a retention of smegma. This is harmless and will disappear spontaneously as the process of separation of the preputium continues.

[A toddler with loose nails]. / Een peuter met loslatende nageltjes.

A father consulted his general practitioner with his 18-month-old son with several loose fingernails. We saw a toddler with nine fingernails that peeled off on the proximal side. The normal nails were visible under the loose nails. Diagnosis: onychomadesis.

[Guidelines: leash or walking stick?] / Richtlijnen: leiband of wandelstok?

Guidelines are undeniably of great value to practicing physicians, but there are also objections. Due to the multitude of guidelines, it is sometimes difficult to find the most appropriate and it is not always clear how well-founded recommendations are. In addition, guidelines can limit the freedom of action. Also, in individual patients - especially in the case of multimorbidity - recommendations from different guidelines can conflict with each other. Finally, drawing up guidelines takes a lot of time, which is at the expense of patient care, and conflicts of interest are difficult to avoid completely. It is therefore important to put the recommendations from guidelines into perspective: they are an aid to individual patient care, not a law. This perspective is also important in education, so that students are taught to use guidelines in a wise way. Finally, it is important to regularly evaluate recommendations and revise them if necessary.

[A man with discoloration of his lower legs]. / Een man met verkleuring van zijn onderbenen.

A 73-year-old man consulted his general practitioner with a non-itchy rash on his lower legs, which developed a few hours after golfing. We saw a blotchy, red, non-blanchable discoloration with some blisters. Microscopic examination showed dermal inflammatory infiltrate with minor vessel wall damage and extravasation of erythrocytes. Diagnosis: exercise-induced vasculitis.

[A man with a crease in his earlobe]. / Een man met een groef in zijn oorlel.

A 68-year-old man consulted his GP with a crease in his earlobe, running diagonally from the tragus over the earlobe backwards. This is the Frank's sign, which is a risk factor for the presence and prognosis of cardiovascular pathology, such as coronary sclerosis, cerebrovascular accident and peripheral arterial disease.

[Reliable diagnostics: clinical gestalt or prediction rule?] / Klinische blik of beslisregel.

Diagnostic prediction models can support the diagnostic process, both for experienced physicians and for physicians with little experience. More attention should be paid to the incorporation of diagnostic prediction models in the electronic patient record, so that a more accurate probability estimate can be made without simplification to rounded sumscores. A uniform cut-off of sum scores with associated categorization is also undesirable, because it does not take the context of the individual patient sufficiently into account. In the case of a very strong gut feeling, the outcome of a diagnostic prediction model rule alone cannot be sufficient for further policy. Diagnostic prediction models 'only' generate individual objectively estimated probabilities; the clinical decision-making based on these probabilities always needs to be made by the doctor in shared decision making with the patient. Conflict of interest and financial support: none declared.

[Health professionals for the climate]. / Zorgprofessionals voor het klimaat.

More than 230 medical journals have called for worldwide action against global warming and for nature restoration. They call on health professionals to actively contribute to increasing support for the radical measures necessary to maintain the health and well-being of life on our planet. This call concerns not only making one's own living and working environment greener, but above all the use of medical knowledge, expertise and authority for measures that matter worldwide. This starts with concrete advice to patients to prevent damage from climate change at an individual level. Health workers must stand up for prevention and care outside the consultation room and across national borders. After all, medical doctors have historically been in a position to speak out about these threats and to remind political leaders of their responsibility.Health professionals can lead by example by realizing greener and more sustainable care themselves.

Assessing the potential effects and cost-effectiveness of programmatic herpes zoster vaccination of elderly in the Netherlands.

BACKGROUND: Herpes zoster (HZ) is a painful disease affecting a considerable part of the elderly. Programmatic HZ vaccination of elderly people may considerably reduce HZ morbidity and its related costs, but the extent of these effects is unknown. In this article, the potential effects and cost-effectiveness of programmatic HZ vaccination of elderly in the Netherlands have been assessed according to a framework that was developed to support evidence-based decision making regarding inclusion of new vaccines in the Dutch National Immunization Program. METHODS: An analytical framework was used combining a checklist, which structured relevant data on the vaccine, pathogen and disease, and a cost-effectiveness analysis. The cost-effectiveness analysis was performed from a societal perspective, using a Markov-cohort-model. Simultaneous vaccination with influenza was assumed. RESULTS: Due to the combination of waning immunity after vaccination and a reduced efficacy of vaccination at high ages, the most optimal cost-effectiveness ratio (21716 euro per QALY) for HZ vaccination in the Netherlands was found for 70-year olds. This estimated ratio is just above the socially accepted threshold in the Netherlands of 20000 euro per QALY. If additional reduction of postherpetic neuralgia was included, the cost-effectiveness ratio improved (approximately 10000 euro per QALY) but uncertainty for this scenario is high. CONCLUSIONS: Vaccination against HZ at the age of 70 years seems marginally cost-effective in the Netherlands. Due to limited vaccine efficacy a considerable part of the disease burden caused by HZ will remain, even with optimal acceptance of programmatic vaccination.

[General Practice: continuously developing]. / Huisartsgeneeskunde: continu in ontwikkeling.

Over the past 10 years there have been significant developments in general practice regarding diagnostics, differentiation of competences of general practitioners, cooperation within primary care and with secondary care, task delegation and patient information provision. Less progress has been made in other areas: E-health applications are rarely used, and there is no clear guideline for an integrated policy in patients with multimorbidity. General practitioners also continue to suffer from excessive regulatory pressure, excessive protocols and standardization. In the coming decade, GPs will continue to work in accordance with the core values ​​of their profession: 'person-oriented', 'medical-generalist', 'continuous' and 'jointly'. Their function to provide guidance is becoming increasingly important. In addition, more diagnostics and treatment will take place at the interface between general practice and secondary care. Chronic care will focus more on the needs and wishes of the individual patient. GPs retain their important role in terminal palliative care and emergency care.

[Respiratory complaints in the time of COVID-19]. / Luchtwegklachten in tijden van corona.

The current guidelines for diagnosis and treatment of primary respiratory infections are still useful during the COVID-19 epidemic.Telephone triage of patients with respiratory complaints aims to identify patients with complications or an increased risk of complications.There are no indications to test for SARS-CoV-2 virus in general practice.During this COVID-19 epidemic, protective clothing is recommended in all physical contacts with patients with respiratory complaints.There is no reason to be cautious about using NSAIDs in patients suspected of COVID-19.Amoxicillin is first choice treatment for respiratory infections during the COVID-19 epidemic; there is lack of evidence to support azithromycin as a first choice.Respiratory rate > 24 / min or saturation <92-94% indicate imminent respiratory decompensation and may be reasons for referral.

Threat of an influenza pandemic: family physicians in the front line.

BACKGROUND: The chance of an influenza pandemic is real and clinicians should keep themselves informed about the rationale and science behind preventive and therapeutic principles relating to an (impending) influenza pandemic. DISCUSSION: Vaccination is considered the best prevention in case of a pandemic threat and first choice to contain the impact of a pandemic. Pending the availability of an effective pandemic vaccine, antivirals are likely the only effective agents for prevention and treatment. When an influenza pandemic is impending, all interventions aim to prevent people becoming infected and to suppress replication and transmission of the virus as much as possible. Antivirals will be prescribed to patients with laboratory confirmed pre-pandemic influenza as well as to their contacts (post-exposure prophylaxis) which may delay development of or even prevent a pandemic. During a manifest influenza pandemic, however, there is large-scale spreading of the influenza virus. Therefore, preventive use of antivirals is less efficient to prevent transmission. Delaying the pandemic is then important in order to prevent exhausting public health resources and disruption of society. Thus, during a manifest pandemic everyone with influenza symptoms should receive antivirals as quickly as possible, regardless of virological confirmation. To ensure optimal effectiveness of antivirals and to minimize development of drug resistant viral strains, the use of antivirals for annual influenza should be restrictive. The crucial position of family physicians during an (impending) influenza pandemic necessitates the development of primary health care guidelines on this topic for all countries. SUMMARY: Family physicians will play a key role in assessing and treating victims of a new influenza virus, and in reassuring the worried well. We outline various possible interventions in the event of an impending and a manifest influenza pandemic, such as non-medial measures, prescription of antivirals, and vaccination, and emphasize the need for pandemic influenza preparedness.

[Paraneoplastic syndromes]. / Paraneoplastische syndromen.

A paraneoplastic syndrome is a phenomenon or complex of symptoms that can occur with malignancy, without this being the result of tumour cells in the affected area. In this article, we describe the following paraneoplastic syndromes: thrombophlebitis migrans, clubbing, pemphigus, acanthosis nigricans, blue fingers, dermatomyositis, and myasthenia gravis.

Estimating Morbidity Rates Based on Routine Electronic Health Records in Primary Care: Observational Study.

BACKGROUND: Routinely recorded electronic health records (EHRs) from general practitioners (GPs) are increasingly available and provide valuable data for estimating incidence and prevalence rates of diseases in the population. This paper describes how we developed an algorithm to construct episodes of illness based on EHR data to calculate morbidity rates. OBJECTIVE: The goal of the research was to develop a simple and uniform algorithm to construct episodes of illness based on electronic health record data and develop a method to calculate morbidity rates based on these episodes of illness. METHODS: The algorithm was developed in discussion rounds with two expert groups and tested with data from the Netherlands Institute for Health Services Research Primary Care Database, which consisted of a representative sample of 219 general practices covering a total population of 867,140 listed patients in 2012. RESULTS: All 685 symptoms and diseases in the International Classification of Primary Care version 1 were categorized as acute symptoms and diseases, long-lasting reversible diseases, or chronic diseases. For the nonchronic diseases, a contact-free interval (the period in which it is likely that a patient will visit the GP again if a medical complaint persists) was defined. The constructed episode of illness starts with the date of diagnosis and ends at the time of the last encounter plus half of the duration of the contact-free interval. Chronic diseases were considered irreversible and for these diseases no contact-free interval was needed. CONCLUSIONS: An algorithm was developed to construct episodes of illness based on routinely recorded EHR data to estimate morbidity rates. The algorithm constitutes a simple and uniform way of using EHR data and can easily be applied in other registries.

Treatment and prevention of herpes labialis.

OBJECTIVE: To review the evidence regarding the treatment and prevention of herpes labialis. QUALITY OF EVIDENCE: The evidence relating to treatment and prevention of herpes labialis is derived from randomized controlled trials (level I evidence). MAIN MESSAGE: Treatment with an indifferent cream (zinc oxide or zinc sulfate), an anesthetic cream, or an antiviral cream has a small favourable effect on the duration of symptoms, if applied promptly. This is also the case with oral antiviral medication. If antiviral medicine (cream or oral) is started before exposure to the triggering factor (sunlight), it will provide some protection. Research on sunscreens has shown mixed results: some protection has been reported under experimental conditions that could not be replicated under natural conditions. In the long term, the number of relapses of herpes labialis can be limited with oral antiviral medication. CONCLUSION: Only prompt topical or oral therapy will alleviate symptoms of herpes labialis. Both topical and oral treatment can contribute to the prevention of herpes labialis.

Treatment of herpes zoster.

OBJECTIVE: To review the evidence regarding treatment of herpes zoster (HZ) in the short-term, focusing on the prevention of postherpetic neuralgia (PHN). QUALITY OF EVIDENCE: The evidence relating to treatment of HZ is derived mainly from randomized controlled trials (level I evidence). MAIN MESSAGE: Antiviral drugs might have some effect on the severity of acute pain and on the duration of skin lesions. Corticosteroids also alleviate acute pain. Oral antiviral medication reduces the risk of eye complications in patients with ophthalmic HZ. There is no convincing evidence that antiviral medication reduces the risk of PHN. Some studies, however, have shown that famciclovir and valacyclovir shorten the duration of PHN. The effectiveness of amitriptyline or cutaneous and percutaneous interventions in preventing PHN has not been proven. CONCLUSION: Oral antiviral drugs should be prescribed to elderly HZ patients with high risk of PHN. Moreover, these drugs should be prescribed to all patients at the first signs of ophthalmic HZ, irrespective of age or severity of symptoms.