[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.

[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 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.

[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.

[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.

[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.

[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.

[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.

[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.

[Continuity of care in primary care; a bygone ideal or new perspective?] / Continuïteit van de huisartsenzorg.

Relational continuity of care has traditionally been an important core value of primary care. Research shows that relational continuity of care contributes to better patient health. However, due to social changes and an altered organization of our health system, it has become more difficult to put this core value into practice. General practitioners, for example, increasingly work part-time and general practices have become larger-scaled. Within practices, there is also an increase of delegation and specialization, leading to fragmentation of healthcare. A weekly rota involving at least three clinical consultation days for each doctor, the establishment of small general practice teams within a larger organisation, and a reduction in the size of a standard practice can facilitate relational continuity of care. In addition, it is necessary for GPs to concentrate on the core activity of their profession: direct personal care.

[A woman with a white skin lesion of her toe]. / Een vrouw met een witte huidafwijking van haar teen.

A 78-year-old woman visited her general practitioner with a sharply bounded white lesion of her toe. We diagnosed it as gouty tophus, which was confirmed by a high serum urate level. Gout is a chronic disease, characterised by deposition of monosodium urate crystals in joints and tissues. The preferable sites of gouty tophi are fingers, toes, knees, elbows, conchae and heels. Treatment of acute gout consists of NSAIDs, steroids or colchicine. Gouty tophi require lifelong urate-lowering treatment.

Influenza vaccination in adult patients with solid tumours treated with chemotherapy.

Patients with solid tumours receiving chemotherapy are at risk for influenza complications. Yearly influenza vaccination is recommended to patients treated with chemotherapy. However, adherence to vaccination is low, most likely due to lack of data on efficacy, optimal timing and safety of vaccination. There is scarce evidence for the effectiveness of the influenza vaccine in adult patients with solid tumours and chemotherapy on reduction of pneumonia, decreased mortality and fewer interruptions of oncological treatment. A review of 20 non-randomised serological studies in adult patients with different cancer types and chemotherapy provides insight in general trends of response to vaccination. Overall, the magnitude of the antibody response after influenza vaccination (i.e. seroconversion) can be lower than in healthy controls, but the majority of patients with solid tumours is able to mount a timely, protective immunological response (i.e. seroprotection) regardless of chemotherapy schedule, similar to healthy controls. Small sample sizes, patient heterogeneity and lack of comparable study designs limit more specific recommendations related to cancer type and optimal timing of vaccination. The inactivated influenza vaccine is safe to administer to immunosuppressed patients; side-effects are similar to those in healthy individuals. Although vaccination before start of chemotherapy is preferred to ensure optimal protection in adults with solid tumours, also vaccination during chemotherapy can reduce influenza-related complications considering the overall trends in serological response. Given the increased morbidity and mortality of influenza, influenza vaccination should be advocated as an inexpensive and safe preventive measure in patients with solid tumours receiving chemotherapy.

Burden of four vaccine preventable diseases in older adults.

BACKGROUND: Implementation of additional targeted vaccinations to prevent infectious diseases in the older adults is under discussion in different countries. When considering the added value of such preventive measures, insight into the current disease burden will assist in prioritization. The aim of this study was derive the first estimates of the disease burden in adults aged 50 years or over in the Netherlands for influenza, pertussis, pneumococcal disease and herpes zoster. METHODS: The average annual disease burden for these four diseases in the Netherlands was calculated for the period 2010-2013 using the disability-adjusted life years (DALY) measure. Disease models and parameters were obtained from previous research. Where possible we adapted these models specifically for older adults and applied age-specific parameters derived from literature. The disease burden based on these adapted models and parameters was compared with the disease burden based on the general population models. RESULTS: The estimated average annual disease burden was from high to low: pneumococcal disease (37,223 DALYs/year), influenza (7941 DALYs/year), herpes zoster (942 DALYs/year), and pertussis (812 DALYs/year). The adaptation of models and parameters specifically for the elderly resulted in a higher disease burden compared to the use of general population models. CONCLUSIONS: Among older adults, the disease burden in the period 2010-2013 was highest for pneumococcal disease, mostly because of high mortality, followed by influenza. Disease burden of herpes zoster and pertussis was relatively low and consisted mostly of years lived with disability. Better information on the course of infectious diseases and long-term consequences would enable more accurate estimation of disease burden in older adults.