[Revised multidisciplinary guidelines 'Varicella'; broader indication for post-exposure prophylaxis]. / Herziene multidisciplinaire richtlijn 'Varicella'.

Post-exposure prophylaxis (PEP) with varicella zoster immunoglobulins (VZIG) should be administered as soon as possible after exposure to the virus, but always within ten days; in the previous guidelines this was within 96 hours. In cases of perinatal exposure, PEP with VZIG should be administered to neonates if the mother develops clinical chickenpox between seven days before delivery and seven days after delivery; in the previous guidelines this was between five days before delivery and two days after delivery. A new chapter on the treatment of chickenpox has been added to the guidelines.

[An infant with vesicles on the arm]. / Een zuigeling met blaasjes op de arm.

A 9-month-old infant presentedwithvesicles on the arm in theeighthcervicaldermatomesinceseveraldays. PCR analysis of thefluid of thevesiclesrevealedthepresence of the varicella zoster virus (VZV). It turned out thatthe infant had been in contact withthis virus at theage of 5 months; bythenthechild was protectedbymaternal VZV-antibodies, whichprevented adequate development of immunityagainstthe virus. Therefore, herpes zoster coulddevelop a few months later.

[Hope-Simpson and shingles]. / Hope-Simpson en gordelroos.

Dr Robert Edgar Hope-Simpson (1908-2003) was a British general practitioner, who has laid the foundation for unravelling the pathogenesis of shingles. At the beginning of the 20th century, both conditions were known to be related, but the precise relationship was unclear. It was assumed that chickenpox could originate after infection by both a person with shingles or someone with chickenpox, but that both diseases were caused by different viruses. Through rigorous observations in his GP practice and during his field work on the island of Yell, Hope-Simpson developed his hypothesis about the - now scientifically accepted - pathogenesis of shingles. Hope-Simpson's work shows how accurate observations can lead to unexpected new insights and hypotheses.

[A girl with a tumour on the thorax]. / Een meisje met een tumor op de borst.

A healthy 1-year old girl visits her general practitioner with a solitary dome-shaped tumour on her thorax. The lesion is about one cm in diameter and is present since several months. Pathological research reveals a solitary giant molluscum contagiosum. This is a common viral disease of the childhood. In contrast to this case, mollusca contagiosa typically present as several small papules.

[Influenza vaccination of patients with solid tumours during chemotherapy: efficacy and safety]. / Griepvaccinatie tijdens chemotherapie bij patiënten met solide tumoren.

- Adult patients with solid tumours receiving chemotherapy have reduced immunity against infections and are at increased risk of influenza infection and its complications. However, many of said patients are not vaccinated for influenza.- Limited observational research in this patient group has given some indication of the protective effects of the influenza vaccine on clinical outcome measures.- Serological studies have shown that the antibody response following influenza vaccination is often less pronounced in patients with solid tumours compared to healthy individuals. Nonetheless, in most cases a timely protective antibody response can be achieved.- The inactivated influenza vaccine is safe in immunosuppressed patients, irrespective of the moment at which it is administered. Side-effects are similar, both in nature and number, to those seen in healthy individuals.- Influenza vaccination can be offered to all adult patients with solid tumours, preferably before chemotherapy is commenced. Vaccination during chemotherapy, however, usually also generates sufficient vaccination response and can reduce the risk of influenza-related complications. Therefore, chemotherapy should not preclude patients from being administered the influenza vaccine.

[Research in the GP's practice is good for the health of all]. / Onderzoek in de huisartsenpraktijk: daar wordt iedereen beter van.

The Health Council of the Netherlands has issued a report on the importance of extramural medical research. More attention is needed for diseases with high prevalence or a high disease burden, and results from intramural research cannot always be extrapolated to the primary care setting. Scientific research is crucial for developing and evaluating primary health care, so all general practitioners (GPs) should at least open their practices to data collection for scientific research purposes. Additionally, researchers from departments of general practice, together with healthcare professionals, should develop research questions that are in line with observed knowledge gaps in general practice. It is also important that university medical centres actively support research in primary care. A national primary care research agenda could contribute to the promotion of GP participation in scientific research in daily practice.

[The Dutch College of General Practitioners practice guideline 'Suspicious skin lesions']. / De NHG-standaard 'Verdachte huidafwijkingen'.

- The Dutch College of General Practitioners practice guideline 'Suspicious skin lesions' provides recommendations for diagnosis, treatment and referral for the most common premalignant and malignant skin disorders.- The practice guideline includes a flowchart which starts by looking at the colour and surface of the skin lesion to direct the general practitioner to the most likely diagnosis.- In case of strong suspicion of squamous cell carcinoma, keratoacanthoma or melanoma and in case of basal cell carcinoma or Bowen's disease with high-risk characteristics, the general practitioner will refer the patient to a dermatologist.- The general practitioner will take into account the histopathological diagnosis in determining treatment and referral policy in case of other suspicious skin lesions. It will be obtained by means of punch biopsy or - in the case of naevi - diagnostic excision.- In case of suspicious skin lesions, the general practitioner will inspect the whole skin.- General practitioner and patient should determine a treatment plan together in case of actinic keratosis, histopathologically diagnosed basal cell carcinoma, and Bowen's disease. To this end, the practice guideline includes information on treatment options for general practitioners and dermatologists.

[Syncope; suspect pulmonary embolism, especially in the elderly]. / Syncope: wees bedacht op een longembolie, vooral bij ouderen.

Syncope can be caused by a pulmonary embolism. This applies in particular to elderly patients admitted with syncope; in the general population, however, syncope is far more frequently caused by a vasovagal response or orthostatic hypotension. Syncope can be the symptom of a pulmonary embolism, even in the absence of any clinical manifestations of this diagnosis; it is, therefore, important to exclude pulmonary embolism in any syncope patient in the accident and emergency department by applying the Wells clinical decision rule. GPs should also be alert to syncope as a possible symptom of pulmonary embolism, and be alert to breathing rate and signs of venous thrombosis.

[Revision of the Dutch College of General Practitioners practice guideline 'Children with fever']. / Herziene NHG-standaard 'Kinderen met koorts'.

- Fever in children is usually caused by benign viral infection.- Approximately 1-10% of children with fever has or develops a serious infection such as pneumonia, meningitis or pyelonephritis.- It is more important to timely recognize symptoms that may indicate a potentially serious disease course than to make an exact diagnosis.- Children < 3 months are at greater risk for a serious disease course.- During follow-up it is important to provide parents with proper advice on the expected disease course and who they should contact, and when, in cases of deterioration or concern.- Paracetamol or ibuprofen should only be given when there is a combination of fever and pain. Combating fever is not an end in itself.

[Impaired immunity: risk groups and consequences for general practice]. / Verminderde afweer.

- Due to medication use, comorbidities and/or age, an increasing number of patients have an impaired immunity to infection.- Impaired immunity may lead to an increased risk of (opportunistic) infection, complications from infections, and difficulties in the diagnosis of infections.- Guided by clinical parameters, a general practitioner can classify an impaired immunity as 'clinically irrelevant', 'limitedly relevant' or 'potentially serious'.- Tocilizumab impairs the production of CRP, which makes it unreliable as an infection parameter.- In case of a suspected infection in patients with severe immunosuppression, it will often be necessary to consult a specialist as quickly as possible about further diagnostic procedures and the need for, type and administration route of antimicrobials.- In patients with an impaired immunity, adaptation of the antibiotic policy and prophylactic measures, such as vaccination, may be indicated.- Patients with (functional) asplenia should immediately start antibiotic treatment in case of fever, pending clinical evaluation by a physician.

[Reducing problematic sickness absence: of importance to every general practitioner]. / Terugdringen van stagnerend arbeidsverzuim.

Problematic sickness absence is an issue that concerns not only occupational health physicians, but all physicians. More collaboration between occupational health and treating physicians, plus improved alignment of symptom treatment and reintegration counselling, can help avoid long-term sickness absence of employees. Achieving this goal presupposes mutual knowledge of each other's professions. Medical practice guidelines are a tool par excellence to share knowledge and bring this into practice. Treating physicians should not refrain from posing work-related and return-to-work questions, even if the overall responsibility lies with the occupational health physicians in terms of reintegration efforts. The patient's interest should be the leading principle for all physicians involved. This means not only provision of good care, aimed at patient recovery, but also adequate reintegration in the labour market. Occupational health physicians, general practitioners and consultant specialists should share this common goal.

Estimating the cost-effectiveness of vaccination against herpes zoster in England and Wales.

A live-attenuated vaccine against herpes zoster (HZ) has been approved for use, on the basis of a large-scale clinical trial that suggests that the vaccine is safe and efficacious. This study uses a Markov cohort model to estimate whether routine vaccination of the elderly (60+) would be cost-effective, when compared with other uses of health care resources. Vaccine efficacy parameters are estimated by fitting a model to clinical trial data. Estimates of QALY losses due to acute HZ and post-herpetic neuralgia were derived by fitting models to data on the duration of pain by severity and the QoL detriment associated with different severity categories, as reported in a number of different studies. Other parameters (such as cost and incidence estimates) were based on the literature, or UK data sources. The results suggest that vaccination of 65 year olds is likely to be cost-effective (base-case ICER=pound20,400 per QALY gained). If the vaccine does offer additional protection against either the severity of disease or the likelihood of developing PHN (as suggested by the clinical trial), then vaccination of all elderly age groups is highly likely to be deemed cost-effective. Vaccination at either 65 or 70 years (depending on assumptions of the vaccine action) is most cost-effective. Including a booster dose at a later age is unlikely to be cost-effective.

[Summary of the practice guideline 'Influenza and influenza vaccination' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Influenza en influenzavaccinatie' (eerste herziening) van het Nederlands Huisartsen Genootschap.

The first revision of the guideline 'Influenza and influenza vaccination' from the Dutch College of General Practitioners contains the new indications for influenza vaccination. The most important revisions are: the minimum age has been lowered from 65 to 60 years, the indication for furunculosis patients and their families has been removed, and vaccination is recommended to healthcare professionals who have regular and intensive contact with patients. The purpose of vaccinating healthcare professionals against influenza is to reduce the transmission of the influenza virus to patients at very high risk of complications from influenza and reduce sick leave among healthcare professionals. The use of antiviral agents should only be considered for patients with a very high risk of complications from influenza.

[Influenza vaccination in the elderly: effectiveness not in doubt]. / Griepvaccinatie bij ouderen: geen twijfel aan de effectiviteit.

In a recent review the effectiveness of influenza vaccination in the elderly was brought into question. Selection bias, which would occurr if healthy people were more likely to be vaccinated than their infirm peers, and the use of non-specific outcomes, such as death from all causes, were considered to have contributed to the effectiveness of the vaccine as to morbidity and mortality being overestimated. However, a recent study has shown that even when potential bias and residual confounding were addressed, influenza vaccination was associated with a significant reduction in the risk of influenza-related morbidity and mortality among community-dwelling elderly persons. Direct estimates of influenza-related morbidity were hampered by delayed and insufficiently sensitive diagnostics. Excess studies, however, comparing morbidity and mortality during periods with and without influenza predominance, present reliable indirect estimates in favour of vaccination. While the vaccination rate of high-risk subjects in The Netherlands is traditionally high, the age limit for influenza vaccination was lowered from 65 to 60 in 2008, taking into account influenza-related morbidity and mortality in healthy people aged 60 to 65 years and the undisputed effectiveness of vaccination against influenza.

[Summary of the practice guideline 'Otitis externa' (first revision) from the Dutch College of General Practitioners]. / Samenvatting van de standaard 'Otitis externa' (eerste herziening) van het Nederlands Huisartsen Genootschap.

* The practice guideline 'Otitis externa', first developed by the Dutch College of General Practitioners in 1995, has been revised and updated. * It is no longer recommended to perform a KOH test on material collected from the auditory canal in patients with otitis externa. * Eardrops that contain both acid and corticosteroids are preferred over eardrops that contain acid only. * Suitable options include acidic eardrops with hydrocortisone 1% FNA and acidic eardrops with triamcinolone acetonide 0.1% FNA at a dose of 3 drops thrice daily. * The guideline contains a detailed discussion of the ototoxicity of eardrops in patients with tympanic membrane perforation. * Management of these patients, however, remains unchanged: the preferred approach is aluminium acetotartrate eardrops 1.2% FNA.

[Pharmacological treatment of Bell's palsy: favourable effects of prednisolone-based therapy now demonstrated]. / Medicamenteuze behandeling van bell-paralyse: gunstig effect van prednisolon nu aangetoond.

Bell's palsy accounts for two-thirds ofall acute facial palsies. Presumed reactivation of the herpes simplex virus and concurrent swelling of the facial nerve prompted the use of antivirals in combination with corticosteroids, although evidence supporting the effectiveness of this approach was weak. A recently published randomized placebo-controlled clinical trial assessed the effectiveness of adding valacyclovir to prednisolone; another larger primary-care-based study compared treatment with prednisolone, acyclovir or both with placebo. In patients with severe or complete facial palsy, the addition of valacyclovir improved the chance of complete recovery, but as this study was single-blinded, results should be interpreted with caution. Early treatment with prednisolone (25 mg twice daily for to days) significantly improved the chance of complete recovery at 3 and 9 months. Acyclovir, given alone or in addition to prednisolone, did not show any benefit.

[The use of antiviral agents during an (impending) influenza pandemic]. / Het gebruik van antivirale middelen tijdens een (dreigende) influenzapandemie.

The preventive and therapeutic principles during an (impending) influenza pandemic differ fundamentally from those prevailing during the annual episodes ofinfluenza. Pending the availability of an effective pandemic vaccine, neuraminidase inhibitors are the only effective agents for the prevention and treatment of infections caused by a pandemic influenza virus. The development of an influenza pandemic has 6 phases: phases 3-5 reflect an increasing threat; phase 6 represents a manifest pandemic. During phases 3-5, a maximum effort is made to prevent or delay a pandemic. Neuraminidase inhibitors should be given not only to patients but also to their close contacts (post-exposure prophylaxis). During phase 6, post-exposure prophylaxis is no longer indicated and neuraminidase inhibitors are prescribed for all patients with symptoms ofpandemic influenza. Prophylaxis without preceding close contact with an influenza patient (primary prophylaxis) is recommended only in exceptional cases. Physicians should not prescribe antiviral drugs on demand to concerned citizens for stockpiling.

[Treatment of patients with herpes zoster by epidural injection of steroids and local anaesthetics: less pain after 1 month, but no effect on long-term postherpetic neuralgia--a randomised trial]. / Behandeling van patiënten met herpes zoster door epidurale injectie van steroïden en lokale anesthetica: minder pijn na 1 maand, maar geen effect op langdurige postherpetische pijn; gerandomiseerd onderzoek.

OBJECTIVE: To assess the effectiveness of a single epidural injection of steroids and local anaesthetics, as a supplement to the standard treatment, for the prevention ofpostherpetic neuralgia in older patients with herpes zoster. DESIGN: Open randomised trial. METHOD: In the period September 2001-February 2004, 598 patients, aged > 50 years, with acute herpes zoster (rash for < 7 days) below dermatome C6, were randomly assigned to receive either standard therapy (oral antiviral agents and analgesics) alone or standard therapy plus an additional single epidural injection of 80 mg methylprednisolone and 10 mg bupivacaine. The primary endpoint was the proportion of patients with zoster-associated pain one month after inclusion. The presence and severity of zoster-associated pain at other time points were secondary endpoints. RESULTS: At one month, pain was reported by 137 (48%) patients in the injection group versus 164 (58%) in the control group (relative risk; RR: 0.83; 95% CI: 0.71-0.97; p = 0.02). After three months, these values were 58 (21%) and 63 (24%), respectively (RR: 0.89; 95% CI: 0.65-1-21; p = 0.47), and at 6 months: 39 (15%) and 44 (17%) (RR: 0.85; 95% CI: 0.57-1-13; p = 0.43). No subgroups were detectable in which the relative risk for pain at one month after inclusion substantially differed from the overall estimate. At one month, the median severity of pain in the injection group was 2 (on a 100-points scale) versus 6 in the control group (p = 0.02). At later follow-up, there was no longer any statistically significant difference in the severity of pain between the two groups. No patient had major adverse events related to the epidural injection. CONCLUSION: A single epidural injection of steroids and local anaesthetics in the acute phase of herpes zoster resulted in a modest decrease in zoster-associated pain in the first month. This treatment did not, however, prevent long-term postherpetic neuralgia.