[The practice guideline 'Acne' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Acne' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The strength of the second revision of the practice guideline 'Acne' from the Dutch College of General Practitioners (NHG) lies mainly in bringing its therapy up to date. The guideline also points out psychosocial problems that can arise with acne, but discounts stress and diet as the possible cause. Schedules showing a medical plan of action and information on medications complete this clear and practical guideline.

[The practice guideline 'The red eye' (first revision) of the Dutch College of General Practitioners; a response from the perspective of the general practitioner]. / De standaard 'Het rode oog' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The revised version of the practice guideline 'The red eye' of the Dutch College ofGeneral Practitioners gives the general practitioner useful information on new insights into diagnosis and therapy for a red eye. An important therapeutic advice is prescribing chloramphenicol ointment instead of fusidic acid ointment in the case of bacterial conjunctivitis after one-week treatment without positive results, since 80% of the conjunctivitis causing bacteria does not react to fusidic acid. A slit lamp is helpful in the diagnosis of a case of red eye, but is not present in every general practitioner's office. Joint efforts of a group of general practitioners in obtaining such a slit lamp may reinforce the diagnosis in general practice.

[The practice guideline 'Otitis media with effusion' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Otitis media met effusie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The usefulness of tympanotomy tubes in children with otitis media with effusion who also have speech and language retardation is doubtful in view of the natural development. The second revision of the practice guideline 'Otitis media with effusion' from the Dutch College of General Practitioners is still not in complete agreement with this. The indications for performing an adenoidectomy are now more limited. Pneumatic otoscopy and tympanometry are diagnostic aids that may deserve a permanent place in the general practitioner's medical practice in the future.

[The practice guideline 'Depressive disorder' (first revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Depressieve stoornis' (eerste herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The revised Dutch College of General Practitioners' practice guideline 'Depressive disorder' no longer distinguishes between mild and severe depression because the management in both cases is identical. This guideline focuses much attention on diagnosis, support and information, all of this in dialogue with the patient. The choice between the antidepressants, a tricyclic antidepressant or a specific serotonin reuptake inhibitor is based on the contraindications of these drugs.

[The treatment of tobacco dependence in clinical practice is promising but difficult to implement]. / Aanpak van tabaksverslaving in de klinische praktijk: veelbelovend, maar lastig te implementeren.

According to the Dutch interdisciplinary guideline 'Treatment of tobacco dependence', medical practitioners in The Netherlands should play a more active role in discouraging the use of tobacco. They should try to motivate their patients to stop smoking and offer their support. The various treatments aimed at helping people to stop smoking require large amounts of personnel, time and money. Clear guidelines and follow-up programmes are still missing. Much will depend on a strict anti-smoking policy from the government and the availability of financial support in order to effectively reduce the amount of smoking-related illness. At present, an optimistic view in this respect does not seem realistic.

[The practice guideline 'Stable angina pectoris' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Stabiele angina pectoris' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The Dutch College of General Practitioners' (Dutch acronym: NHG) practice guideline 'Stable angina pectoris' (second revision) provides clear guidelines for the diagnosis and treatment of patients who experience chest pains as a result of angina pectoris, especially if coronary artery disease is the underlying cause of the complaints. The practice guideline clearly indicates for which complaints the general practitioner should suspect angina pectoris and which information from the anamnesis, family history and risk factors can contribute to distinguishing between stable and unstable angina pectoris. However, the physical examination should not be omitted because this can provide important indications for coronary or pulmonary dysfunction. According to the practice guideline, the treatment policy is determined by the estimated risk of significant coronary artery disease. However, additional tests can be useful even in the case of a small risk, as these can reassure patients. The indications and contraindications for medicinal substances are clearly presented.

[The practice guideline 'Hormonal contraception' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Hormonale anticonceptie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The second revision of the Dutch College of General Practitioners' practice guideline on hormonal contraception discusses the various methods of hormonal birth control and can help the general practitioner to inform the patient when choosing the most desirable method. A thorough anamnesis is necessary with regard to the increased risks for breast cancer, uterine cancer and cardiovascular diseases in women using hormonal contraception, especially in those who smoke. The guideline also discusses non-hormonal methods briefly.

[The practice guideline 'Dementia' (second revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Dementie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

With growing numbers of older adults in the population, the number suffering from dementia will increase. The general practitioner has to try to determine the difference between Alzheimer's disease and vascular dementia on the one hand, and fronto-temporal dementia and dementia with Lewy bodies on the other hand, while also considering the therapeutic options now and in the future. Support for patients and their family is the responsibility of the general practitioner, who must also consider the patient's driving proficiency and the wishes for euthanasia of the demented older adult. The revised version of the practice guideline 'Dementia' of the Dutch College of General Practitioners is well suited to the work of the general practitioner. It is advisable to read the practice guideline several times and in such cases not only to use the summary card but the entire practice guideline.

[The practice guideline 'Hypertension' (third revision) from the Dutch College of General Practitioners; a response from the perspective of general practice]. / De standaard 'Hypertensie' (derde herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

In the revised practice guideline on hypertension from the Dutch College of General Practitioners, some changes have been made in the areas of diagnosis and therapy in comparison to the previous edition. Finding people with hypertension is a major goal for the prevention of cardiovascular disease. A systolic blood pressure > 140 mmHg (> 160 mmHg in patients > 60 years) necessitates non-pharmaceutical advice and antihypertensive therapy with diuretics, beta-blockers, angiotensin-converting-enzyme (ACE) inhibitors or calcium antagonists, either as monotherapy or in combination. In view of the ever-increasing importance of ACE inhibitors in antihypertensive therapy, we expect that the next revision of the practice guideline will soon be necessary.

[Marked similarity between the Dutch Institute for Health Care Improvement guideline 'Aspecific low back pain complaints' and the Dutch College of General Practitioners guideline 'Low back pain']. / CBO-richtlijn 'Aspecifieke lage rugklachten' sterk vergelijkbaar met de standaard 'Lage-rugpijn' van het Nederlands Huisartsen Genootschap.

The Dutch Institute for Healthcare Improvement's (CBO) guideline on the diagnosis and treatment of aspecific, acute and chronic, low back complaints corresponds in general to the Dutch College of General Practitioners' guideline with regard to the following topics: time-contingent treatment, restricted use of X-ray examination, and the options for non-medical treatment. A noteworthy exception in the CBO-guideline is the suggestion of manipulation of the spine as a possible treatment although there is no mention of proof of effectiveness.

[Fitness to drive in people with diabetes mellitus; a recommendation from the Health Council of the Netherlands]. / Rijgeschiktheid van mensen met diabetes mellitus; een advies van de Gezondheidsraad.

The Health Council of the Netherlands published a medical fitness-to-drive recommendation in December 2002 for people suffering from diabetes mellitus. This applies to all types of driver's licenses. General restrictions for people suffering from diabetes mellitus cannot be applied. For diabetes patients receiving treatment with drugs that can cause hypoglycemia, a limited period of validity of their driver's license is enforced. The report provides guidelines for required ophthalmologic, cardiovascular and neurological examinations by a specialist. People suffering from diabetes are personally responsible for reporting any changes in their medical condition.

[The Dutch College of General Practitioners' practice guideline, "Vaginal bleeding"; reaction from a general practice perspective]. / De standaard 'Vaginaal bloedverlies' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

The most important changes in the first revised version of the Dutch College of General Practitioners' practice guideline 'Vaginal bleeding' are the passages about the progesterone-containing 'intra-uterine device' (IUD), the combination of progesterone and oestrogen by prescribing, for example, a sub-50-pill for the treatment of menorrhagia, and advising the patient to undergo a transvaginal ultrasound to determine the amount of build-up in the endometrium. Vacuum aspiration of the endometrium to establish the cause of menorrhagia is not mentioned. This first revised version can contribute to the quality of care in general practice.

[The Dutch College of General Practitioners' 'Irritable bowel syndrome' standard; reaction from the field of general practice]. / De standaard 'Prikkelbaredarmsyndroom' van het Nederlands Huisartsen Genootschap; reactie vanuit de huisartsgeneeskunde.

In the recently published Dutch College of General Practitioners' standard entitled 'Irritable bowel syndrome', questions for use in establishing this difficult syndrome are provided. Being reserved during examination and using moderation in choosing a treatment regime are the most important recommendations. The emphasis should be on explaining that this is usually a harmless syndrome. This guideline is very helpful to the general practitioner.

[An eye on the vocal cords: family practitioner and hoarseness]. / Met het oog op de stembanden; huisarts en heesheid.

In four patients with hoarseness, men aged 53 and 67 years, and women aged 8 and 37 years, indirect laryngoscopy revealed, respectively, a squamous cell carcinoma of the vocal cord, recurrent nerve paralysis due to pulmonary carcinoma, irritative noduli due to forced use of the voice, and psychic stress as the cause. In a patient with existing hoarseness over a period of 3 to 6 weeks, the vocal cords will have to be examined with indirect laryngoscopy. Where the general practitioner is not equipped to handle this procedure, he can make a referral to an ear, nose and throat specialist. It would, however, be to the benefit of the patient and the general practitioner if the latter were to master the technique of indirect laryngoscopy. This would enable the patient to be treated without further delay, and it might also make selective referral possible.

[Family doctor: acrobat or drugstore clerk?]. / Huisarts: acrobaat of lokettist?

In four cases there existed a discrepancy between the patient's request and the views of the GP who went by the guidelines of the Dutch College of General Practitioners. The requests concerned were those of a woman aged 56 who wanted a serum cholesterol determination and a youth aged 17 with a sprained ankle who asked for an X-ray--they were not satisfied until their wishes had been fulfilled--and those of a man aged 43 with recurrent low back pain who wanted to be referred to physical therapy and a woman aged 39 with a common cold who wanted a prescription for an antibiotic--they were only satisfied after a favourable development. The general practitioner has to choose whether to fulfill the patient's wishes or try to explain that the advice--based on medical evidence--is preferable. Good patient information is necessary for a better understanding of each other's points of view and, moreover, gives the doctor more satisfaction in his or her work.

Electrocardiographic abnormalities in a murine model injected with IgG from mothers of children with congenital heart block.

BACKGROUND: It is a widely held view that congenital heart block (CHB) is caused by the transplacental transfer of maternal autoantibodies (anti-SSA/Ro and/or anti-SSB/La) into the fetal circulation. To test this hypothesis and to reproduce human CHB, an experimental mouse model (BALB/c) was developed by passive transfer of human autoantibodies into pregnant mice. METHODS AND RESULTS: Timed pregnant mice (n=54) were injected with a single intravenous bolus of purified IgG containing human anti-SSA/Ro and anti-SSB/La antibodies from mothers of children with CHB. To parallel the "window period" of susceptibility to CHB in humans, 3 groups of mice were used: 8, 11, and 16 days of gestation. Within each group, we tested 10, 25, 50, and 100 microg of IgG. At delivery, ECGs were recorded and analyzed for conduction abnormalities. Bradycardia and PR interval were significantly increased in 8-, 11-, and 16-day gestational groups when compared with controls (P<0.05). QRS duration was not significantly different between all groups. Antibody levels measured by ELISA in both mothers and their offspring confirmed the transplacental transfer of the human antibodies to the pups. CONCLUSIONS: The passive transfer model demonstrated bradycardia, first-degree but not complete atrioventricular block in pups. The greater percentage and degree of bradycardia and PR prolongation in the 11-day mouse group correlates with the "window period" of susceptibility observed in humans. The high incidence of bradycardia suggests possible sinoatrial node involvement. All together, these data provide relevant insights into the pathogenesis of CHB.

Ten-year neonatal hepatitis B vaccination program, The Netherlands, 1982-1992: protective efficacy and long-term immunogenicity.

From 1982 to 1989, 705 infants born to HBsAg-positive mothers entered the Dutch neonatal hepatitis B vaccination program and received passive-active hepatitis B immunization in three randomized controlled trials testing variations in time of starting active vaccination, dose and type of vaccine, and number of hepatitis B immunoglobulin (HBIg) injections. A meta-analysis of individual patient data of the three randomized trials was performed to determine which independent host and vaccination related factors influence protective efficacy and long-term immunogenicity, and to assess whether hepatitis B vaccination concomitant with standard DKTP vaccination provides optimal protection. Statistical methodology included multivariate logistic regression analysis. Eight infants (1.1%), all born to HBeAg-positive mothers, became HBsAg carriers within the first year of life. The protective efficacy rate (PER) of passive-active immunization at 12 months follow-up was 92% for the total group of children from 114 HBeAg-positive mothers with no significant differences between children starting active immunization at birth or at 3 months of age, between infants starting at 3 months of age receiving one or two doses of HBIg or between those receiving plasma derived or recombinant vaccine. The only factor that affected the PER significantly was the level of maternal HBV DNA; PER was 100% if maternal HBV DNA was < 150 pg ml-1 and 68% for HBV DNA levels > 150 pg ml-1. After 5 years of follow-up, the group that started active immunization at birth had significantly more infants with loss of seroprotection (anti-HBs levels < 10 IU l-1, 15%) than the corresponding group starting at 3 months of age (anti-HBs < 10 IU l-2, 2%). One of 35 children with loss of seroprotection at 2 years became a HBsAg carrier in the fifth year of follow-up. This meta-analysis shows that the protective efficacy of passive-active hepatitis B vaccination is mainly influenced by material HBV DNA levels, and independent of the time of starting active vaccination at birth or at 3 months of age; long-term immunity was enhanced by starting active vaccination concomitant with DKTP vaccination. These findings allow incorporation of hepatitis B vaccine into the standard infant immunization programs for countries with a passive-active immunization strategy for the control of hepatitis B. Additional measures are needed to protect neonates of highly viremic women.

[Clinical judgment and decision making in medical practice. A patient with shoulder symptoms]. / Klinisch denken en beslissen in de praktijk. Een patiënt met schouderklachten.

A 49-year-old man consulted his general practitioner because of left shoulder pain. Analgesics brought no relief. He had a numb feeling in the left axilla. Cervical MRI revealed a herniated disc Cv-Cvi, for which the patient was treated surgically. However, the pain persisted. In retrospect, the axillary numbness could not have been caused by a Cv-Cvi problem, because C6 does not innervate the axilla. Repeated MRI, now of the cervicothoracic region, revealed a tumourous process around TI-TII. Thoracotomy was performed and a mesothelioma was found. The patient died shortly afterwards. It is stressed that the diagnostic satisfaction of a positive MRI finding should not lead to disregarding discrepancies between these radiological results and the clinical findings.

Proposal for routine antenatal screening at 14 weeks for hepatitis B surface antigen. Dutch Study Group on Prevention of Neonatal Hepatitis.

OBJECTIVE: To develop a low cost, high compliance screening programme for identification of carriers of hepatitis B surface antigen in the obstetric population of the Netherlands. DESIGN: A seven year open, descriptive study of screening for hepatitis B surface antigen as part of routine prenatal laboratory testing at 14 weeks of gestation. Compliance with programme evaluated by checking delivery records (hospitals) or registration of births in the 30 participating municipalities (rural area). SETTING: Three large city hospitals (two tertiary referral centres) and one rural area with a large number of home deliveries. SUBJECTS: 99,706 pregnant women applying for prenatal care for the first time. MAIN OUTCOME MEASURES: Proportion of pregnant women routinely screened; prevalence of hepatitis B surface antigen in large cities and rural area. RESULTS: Uptake of screening reached 97% in the hospitals after inclusion of 10% screened at delivery; the estimated uptake in the rural area was > 95%. Prevalence of hepatitis B surface antigen was 1.6% in the large cities and 0.3% in the rural area. For screening at delivery the prevalence was 2.5 times higher (4%, P < 0.01) than for screening at week 14 of gestation. CONCLUSION: Incorporation of universal testing for hepatitis B surface antigen into routine prenatal laboratory testing is practical; high compliance is achieved when screening is supplemented with rapid screening at delivery for those who escaped routine prenatal care.