[How to ensure the accessibility of primary care].

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.

[A toddler with a lump on his 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.

[Guidelines: leash or walking stick?].

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.

[A man with a crease in his earlobe].

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?].

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.

[A toddler with loose nails].

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.

[A man with discoloration of his lower legs].

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.

[Health professionals for the climate].

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.

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

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].

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.

[Respiratory complaints in the time of COVID-19].

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.

[General Practice: continuously developing].

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.

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.

[Paraneoplastic syndromes].

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.

[Continuity of care in primary care; a bygone ideal or new perspective?].

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.

[A woman with a white skin lesion of her toe].

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.

[Hope-Simpson and shingles].

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.

[A girl with a tumour on the thorax].

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.

[Research in the GP's practice is good for the health of all].

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.

[Influenza vaccination of patients with solid tumours during chemotherapy: efficacy and safety].

- 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.

[The Dutch College of General Practitioners practice guideline 'Suspicious skin lesions'].

- 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.

[Syncope; suspect pulmonary embolism, especially in the elderly].

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.