[Should we follow the HEART score in patients presenting with chest pain?].

This article comments on the use of the HEART score as a guide for further management in patients presenting with chest pain. Although use of the HEART score has been demonstrated to be safe, further research should focus on cost-effectiveness and outcomes.

[Optimal duration of antibiotic therapy: there is no 'one size fits all'].

The increasing use of antibiotics is the main driving force behind the rise of antibiotic resistance. Furthermore, there is a large variation in antibiotic use amongst prescribers. We describe the current duration of antibiotic therapy for common infections in the Netherlands and the new studies we can expect in this field in the years to come.

[Sepsis: new insights, new definition].

- Incidence of sepsis is increasing, partly due to an ageing population, increased use of immunosuppressants, and antibiotic resistance. Sepsis survival has improved substantially, in part because of continuously improving intensive care and implementation of evidence-based guidelines.- Sepsis is defined as 'life-threatening organ dysfunction due to a dysregulated host response to infection'.

[Non-ST segment elevation acute coronary syndrome; recent developments in diagnostics and treatment].

- This paper covers recent developments in diagnostics and treatment of patients presenting with non-ST segment elevation acute coronary syndrome.- For the diagnostic phase we focus on the role of the clinical presentation, the ECG and biomarkers.- In the acute phase, treatment mainly consists of pharmacological therapy and revascularisation; long-term treatment mainly involves pharmacological therapy, cardiac rehabilitation, and lifestyle changes.

[Video recording and data collection in the operating room: the way to a 'just culture' in the OR].

The Academic Medical Center, Amsterdam, has started a trial to evaluate the usefulness to team debriefings of performance reports generated by a medical data recorder (MDR) in the operating room (OR). Outcome performance reports in structured debriefings in a secure, non-punitive environment are likely to heighten the level of situational awareness of OR teams. This may prevent future error.

[A baby with progressive skin lesions on the scalp].

An eight-month-old girl was referred to the dermatologist with a progressive desquamative and purulent eruption on the scalp. Laboratory tests confirmed the diagnosis kerion celsi and the girl was successfully treated with an antimycoticum. Kerion celsi is a deep inflammatory fungal infection on the scalp.

[Socioeconomic differences and smoking: clear connections with implications for tobacco policy].

- Smoking is more common among people with a lower educational level, professional qualifications and income. This is a major contributor to inequalities in health and mortality.- Inequalities in smoking appear to have their origin in early adolescence.

[Shared decision-making for good care; we cannot make it any easier].

Despite the increase in treatment options and the rise of patient empowerment, cancer can still make people vulnerable and insecure. In such cases, an appeal on autonomy can be a burden. We argue that the main goal of shared decision-making is, however, not to have patients make autonomous choices, but to be able to provide high quality patient-centred care.

Which patients with epilepsy are at risk for psychogenic nonepileptic seizures (PNES)? A multicenter case-control study.

Objective: We sought to examine the clinical and electrographic differences between patients with combined epileptic (ES) and psychogenic nonepileptic seizures (PNES) and age- and gender-matched patients with ES-only and PNES-only.

Methods: Data from 138 patients (105 women [77%]), including 46 with PNES/ES (39±12years), 46 with PNES-only (39±11years), and 46 with ES-only (39±11years), were compared using logistic regression analysis after adjusting for clustering effect.

Results: In the cohort with PNES/ES, ES antedated PNES in 28 patients (70%) and occurred simultaneously in 11 (27.

[Return to work after acquired brain injury. Invisible consequences may interfere with vocational participation].

Acquired brain injury may lead to cognitive, emotional and behavioural problems which often go unrecognised. Combined with the patient's lack of self-awareness this may impede social participation, in particular in returning to work. To stress the importance of diagnosing and treating such consequences, we present two patients.

[STARD 2015 for the evaluation of diagnostic tests].

Each year, many new diagnostic tests appear on the market that claim to be better, faster, cheaper, less invasive and more reliable than those already available. Diagnostic accuracy studies can assist in the objective assessment of such claims but, unfortunately, important information is often missing from the corresponding study reports. Authors are responsible for the completeness of their study reports, but they may not always be aware of the type of information that needs to be provided for an adequate appraisal of the study.

Long term follow up of the EORTC 18952 trial of adjuvant therapy in resected stage IIB-III cutaneous melanoma patients comparing intermediate doses of interferon-alpha-2b (IFN) with observation: Ulceration of primary is key determinant for IFN-sensitivity.

Background: We report on the long term outcome of the EORTC 18952 adjuvant interferon (IFN) trial in 1388 resected stage IIB/III melanoma patients and identify key predictive factors for outcome.

Methods: We analysed outcome of the EORTC 18952 trial (4 weeks of IFN, 10 MU, 5 times/week for 4 weeks followed by 12 months IFN at 10 MU, 3 times/week versus followed by 24 months IFN at 5 MU 3 times/week versus observation) regarding relapse-free survival (RFS), distant metastasis-free interval/survival (DMFI/DMFS), and overall survival (OS), and analysed potential predictive factors of outcome.

Findings: At a median follow-up of 11 years, the comparison of IFN 13 months versus IFN 25 months versus observation yielded estimated hazard ratios (HR) for RFS of 0.

[The 'interesting case' and patient privacy: handling patient data in medical education].

The use of patient histories has become an essential part of medical education. Patient histories are important for the relevance, effectiveness and appeal of medical education. The sharing of patient-related information in education and further training is expected to increase in the coming years.

[Sidelined under the Participation Act].

In January this year, a new law was introduced in the Netherlands aimed at improving opportunities for people who cannot find work, among them young people with impairments who still have - limited - ability to work. This law, the Participation Act, is executed by municipalities. All young people with the ability to work despite their impairments are entitled to support from the municipalities in finding a job.

[Per-oral endoscopic myotomy in achalasia].

The treatment of patients with achalasia is complex due to a considerably high recurrence rate and risk of treatment-related complications. The per-oral endoscopic myotomy (POEM) is a new endoscopic technique that combines the benefits of a minimally invasive endoscopic procedure with the efficacy of a surgical myotomy. Implementation of the POEM technique may lead to fewer complications, a lower recurrence rate and reduced costs.

[Optical diagnosis of colorectal polyps: electronic chromoendoscopy].

Polyps of 1-5 mm are often detected during colonoscopy; these are only sporadically malignant. The removal, collection and pathological analysis of these polyps accounts for a significant part of the costs of a colonoscopy. The histologist's assessment is the gold standard and is endorsed in all guidelines for determination of the recommended interval for surveillance colonoscopy.

[Patients are not prepared to choose: another example of a failing market?].

The Netherlands has a demand-driven health care system based on market mechanisms. However, the system is a hybrid between two potential situations: one in which healthcare insurance companies have a leading role, with consumers and patients choosing for the company that most suits them, and one in which patients have a leading role and select their favourite caregiver, whereby the insurance company has to follow. Current research concludes that the vast majority of patients are not able or even willing to choose, but instead place their trust in referring physicians and local hospitals.

[Dieffenbachia poisoning in an infant].

Background: Plant poisoning is becoming an increasingly common reason to consult a doctor.

Case Description: A 7-month-old infant was sent to the emergency room by her general practitioner with a suspected apparent life-threatening event (ALTE). Her parents reported the sudden development of fluctuating restlessness and listlessness, superficial breathing, vomiting, drowsiness and episodes of loss of consciousness.

[May physicians amputate a healthy limb?].

A recent article in the Dutch Journal of Medicine describes two cases of patients with body integrity identity disorder (BIID), a disorder in which patients might resort to self-amputation in order to create the body they wish for. The authors wonder if medical professionals should provide elective amputations in BIID patients in order to prevent them from harm and death. The amputation of a healthy limb in BIID in a medical context is currently under discussion.

[Desire for amputation in body integrity identity disorder].

Background: Body integrity identity disorder (BIID) is a rare neuropsychiatric disorder in which patients experience a mismatch between the real and experienced body from childhood. BIID results in a strong desire to amputate or paralyse one or more limbs.

Case Description: We describe two BIID patients.

[Give more attention to work participation].

As a result of an ageing work force and the continuing economic crisis, the coming decades will demand a long-term active role on the part of the Dutch in participating in paid and voluntary work as well as volunteer aid. This will provide a significant stimulus for so-called work-related healthcare: care that incorporates prevention and treatment of work-related symptoms and diseases, thereby enabling timely and sustainable work participation. Both patients and an increasing number of doctors are willing to contribute to this system of integrated care.

[Inflammation and structural organ damage: chicken or egg?].

It is not inflammation but functional and/or anatomical loss of integrity of target organs that is the major determinant of morbidity in many immune-mediated inflammatory diseases (IMIDs). This structural and often irreversible tissue damage is generally considered to be a direct or indirect consequence of inflammation (through failed repair mechanisms). However, recent clinical observations in rheumatic diseases, demonstrate clearly that the postulated causal relationship between inflammation and structural damage does certainly not hold true in all IMIDs.

[Off-label use of biologics for rare immunological disorders].

Patients with severe therapy-refractory immune-mediated inflammatory diseases (IMIDs) are increasingly treated with biologics. Since official practice guidelines for these rare diseases are lacking, these drugs are often prescribed off-label. However, treating physicians encounter difficulties and risks when prescribing drugs off-label.

[Biomedical research in the Netherlands: high quality due to cooperation between University Medical Centers and non-academic large teaching hospitals].

Objective: Most of the biomedical research is performed in University Medical Centers (UMC's). Increasingly, however, biomedical research is also done in non-academic large teaching hospitals, united in the Organization for Topclinical Hospitals (STZ) in the Netherlands. The objective of this study was to compare citation scores of biomedical publications from UMC's and STZ hospitals.