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The decision to attempt or refrain from resuscitation is preferably based on prognostic factors for outcome and subsequently communicated with patients. Both patients and physicians consider good communication important, however little is known about patient involvement in and understanding of cardiopulmonary resuscitation (CPR) directives.To determine the prevalence of Do Not Resuscitate (DNR)-orders, to describe recollection of CPR-directive conversations and factors associated with patient recollection and understanding.This was a two-week nationwide multicentre cross-sectional observational study using a study-specific survey. The study population consisted of patients admitted to non-monitored wards in 13 hospitals. Data were collected from the electronic medical record (EMR) concerning CPR-directive, comorbidity and at-home medication. Patients reported their perception and expectations about CPR-counselling through a questionnaire.A total of 1136 patients completed the questionnaire. Patients' CPR-directives were documented in the EMR as follows: 63.7% full code, 27.5% DNR and in 8.8% no directive was documented. DNR was most often documented for patients80 years (66.4%) and in patients using10 medications (45.3%). Overall, 55.8% of patients recalled having had a conversation about their CPR-directive and 48.1% patients reported the same CPR-directive as the EMR. Most patients had a good experience with the CPR-directive conversation in general (66.1%), as well as its timing (84%) and location (94%) specifically.The average DNR-prevalence is 27.5%. Correct understanding of their CPR-directive is lowest in patients aged ≥80 years and multimorbid patients. CPR-directive counselling should focus more on patient involvement and their correct understanding.

The SARS-CoV-2 pandemic presents a challenge for healthcare worldwide. In this context, rapid, correct diagnosis and early isolation of infected persons is of great importance. Pneumonia as an expression of COVID-19 is responsible for the most part of morbidity and mortality. Lung ultrasound can provide valuable information about the diagnosis of a COVID-19 pneumonia in daily practice. A normal ultrasound excludes COVID-19 pneumonia. Conversely, finding abnormalities matching with a COVID-19 pneumonia can be useful for isolation policy. Follow up lung ultrasound visualizes the development of the pneumonia and a possible alternative diagnosis can thereby be determined in the event of a deviating clinical course.

In early July 2018, it became known that a number of generic preparations containing the active substance valsartan could be carcinogenic. This news took caregivers and patients by surprise. Initially, a recall was initiated at the pharmacy level. A few weeks later, the recall was expanded to the patient level. The source of the contamination was a factory of the Chinese company Zhejiang Huahai Pharmaceutical, where the active ingredient valsartan is produced. It was found that batches from that factory had contained too high a concentration of N-nitrosodimethylamine since as early as 2012. The EMA estimates that if 5000 patients took the maximum dose of 320 mg of tainted valsartan tablets every day in the period from July 2012 to July 2018, there will be one extra case of cancer. The valsartan contamination raises the question of whether or not the Dutch authorities involved responded adequately. It has become clear from the contamination of valsartan that good and timely communication is important.

To make an advanced decision about resuscitation it is important to know what its outcomes are. In-hospital resuscitation cannot always be compared with out-of-hospital resuscitation; furthermore, outcomes of in-hospital resuscitation vary between hospital wards and patient populations. Age plays a role in the outcome of a resuscitation procedure. However, older patients who leave hospital alive have a reasonable prognosis as far as survival and neurological function are concerned. Data on quality of life and self-reliance after resuscitation are scarce or non-existent. Comorbidities and ADL status also contribute to the outcome of resuscitation, independent of age. One of the goals of Emergency Intervention Systems is to limit the number of in-hospital resuscitations. Although these systems are probably successful at this point, this cannot be demonstrated in all studies. Much of our knowledge about in-hospital resuscitation is based solely on American research.

Many courses for caregivers are aimed at teaching them to commence medical treatment as soon as possible in an acute situation. However, this treatment may not always be in line with the patient's wishes. In this article we describe three patients who received treatment despite their wish not to be treated. More attention should be given to talking to patients about their advanced directives; we suggest how these discussions can be initiated in the daily care of our patients.

Ebola is an exceptionally risky infection and safety measures are therefore unprecedentedly strict. However, despite stringent measures infection of health care providers by the Ebola virus cannot be excluded. Strict barrier care is physically and mentally demanding for the care provider. Before undertaking care for Ebola patients, 'fit for the job'screening is necessary. We should only expose our care givers if we know that they are physically and mentally up to the task.

A 70-year old woman came to the emergency department with dyspnea and syncope. Hemoglobin level was 2,9 mmol/l (reference: 7,6-9,9 mmol/l). Gastroscopy was negative, CT-abdomen showed a hypervascular jejunal tumour. Laparoscopic jejunal segment resection was performed with resection of the tumour, after which the hemoglobin level improved. Pathological examination showed a gastrointestinal stromal tumour.

Skin conditions such as acne, urticaria, psoriasis, and particularly eczema (dermatitis) may have many causes. However, a work-related aetiology is often forgotten. Hand eczema is the most common occupational dermatosis. Exposure to skin irritants is the main cause with wet work playing a major role. The cause cannot be inferred from the clinical picture and it is almost impossible to distinguish between irritant and allergic contact dermatitis. Besides observation and history-taking, epicutaneous contact allergological (patch) testing is necessary for this. In occupational dermatoses, patch testing using the European Standard Series alone is often inadequate for diagnosing. Everyone with hand eczema in a risk profession is eligible for patch testing. The prognosis of hand eczema is poor: in 60% of patients the eczema becomes chronic. Genetic predisposition, such as atopic dermatitis, is seriously underestimated. This is the main risk factor for irritant contact dermatitis and, indirectly, for allergic contact dermatitis. This predisposition should give direction to career choices in young people.

The practice guideline 'Diagnosis and treatment of the subacromial pain syndrome' provides a thorough overview of the treatment possibilities that a doctor has when a patient with a painful shoulder presents. This guideline recognizes the importance of occupational exposure and functioning in the development, maintenance and treatment of health problems too. As is the case with so many multidisciplinary guidelines, it can be seen as an appeal to doctors to inquire about work and an appeal to occupational physicians to become active in the functional recovery of patients with a subacromial pain syndrome.

Skin conditions such as acne, urticaria, psoriasis, and particularly eczema (dermatitis) may have many causes. However, a work-related aetiology is often forgotten. Hand eczema is the most common occupational dermatosis. Exposure to skin irritants is the main cause with wet work playing a major role. The cause cannot be inferred from the clinical picture and it is almost impossible to distinguish between irritant and allergic contact dermatitis. Besides observation and history-taking, epicutaneous contact allergological (patch) testing is necessary for this. In occupational dermatoses, patch testing using the European Standard Series alone is often inadequate for diagnosing. Everyone with hand eczema in a risk profession is eligible for patch testing. The prognosis of hand eczema is poor: in 60% of patients the eczema becomes chronic. Genetic predisposition, such as atopic dermatitis, is seriously underestimated. This is the main risk factor for irritant contact dermatitis and, indirectly, for allergic contact dermatitis. This predisposition should give direction to career choices in young people

A negative water and sodium balance develops during the first hours to days after reaching a high altitude. The fluid and sodium balance does not alter in cases of altitude sickness, or may even become positive. This is attributed to a decreased diuresis and natriuresis in those who develop altitude sickness, while their fluid intake is no different to that of people who do not suffer from altitude sickness. This is a consequence of stimulation of the renin-angiotensin-aldosterone system (RAAS) and an increased secretion of antidiuretic hormone (ADH) combined with a higher than normal sympathetic activity. Therefore there is no argument for an increased fluid intake for the prevention of altitude illness. In theory this might even be harmful.

The Dutch quality control plan for climatisation of the operating room (OR), which was published in 2005, describes the management and maintenance of the air conditioning system. This management plan proposes a standard for air quality in class 1 ORs. This has been adopted by the Dutch Orthopaedic Society, but not by other surgical societies. The British study which underlies the proposed norm for air quality in class 1 ORs, a study on the infection preventive effect of ultraclean air, dates from 1982 and is inadequately controlled for prophylactic use of antibiotics. Antibiotic prophylaxis in itself already reduces the number of surgical site infections.-More recent studies fail to show an infection preventive effect of ultraclean air in the OR. The Dutch Working Party for Infection Prevention (WIP) ought to take the initiative, together with the medical Scientific Societies and the Society of Infection Prevention and Control in the health care setting (VHIG), to establish enforceable norms for microbiological air quality and to set criteria as to which types of operations are allowed to be performed in which class of OR.