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In a newborn boy, a tumour was seen on the tongue and mandibula. A diagnosis of congenital epulis was made. This usually pedunculated tumour is present at birth and located on the maxillary or mandibular alveolar ridge (more commonly on the maxilla), but rarely on the tongue. It varies greatly in size from just a few millimetres in diameter to several centimetres. Treatment is only necessary when feeding problems occur.

ICDs are used to prevent sudden death caused by ventricular fibrillation. The number of patients with an ICD will keep growing. ICD shocks can severely disturb the dying process in terminally ill patients. Patients must be informed about this at the time of ICD implantation. The attending physician is responsible for proactive communication regarding deactivation when death is expected imminently. The decision to deactivate the ICD depends on personal wishes, and has proved to be difficult even if the patient has been well informed. Deactivation at home must be available so that severely ill patients do not need to travel to a hospital.

October 2010 the Dutch College of General Practitioners issued a revised version of their previous practice guideline of 1995 on food hypersensitivity in infants. If patients suspect either themselves or their child of having a food allergy, this is usually not demonstrated in subsequent investigation. Wrongly prescribed elimination diets may have adverse effects. Examination of serum specific IgE levels has no place in the diagnosis of food allergy in general practice. An open elimination challenge is especially suitable in order to exclude a food allergy. A sure diagnosis of food allergy can only be made by a double-blind placebo-controlled food challenge. There are no proven effective measures that can prevent food allergy.

Adults with obesity have a decreased life expectancy and an increased risk of disease. Preferred treatment is a combination of lifestyle interventions, consisting of changes in diet, physical exercise and psychological support. Normal weight is not an achievable target in most adults, but even a 5-10% weight loss yields significant health gains. Obese children run a significant risk of mental and physical illness and often become obese adults. Indeed, the practice guidelines recommend an active approach by the general practitioner if a child appears obese at a consultation, irrespective of the reason for consultation.

Rectal bleeding is often caused by a harmless disorder such as haemorrhoids or an anal fissure, but may be a symptom of colorectal cancer or inflammatory bowel disease. Risk factors for colorectal cancer are: older age (arbitrary > 50 years), a first-degree relative aged < 70 years with colorectal cancer, change in bowel habit, blood mixed with stools and the absence of anal or perianal symptoms. Colonoscopy should be performed when colorectal cancer is suspected. Treatment of haemorrhoids and anal fissures by the general practitioner especially includes education, treatment of comorbidity and, if necessary, local treatment. Proctoscopy is feasible in general practice.

The practice guideline 'The intrauterine device' from the Dutch College of General Practitioners, first published in 2000, has been revised. Copper and hormonal IUDs have more or less the same level of reliability with respect to preventing pregnancy. During the use of a copper IUD, menstruation tends to be longer with a greater loss of blood; in 70% of women who use a hormonal IUD oligomenorrhea or even amenorrhoea develops. Women with a history of venous thromboembolism can use a hormonal IUD safely. In the first weeks after IUD insertion, there is an increased risk of pelvic inflammatory disease (PID). Therefore prior to insertion, the general practitioner should enquire about the risk of a SOA being present and, if necessary, perform SOA tests. In the Netherlands, IUD insertion can usually be performed at a general practice.

A persistent infection with human papillomavirus (HPV) underlies all cases of cervical cancer. HPV testing is repeated 6 months after initial Pap smears 2 or 3a1. As vaccination against HPV is now included in the National Immunisation Programme of the Netherlands, yearly cervical cancer morbidity and mortality rates are expected to be cut by half. After vaccination against HPV, women still need to participate in the cervical cancer screening programme. Breastfeeding is no longer a contraindication for making Pap smears, provided that breastfeeding is indicated on the cytology application form. Liquid-based cervical cytology is an equivalent to conventional cervical cytology and offers the possibility of testing for HPV. General practitioners are responsible for communicating results from the cervical cancer screening programme to the participating women.

The Dutch College of General Practitioners has revised the practice guideline 'Urolithiasis'. In the acute phase, violent colic pain is treated with diclophenac or morphine. In the post-acute phase, imaging diagnostics are performed. Initially this is ultrasound examination and, ifindicated, an x-ray of the abdomen and at a later stage, a CT scan. The recommendation to consider the use oftamsulosin in the post acute phase is new. This alpha-1 blocking agent can enhance expulsion of the stone and contribute to the relief of pain.

The revised practice guideline 'Bacterial skin infections' developed by the Dutch College of General Practitioners replaces the previous practice guideline from 1998. Most bacterial skin infections can be diagnosed based on the patient history and clinical findings. Skin cultures and serologic analysis (in the case oferythema migrans) are not necessary. Exceptions are made for patients with bacterial skin infection and a high risk of MRSA involvement, or if nasal treatment is indicated for patients with recurring furunculosis. A superficial skin infection can be treated with local therapy. In case of a deep skin infection, oral antibiotics or surgical intervention is recommended. Antibiotic prophylaxis after a tick bite is not recommended. Erysipelas is considered a specific type of cellulitis and is treated as such.

The 1999 practice guideline 'Acne vulgaris' from the Dutch College of General Practitioners has been revised. Benzoyl peroxide and local retinoids are first choice in local treatment of acne. When treatment with oral antibiotics is indicated, doxycycline is first choice. Use of minocycline is not recommended in general practice. It is recommended that both local and oral antibiotics are always combined with local benzoyl peroxide or a local retinoid. Oral contraceptives are only recommended in women with acne who also desire contraception. Use of oral contraceptives containing cyproterone acetate is no longer recommended in women with acne, because they are not more effective than other oral contraceptives. Treatment with oral isotretinoin may be given by the general practitioner, as long as the treatment guidelines are carefully followed.

The second version of the practice guideline 'Sore throat' has been updated from the 1999 version. --Infections of the throat generally cure spontaneously within 7 days. In most cases the sore throat is caused by a virus. Group A beta-haemolytic streptococci (GABHS) are the most important bacterial cause ofa sore throat. --In diagnostics, the main focus is placed on evaluating how sick the patient is in general. --In adolescents who have had a sore throat for more than 7 days, the possibility of mononucleosis infectiosa should be borne in mind. This diagnosis can be verified by a test for IgM against Epstein-Barr-virus. --Additional investigations to detect GABHS are not recommended. --Prescribing antibiotics is only recommended for patients who have a severe throat infection or an increased risk of complications. Pheneticillin or phenoxymethylpenicillin remains first choice. --Referral for tonsillectomy should meet the following criteria: 5 or more episodes of sore throat per year or 3 or more episodes per year in the last 2 years.

Guidelines from the Dutch College of General Practitioners (NHG), the Scientific Institute of Dutch Pharmacists (WINAp), the Dutch Association for Obstetrics & Gynaecology (NVOG) and the Dutch Expert Centre on Sexuality (Rutgers Nisso Groep) all gave different recommendations on the use of the morning after pill in the event of the contraceptive pill being missed. This is an undesirable situation. Using the 2004 WHO-recommendations on missed pills as a starting point, new Dutch guidelines were drawn up. The consensus is that in the case of only one pill being missed, no extra precautions are necessary. This is by far the most frequent situation. The forgotten pill should be taken as soon as possible. Forgetting to take the pill more than once is a rare occurrence. Iftwo or more pills have been missed, advice will be given in accordance with the existing NHG guideline. The WHO has been requested to initiate research in order to establish if its current recommendations on forgetting more than one contraceptive pill can be supported by better data. The new recommendations will be implemented into harmonized guidelines thus enabling women to be given the same simple advice at every advisory centre.

Since clear evidence is lacking that avoidance of exposure to inhalation or food allergens will have a favourable effect on the course of atopic dermatitis, allergological screening should be restricted to patients having acute allergic symptoms. Topical corticosteroids are the treatment of choice. The working group recommends starting with a class 2-3 corticosteroid daily followed by intermittent maintenance therapy with a corticosteroid of the same class or daily administration of a class 1 corticosteroid. When used in this way, corticosteroids are safe as far as local and systemic side effects are concerned; patients with severe atopic dermatitis have decreased serum-cortisol levels but this is due to the illness and not the corticosteroid. Serum-cortisol levels will usually return to normal following topical steroid therapy. Topical calcineurin inhibitors are a good second-line alternative for patients in whom corticosteroids are insufficiently effective or produce side effects. During such treatment, the skin should be protected against ultraviolet light. Non-sedating antihistamines have no place in the treatment of atopic dermatitis. Cyclosporin is the agent of choice for the systemic treatment of severe atopic dermatitis. The attending physician should also pay attention to psychosocial factors, since severe eczema in children, their parents and adults has a serious impact on the quality of life. Patients with severe atopic dermatitis should be discouraged from working in a wet environment. Patients with moderately active atopic dermatitis without eczema of the hands should avoid exposure to water and other irritating factors.

The 1996 practice guideline on atopic dermatitis from the Dutch College of General Practitioners has been updated. For diagnosing atopic dermatitis, the use of Williams' criteria is recommended. Testing for food allergy is only useful in case of children under the age of 2 who have other food-related allergic complaints together with dermatitis. In the treatment of atopic dermatitis, keeping the skin in good condition with emollients is essential; furthermore, topical corticosteroids are the therapy of first choice. In case of a severe exacerbation of atopic dermatitis, starting with a class 3 corticosteroid is preferred. In case of frequent recurrences, 'pulse-therapy' is indicated: topical corticosteroids on 2-4 consecutive days per week as maintenance therapy. The role of preparations from tar is marginal. The use of the topical immunomodulators tacrolimus and pimecrolimus in general practice is discouraged.

The 1996 practice guideline of the Dutch College of General Practitioners (NHG) on vaginal discharge has been updated. Most women who visit their doctor with complaints about vaginal discharge do not have an increased risk of a sexually-transmitted disease. Investigations into vaginal discharge comprise history taking, physical examination and microscopic analysis in the laboratory of the general practitioner. Additional investigation into Chlamydia, gonorrhoea and Trichomonas infection is only necessary if the patient history reveals an increased risk of a sexually-transmitted disease. A Candida infection or bacterial vaginosis should only be treated if the patient experiences bothersome complaints. Treatment of a Candida infection consists of a vaginally applied imidazole compound. Bacterial vaginosis can be treated with oral administration of metronidazole. Patients with vaginal fluor can be examined and, if necessary, treated by their general practitioner. Referral to a gynaecologist is rarely necessary.

The 1995 guideline on pelvic inflammatory disease (PID) has been updated. The general practitioner should consider PID whenever a woman of childbearing age complains of lower abdominal pain; the diagnosis should then be based on 5 criteria: (a) non-acute lower abdominal pain; (b) pain on upward movement or adnexal tenderness during vaginal touch; (c) painful or swollen adnexae; (d) ESR > or = 15 mm in the 1st hour or a temperature > 38 degree C, and (e) no indications for other diseases, such as appendicitis or an extra-uterine pregnancy. In case of diagnostic doubt, a gynaecologist must be consulted. Rapid treatment with antibiotics diminishes symptoms, shortens the course of disease, and may prevent complications such as infertility or extra-uterine pregnancy. Treatment should be started with ofloxacin and metronidazole. Due to the increasing antibiotic resistance of Neisseria gonorrhoeae, when there are indications for this pathogen the medicinal treatment should immediately be directed at it by means of cefotaxim, doxycycline and metronidazole. In his or her information to the patient, the general practitioner should devote attention to the major role of sexually transmissible micro-organisms and give advice, if necessary, regarding high-risk behaviour.

In response to the report 'Immunisation against tetanus following injuries' from the Dutch Health Council, the Dutch College of General Practitioners, the National Coordinating Body for the Control of Infectious Diseases and The Netherlands Vaccine Institute have drawn up guidelines for tetanus prophylaxis in general practice. The number of situations in which the administration of tetanus immunoglobulin or tetanus vaccine is indicated is now considerably lower. Some of the unclear aspects of the report have been further worked out and translated into definite guidelines. The guidelines are not only useful for general practitioners but deserve to be followed by all doctors treating patients with injuries.

When choosing a method of contraception, a woman must consider the pros and cons of various methods together with her family physician. In this process, the doctor provides information on the advantages and disadvantages, while the woman decides. A sub-50 pill of the second-generation preparation is the oral contraceptive of choice. If the woman chooses a newly developed method of contraception, she must be carefully informed about the uncertainties with regard to reliability and safety. Oral contraceptives are absolutely contra-indicated in the following cases: a history of myocardial infarction, stroke (CVA), venous thromboembolism, a known coagulation-factor deficiency, breast or endometrial carcinoma or severe liver-function disorders. Non-hormonal methods of contraception are preferred in such a case. If there are two or more risk factors for cardiovascular disease, the doctor and the patient must consider the pros and cons of hormonal contraception. In this connection, stopping smoking is more effective than not using an oral contraceptive. A prescription for an oral contraceptive can be given without a physical examination, not even a measurement of the blood pressure; follow-up is only necessary in the case of side effects or questions. Progestagen-only contraceptives are absolutely contraindicated in the following cases: current venous thromboembolism, vaginal bleeding of unknown origin, progestagen-dependent tumours such as breast cancer, and severe liver function disorders.

The general practitioner (GP) should be aware of clues pointing to dementia. The GP can establish the diagnosis himself or refer the patient for extended testing. The diagnosis of dementia focuses on memory impairment, other cognitive impairments and decreased functioning in daily life. For patients with dementia and their relatives, information and advice are more important than medication. The GP must take care aspects into consideration as well as the way patients' relatives cope with the dementia patient. The treatment and care of the patient with dementia and the relatives requires good coordination and collaboration with other health workers.

In the first revised version of the Dutch College of General Practitioners' practice guideline 'Vaginal bleeding' a distinction is made between excessive (cyclical), irregular, breakthrough and postmenopausal bleeding. The diagnostic guidelines are aimed at identifying possible causes. However, in a considerable number of patients no underlying cause is found and the bleeding is assumed to be caused by hormonal fluctuations, for instance shortly after the menarche or premenopausal. Other causes can be: myomas, an intra-uterine device (IUD), medication, or endometrial carcinoma. Furthermore, lesions of the perineum, vulva or vagina, a pelvic inflammatory disease, Chlamydia infection, cervical carcinoma, imminent abortion or ectopic pregnancy also have to be excluded. In this practice guideline, the management guidelines are limited to the treatment of bleeding from the endometrium. In most cases bleeding caused by hormonal fluctuations is self-limiting. However, symptomatic treatment with progestogens or sub-50 oral contraceptives is possible. NSAIDs taken during the first three days of menstruation are the second-choice treatment in women with excessive bleeding. Tranexamic acid or a levonorgestrel-releasing IUD are other possibilities. Postmenopausal women with vaginal bleeding, first of all have to be examined by means of a cervical smear and transvaginal ultrasonography, to exclude an endometrial carcinoma. They can initially be reassured if the ultrasonography reveals an endometrial thickness of 4 mm or less. In the case of persistent or recurrent vaginal bleeding, they should still be referred to a gynaecologist.

In the Dutch College of General Practitioners' practice guideline 'The menopause', the menopause is viewed as a physiological phase of life with its associated discomforts, which sometimes require treatment. The GP should inform women with menopausal symptoms about the extent to which oestrogens can diminish vasomotor symptoms and about the benefits and risks of hormonal therapy on various organ systems. Oestrogens can be used when vasomotor symptoms cause serious limitations in daily life. First choice is a sequential combination of oestrogen and progestagen hormones, in which progestagens are given at least ten days per month. When urogenital complaints need to be treated, vaginally applied oestrogens can be prescribed. Depressive symptoms, fatigue, myalgia or arthralgia should not be treated with hormonal therapy. Nor are oestrogens recommended for the prevention of osteoporosis and cardiovascular diseases.

The diagnosis of 'irritable bowel syndrome' can usually already be established after history-taking and a limited physical examination, particularly if the symptoms have persisted for many years in the same form. Additional investigations are indicated in the case of diarrhoea which lasts longer than 2 weeks, especially if the patient is also severely unwell or has rectal bleeding; further investigations are also required if older patients experience the symptoms for the first time, if there is blood loss upon defecation, if unintentional weight loss occurs or if a mass is felt on the left side of the abdomen. Further investigations consist of a rectal examination, measurement of the sedimentation, haemoglobin concentration and leukocyte count, sigmoidoscopy and an X-ray of the colon. Treatment should aim to reduce unnecessary concern and avoidance behaviour, and to positively influence additional stress-inducing factors, nutrition and physical activity. Medication is not indicated except for laxatives if constipation plays an important role and if advice about nutrition and physical activity provide insufficient relief.

Background: About 20% of all men and women age 65 or older are on maintenance therapy with diuretics. Multiple drug use and side effects increase with age whereas a clear indication for long-term diuretic therapy is not always present. The aim of the present study was to assess whether in some patients long-term diuretic therapy could be withdrawn in general practice., Methods: This study is a pilot-study for a large multicentered randomized controlled trial in general practice. In one general practice in The Netherlands, 15 diuretic-using patients were selected from a total population of 52. All had been using diuretics for more than six months, were not hypertensive, and did not show overt symptoms of heart failure. In these 15 patients, diuretic medication was withdrawn under careful medical monitoring conditions., Results: After six months, six patients were still without diuretic therapy. Diuretic therapy had to be resumed in nine cases, because of congestive heart failure (one), hypertension (three), bronchial asthma (one), increased ankle edema (two) and subjective complaints (two). The withdrawal of diuretic therapy caused an increase in mean systolic blood pressure, heart failure score, body weight and ankle edema., Conclusions: Long-term maintenance diuretic therapy in patients age 65 or older in general practice may be successfully withdrawn in selected cases. Careful medical surveillance during and after withdrawal is warranted.