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Various studies suggest that evening dosing of antihypertensive drugs may be more effective. In line, a randomized open-label trial in 19,084 hypertensive patients recently demonstrated that evening dosing of at least one antihypertensive drug resulted in a 3.3 mmHg lower systolic night-time blood pressure and 1.3 mmHg lower systolic 48-hour blood pressure when compared to morning dosing. Cardiovascular outcomes were reduced by 45% in the evening dosing group, which is remarkable as previous meta-analyses have shown that a systolic blood pressure reduction of 3 mmHg is associated with a 7% reduction in cardiovascular outcome. Although this discrepancy may be partly explained by specific beneficial effects related to evening dosing, it is likely that the open-label trial design may have affected the study outcome in different ways. Also, the safety of evening dosing in elderly hypertensive patients and the consequences for therapy compliance in the clinical setting remain to be established.The impact of genital warts on psychological, social and sexual wellbeing is often overlooked, as is the magnitude of the problem. In 2017, the number of consultations in primary care in the Netherlands was 42,000. Real-world evidence shows compelling and impressive results regarding the reduction of genital warts in other countries. Not opting for a vaccine that also protects against genital warts is a missed opportunity for elimination of cervical cancer as well as genital warts.The results of a recent randomised phase 3 clinical trial show that the androgen receptor antagonist darolutamide improves metastasis-free survival in men with non-metastatic, castration-resistant prostate cancer, compared with placebo. The trial included 1509 men with a prostate-specific antigen doubling time of 10 months or less. Non-metastatic disease was defined as the absence of metastases, using conventional imaging rather than the substantially more sensitive PSMA scans. The effect of darolutamide is similar to that of other androgen inhibitors, such as apalutamide and enzalutamide. The value of the current trial to Dutch clinical practice is limited, as the number of patients with non-metastatic, castration-resistant prostate cancer is low due to the increased use of PSMA scans and the reluctance of urologists to start androgen-deprivation therapy in the absence of metastatic disease.BACKGROUND Bálint's syndrome is characterized by the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia. It most commonly occurs following bilateral parieto-occipital brain injury, for which several aetiologies have been described. CASE DESCRIPTION We present a case of a 39-year-old male with penetrating brain injury following a suicide attempt with a crossbow. A CT scan of the head revealed the intracranial position of the arrow, piercing the parietal and occipital cortex from the left-parietal direction with the tip on the right parietal bone. After surgical removal of the arrow, visuospatial symptoms persisted that were consistent with Bálint's syndrome. The characteristic symptoms, patho-anatomy and treatment of this syndrome are discussed in this article. CONCLUSION The patient in this case had visual impairment following a suicide attempt with a crossbow. On the basis of neurological and neuropsychological assessments, the triad of ocular apraxia, dorsal simultanagnosia and optic ataxia was observed, characteristic of Bálint's syndrome.We developed an innovative one-week community clerkship for all fifth-year medical students at Utrecht UMC. Students follow this clerkship in a variety of community care and welfare organizations (eg social community teams or organizations that support psychiatric patients or migrants). Learning goals students get acquainted with organizations and professionals within the social domain, students experience the social context of healthcare, and they reflect on the meaning of these experiences for their work as a physician. The reflection papers show that students gain insight in social determinants of health. Learning about clients in their everyday live is appreciated by students, as well as getting insight in the social domain. However students find it difficult to relate these experiences with the medical context. Participating social organizations value the clerkship because they feel the need to train future doctors in the social domain.It is becoming clear that there are significant differences between the two principal human papillomavirus (HPV) vaccines, namely the bivalent vaccine and the quadrivalent vaccine. Both vaccines contain HPV16 and HPV18, together responsible for approximately 73% of cases of cervical cancer. The quadrivalent vaccine also contains HPV6 and HPV11, thus protecting against genital warts. Real-world data show 89% efficacy for the bivalent vaccine against cervical intraepithelial neoplasia stage 3, irrespective of the HPV type involved, versus 64% for the quadrivalent vaccine. This suggests superior cross-reactivity of the bivalent vaccine against oncogenic HPV types not contained in the vaccine, presumably thanks to the MPLA adjuvant in the vaccine. In the Netherlands, the cross-reactivity of the bivalent vaccine may ultimately lead to a significant additional reduction of cervical cancer deaths per year. Since protection against genital warts should not be pursued at the expense of protection against cervical cancer, we recommend that the Netherlands continue to use the bivalent vaccine in its national immunisation programme.BACKGROUND Anti-NMDA-receptor-encephalitis is a progressive autoimmune disease with significant mortality if left untreated. CASE DESCRIPTION A 58-year-old man without previous psychiatric or neurologic history presented at the emergency department after brief loss of consciousness at work. Within a few hours, the patient developed acute neuropsychiatric symptoms, including altered levels of consciousness, aggression, incoherence, change in behaviour, and psychomotor agitation. Initially, additional blood, cerebrospinal fluid and EEG tests showed no abnormalities. Over the course of the following days, catatonia, orofacial dyskinesia and autonomic-function disorder developed, eventually with respiratory insufficiency, necessitating transfer to the intensive-care unit. At this stage, the EEG did show abnormalities, and cerebrospinal fluid analysis showed marginal pleocytosis. The patient was treated with intravenous methylprednisolone and immunoglobins. Anti-NMDA-receptor antibodies were present in the blood and cerebrospinal fluid. Screening for malignancy identified small-cell lung carcinoma, for which the patient was treated with cytostatic agents. IK-930 clinical trial CONCLUSION Acute neuropsychiatric symptoms in a middle-aged patient with no psychiatric medical history are suggestive of an underlying somatic cause. Timely recognition and treatment of anti-NMDA-receptor encephalitis is essential to improve the prognosis.Over recent decades the prevalence of food allergies and the allergy-related costs of care have increased considerably. The double-blind, placebo-controlled food challenge test is the gold standard for diagnosing food allergy. However, this test is not without risk and it is labour-intensive and expensive. link2 In addition, the food challenge test only has limited availability which has led to (long) waiting lists. Therefore, there is a need for a safe, reliable and patient-friendly test to detect food allergy that is also fast and cheap. The basophil activation test is a potentially good alternative, however, it is only available at a few clinics and laboratories in the Netherlands and it can currently only be used for a limited number of allergens - and therefore only in a limited number of patients. National collaboration between laboratories and allergy centres should lead to more knowledge, the consolidation of which will benefit the validation and national implementation of the test.In patients with cryptogenic stroke, the detection of atrial fibrillation (AF) is important, since it is an indication for the prescription of oral anticoagulation, instead of anti-platelet therapy, to decrease the chance of a recurrent ischaemic cerebral event. The presence of permanent AF is easily detected by means of an electrocardiogram (ECG). However, in paroxysmal AF patients, expensive long-term rhythm monitoring might be necessary to detect the arrhythmia. In the present article, the authors describe an algorithm, constructed by artificial intelligence and big data, to detect a 'footprint' of AF on a 12-lead ECG during sinus rhythm. However, despite this promising premise, the algorithm comes from a 'black-box' calculation and, therefore, it cannot rule out possible bias from medication or patient characteristics. Furthermore, the combination of a moderate test specificity and a low prevalence of only 10% undetected AF in the post-stroke population, results in a low positive predictive value, which is not useful for initiation of anticoagulation therapy.In order to legally conduct clinical research into new cancer treatments with medicinal products based on genetically modified organisms (GMOs) and treat cancer patients with these products, Dutch hospitals must obtain an environmental permit from the Minister of Infrastructure & Water Management. link3 In the Netherlands, permit applications are assessed more strictly than in other EU member states, even if the products do not pose any real risk to the population and the environment. As a result, Dutch patients have to wait longer before the clinical trial or therapy with these GMO products can commence. This makes current Dutch environmental policy a serious obstacle to public health. Recently physicians and researchers have therefore pleaded with Dutch MPs for an adjustment of the lower national environmental regulations. Unfortunately, these pleas were not supported by said elected members of parliament, and the Ministry of Infrastructure & Water Management seems to be holding on to a pointless environmental permit for clinical research and treatment of cancer patients with these GMO medicinal products.A bad-news conversation often evokes strong emotions in a patient and those close to her or him. These emotions may inhibit mental processing of additional information. During a bad-news conversation, you should therefore not only provide information, but also help your patient to cope with these emotions and provide support. All this is necessary if your patient is to come to well-considered decisions in consultation with you.Myocardial infarction with nonobstructive coronary arteries (MINOCA) has multiple potential underlying causes which can be subdivided into coronary, myocardial and non-cardiac disorders. On the basis of three case descriptions, we show that additional investigations are crucial in determining the underlying mechanism and starting suitable treatment. Depending on clinical presentation, risk factors and medical history, an LV angiogram, a provocation test with intracoronary acetylcholine and a cardiac MRI can contribute to finding the correct diagnosis. We further present a diagnostic algorithm to guide the clinician in the management of patients presenting with MINOCA.