[Diagnostic image (374). A neonate with bilateral cranial swelling]. / Diagnose in beeld (374). Een zuigeling met een beiderzijds gezwollen hoofd.

A 13-day-old boy was presented because of progressive bilateral temporoparietal swelling of the head, due to bilateral cephalhaematoma.

[Palliative care is more than palliative antitumour treatment and symptom management]. / Palliatieve zorg: meer dan palliatieve antitumortherapie en symptoombestrijding.

Nowadays, many palliative treatments are available for advanced cancer. These treatments provide relief of symptoms and add months to life, but their price is high, both literally and figuratively. Patients seize on any opportunity to be treated and oncologists find it hard to stop treatment because this means talking and reflecting about dying. This 'conspiracy of silence' makes it hard to say 'we don't have any further treatment'. Instead of saying 'we have no further treatment', patients should be offered palliative care as a positive choice to achieve the best quality of life, not only with physical but also with psychological, social and spiritual support.

[Vitamin D: important from before the cradle and to the grave]. / Vitamine D: belangrijk al vóór de wieg en tot het graf.

Approximately one hundred years ago, vitamin D was recognized as being important for bone health. Nowadays there is increasing evidence that even before birth as well as during lifetime, vitamin D plays a role in the prevention of several chronic diseases as well as cancer. Human beings depend on exposure to the sun to satisfy their daily requirements of vitamin D. Moreover, most doctors in the Netherlands are unaware that the production of vitamin D only takes place in the spring and summertime in the Dutch climate. One Dutch study reports hypovitaminosis D not only in more than half of non-western immigrant mothers and their newborns, but also in 10% of the western mothers and their babies. On a worldwide level, numerous studies report low vitamin-D status in western countries due to our modern way of living, the immigration of dark-skinned people to higher latitudes and the homebound elderly. For some years now the scientific world has called for action on this point; something that in practice appears to be difficult to achieve. Aiming for optimal vitamin-D levels means suppletion either through tablets or food fortification. In general, people do not like to take tablets ('we eat healthy foods already') and many avoid the sun because they are afraid of cancer. Vitamin D is not a commercially rewarding product and has no marketing industry. Although multivitamins are marketed and pushed by industry, they hardly contain the necessary amounts of vitamin D. The population in the Netherlands should be better informed on this issue and general practitioners need more tools in order to play a greater role in informing and advising their patients.

[A pilot study of hypovitaminosis D in apparently healthy, veiled, Turkish women: severe vitamin D deficiency in 82%]. / Pilotonderzoek naar hypovitaminose D bij ogenschijnlijk gezonde gesluierde Turkse vrouwen: ernstige vitamine-D-deficiëntie bij 82%.

A pilot study was performed in March 2001 in order to estimate the prevalence of hypovitaminosis D in veiled women in the Netherlands. In a group of 51 Turkish women aged 14-63 years, 42 (82%) were severely deficient (25-hydroxyvitamin D (25-(OH)D) < 20 nmol/l), and 4 (8%) were moderately deficient (25(OH)D: 20-30 nmol/l). About half of the deficient women complained of muscle pain, muscle weakness or fatigue. These results confirm the presence of a serious public health problem with regard to vitamin D amongst veiled women.

[Hypovitaminosis D: a veiled diagnosis]. / Hypovitaminose D: een versluierde diagnose.

Four cases of hypovitaminosis D were seen in a general practitioner's population in the Netherlands: a Somalian veiled woman aged 53 and her 11-year-old daughter, a dark-skinned Surinam woman aged 31, and a veiled Moroccan woman aged 56 years. This cause of myopathy has only been recently recognised and is more prevalent than often thought, especially in high-risk groups such as veiled and dark-skinned immigrants who lack sunlight in the Netherlands. Symptoms are muscle pain and mainly proximal muscle weakness resulting in difficulties in ascending a staircase or getting up out of a chair. The diagnosis is made on the basis of a detailed history and measurement of serum 25-hydroxyvitamin D. Calcium and serum alkaline phosphatase activity may be normal. Treatment with ergocalciferol is effective and cheap. As diagnosis and treatment are relatively simple, finding and treating hypovitaminosis D is a rewarding challenge to primary health care practitioners in the Netherlands.