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Osteomalacia is often seen together with osteoporosis, and its presence can be inferred by finding low serum levels of 25(OH) vitamin D, low serum calcium, or low serum phosphate A high serum alkaline phosphatase may be present in severe osteomalacia but not osteoporosis The relative contribution of the two entities to diminished bone density may not be apparent until treatment, since a dramatic rise in bone density is often seen with therapy for osteomalacia Phosphate deficiency must be distinguished from hypophosphatemia seen in hyperparathyroidism Bone densitometry by DXA may give a misleadingly low reading for patients who are unusually slender with small bones It must also be remembered that bone density only approximates bone tensile strength

To obtain adequate sunshine vitamin D, the face, arms, hands, or back must have sun exposure without sunscreen for 15 minutes at least twice weekly The main natural food source of vitamin D is fish, particularly, salmon, mackeral, cod liver oil, and sardines or tuna canned in oil Most commercial cow s milk is fortified with vitamin D at about 400 IU per quart; however, skim milk and other dairy products contain much less vitamin D Vitamin supplements containing vitamin D are widely available, but contain plant-derived vitamin D2, which has less biologic availability than once believed In sunlight-deprived individuals (eg, veiled women, confined patients, or residents of higher latitudes during winter), the recommended daily allowance should be 1000 IU daily In such individuals, vitamin D supplements should be given prophylactically Patients receiving long-term phenytoin therapy may be treated prophylactically with vitamin D, 50,000 IU orally every 2 4 weeks Frank vitamin D deficiency is treated with ergocalciferol (D2), 50,000 IU orally once or twice weekly for 6 12 months, followed by 1000 2000 IU daily Ergocalciferol has a duration of action of 7 10 days, so by 2 weeks after a dose of ergocalciferol, the 25(OH) vitamin D level is back

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This rare condition sporadically affects middle-aged patients, who present with progressive bone pain and pathologic fractures Bones have a dense fishnet appearance on radiographs Serum alkaline phosphatase levels are elevated Some patients have a monoclonal gammopathy, indicating a possible plasma cell dyscrasia causing an impairment in osteoblast function and collagen disarray Remission has been reported after repeated courses of melphalan, corticosteroids, and vitamin D analog over 3 years

The expression you are testing (or switching on ) is put in parentheses in the head of the switch statement. Each case statement compares a constant value with the expression. The constant expression can be a literal, symbolic, or enumerated constant. The compiler starts with the first case statement and works its way down the list, looking for a value that matches the expression. If a case is matched, the statement (or block of statements) associated with that case is executed. The case block must end with a jump statement. Typically, the jump statement is break, which abruptly ends the entire switch statement. When you execute a break in a switch statement, execution continues after the closing brace of the switch statement. (We ll consider the use of the optional default keyword later in this section.) In the next, somewhat whimsical listing (Example 5-8), the user is asked to choose her political affiliation among Democrat, Republican, or Progressive. To keep the code simple, we ll hard-wire the choice to be Democrat.

The clinical manifestations of defective bone mineralization depend on the age at onset and the severity In adults,

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