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to baseline Some patients require long-term supplementation with ergocalciferol of up to 50,000 IU weekly In patients with intestinal malabsorption, oral doses of 25,000 100,000 IU of vitamin D2 daily may be required Some patients with steatorrhea respond better to oral 25(OH)D3 (calcifediol), 50 100 mcg/d All patients receive supplemental oral calcium salts (eg, calcium citrate or calcium carbonate), which are given with meals Recommended doses of calcium are as follows: calcium citrate (eg, Citracal), 04 06 g elemental calcium per day, or calcium carbonate (eg, OsCal, Tums), 1 15 g elemental calcium per day In hypophosphatemic osteomalacia, nutritional deficiencies are corrected, aluminum-containing antacids are discontinued, and patients with renal tubular acidosis are given bicarbonate therapy In patients with sporadic adultonset hypophosphatemia, hyperphosphaturia, and low serum 1,25(OH)2D levels, a search is conducted for occult tumors that may be resected; whole-body MRI scanning may be required For those with X-linked or idiopathic hypophosphatemia and hyperphosphaturia, oral phosphate supplements must be given long-term; calcitriol, 025 05 mcg/d, is given also to improve the impaired calcium absorption caused by the oral phosphate Human recombinant growth hormone reduces phosphaturia and may be added to the above regimen

Armas LA et al Vitamin D2 is much less effective than vitamin D3 in humans J Clin Endocrinol Metab 2004 Nov;89(11):5387 91 [PMID: 15531486] Bielesz B et al Renal phosphate loss in hereditary and acquired disorders of bone mineralization Bone 2004 Dec;35(6):1229 39 [PMID: 15589204] Hanley DA et al Vitamin D insufficiency in North America J Nutr 2005 Feb;135(2):332 7 [PMID: 15671237] Jan de Beur SM Tumor-induced osteomalacia JAMA 2005 Sep 14;294(10):1260 7 [PMID: 16160135] Lyman D Undiagnosed vitamin D deficiency in the hospitalized patient Am Fam Physician 2005 Jan 15;71(2):299 304 [PMID: 15686300] Whyte MP et al Adult hypophosphatasia treated with teriparatide J Clin Endocrinol Metab 2007 Apr;92(4):1203 8 [PMID: 17213282]

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Paget s disease of bone is a common condition manifested by one or more bony lesions having high bone turnover and disorganized osteoid formation Involved bones become vascular, weak, and deformed Paget s disease is present in 1 2% of the population of the United States, with a higher prevalence in the elderly and in the Northeast It is usually discovered incidentally during radiology imaging or because of incidentally discovered elevations in serum alkaline phosphatase Only 27% of affected individuals are symptomatic at the time of diagnosis Familial Paget s disease is unusual but is generally more severe than sporadic cases A rare form occurs in young people

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Paget s disease is usually diagnosed in patients over 40 years of age and is often mild and asymptomatic It can involve just one bone (monostotic) or multiple bones (polyostotic), particularly the skull, femur, tibia, pelvis, and humerus Pain is the usual first symptom The bones become soft, leading to bowed tibias, kyphosis, and frequent fractures with slight trauma If the skull is involved, the patient may report headaches and an increased hat size Deafness may occur Increased vascularity over the involved bones causes increased warmth

Serum calcium and phosphorus are normal, but serum alkaline phosphatase is markedly elevated Urinary hydroxyproline is also elevated in active disease Serum calcium may be elevated, particularly if the patient is at bed rest

The involved bones are expanded and denser than normal on radiographs Multiple fissure fractures may be seen in the long bones The initial lesion may be destructive and radiolucent, especially in the skull ( osteoporosis circumscripta ) Technetium pyrophosphate bone scans are helpful in delineating activity of bone lesions even before any radiologic changes are apparent

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PAGET S DISEASE OF BONE (OSTEITIS DEFORMANS)

Paget s disease must be differentiated from primary bone lesions such as osteogenic sarcoma, multiple myeloma, and fibrous dysplasia and from secondary bone lesions such as metastatic carcinoma and osteitis fibrosa cystica Fibrogenesis imperfecta ossium is a rare symmetric disorder that can mimic the features of Paget s disease; alkaline phosphate is likewise elevated If serum calcium is elevated, hyperparathyroidism may be present in some patients as well

This section discusses the GNU Project (GNU), the Free Software Foundation (FSF), and the open source movement, focusing on their importance to software developers. There are fundamental philosophical differences among these groups, reflected in their advocated licensing policies. Richard Stallman founded the GNU Project in 1984.11 The GNU Project s stated software goal is to develop a completely free UNIX-like operating system. The FSF supports the GNU Project. The following quote describes the FSF:

Often asymptomatic Bone pain may be the first symptom Kyphosis, bowed tibias, large head, deafness, and frequent fractures Serum calcium and phosphate normal; alkaline phosphatase elevated; urinary hydroxyproline elevated Dense, expanded bones on radiographs

Republican, Progressive } static void Main( ) { // hardwire to Democratic Party myChoice = Party.Democrat; // switch on the value of myChoice switch (myChoice) { case Party.Democrat: Console.WriteLine("You voted Democratic."); break; case Party.Republican: Console.WriteLine("You voted Republican."); break; case Party.Progressive: Console.WriteLine("You voted Progressive."); break; } Console.WriteLine("Thank you for voting."); } } }

Fractures are frequent and occur with minimal trauma If immobilization takes place and there is an excessive calcium intake, hypercalcemia and kidney stones may develop Verte-

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