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PubMed1997

A new radiographic method for evaluating the degree of sliding in devices used in hip-fracture surgery.

PURPOSE: To find a practical method for estimating the degree of sliding that occurs in screw-plate devices used in hip-fracture surgery. Greater understanding of the sliding mechanisms in different fracture types should improve surgical technique and reduce the failure rate. METHODS AND RESULTS: In dynamic screw-plate devices, the lag screw slides inside the barrel of the plate. A recent innovation allows the barrel-plate to slide inside a side-plate, thus making possible a combined fracture compression along the neck and the shaft of femur. The lengths of the different parts and the angle of a device in vivo, measured on a radiograph, depend on the position of the femur relative to the photographic film and the roentgen source. We obtained these measurements with a ruler and a protractor from sequential a.p. radiographs of the hip and implemented them in a special computerized program that used the principles of the scaled orthographic and the central projection models. These calculations provided the correct amount of sliding by the lag screw and by the barrel-plate within the side-plate. CONCLUSION: The method presented here can establish the real degree of sliding in screw-plate devices from standard a.p. radiographs independently of the position of the hip.

Algorithms↗

PubMedDate not supplied

An assessment of encapsulated versus hand-mixed glass ionomer restoratives.

Capsulation should enable uniform proportioning and mixing of dental restoratives so that functional properties of the cementitious mass will not be susceptible to clinically induced variability. Mechanical mixing induces a definite pore distribution determined by the viscosity of the system. This study evaluated the mixing process on the performance of a range of glass ionomer dental restoratives. Mean compressive fracture strengths and standard deviations and the associated Weibull Moduli (m) were determined for six glass ionomer restoratives that were either encapsulated or mixed by hand. Working characteristics were assessed using an oscillating rheometer. Scanning electron microscopy and image analysis was used to investigate the influence of the mixing method on pore distribution. The fracture strength data for some encapsulated restoratives resulted in significant differences compared with hand-mixing. Rotomix (compared with the Capmix mechanical agitator) resulted in increased Weibull moduli and 10% failure stress for the two restoratives that were investigated. Encapsulated restoratives that were prepared utilizing Rotomix or Capmix resulted in no significant differences for working characteristics; however, the setting time for the ChemFlex in Caps was extended compared with the hand-mixed ChemFlex. Not all restoratives had reduced porosity and improved performance following mixing with a Rotomix. This suggested that optimization of the initial viscosity of the system by manipulating the individual proportions of the constituents may not have been appropriate for all the restoratives investigated. The increased viscosity for hand-mixed ChemFlex prepared to a consistency of 3.8 g/ml compared with encapsulated ChemFlex in Caps prepared to a consistency of 3.5 g/ml was responsible for the reduced setting time.

Analysis of Variance↗

PubMed1986

Outpatient percutaneous biopsy of the iliac crest: methods, morbidity, and patient acceptance.

Bone histology and histomorphometry have become important in the diagnosis and management of metabolic bone disease, but the invasive nature of the biopsy procedure has limited its use. We describe an outpatient technique for obtaining one or more transiliac bone biopsy specimens. Thirty-eight women with osteoporosis, each of whom had sustained one or more spinal compression fractures, underwent two separate bone biopsies during which two 7.5-mm transiliac cores of bone were removed. No morbidity (such as infection or hemorrhage) was encountered. Subjective responses to the level of pain were surveyed by questionnaire. At the time of biopsy, 46% of the study subjects experienced no or only mild discomfort, and 24% judged their pain to be severe. At 16 hours after biopsy, 64% had no or mild pain and 8% experienced severe pain. At 7 days after biopsy, 79% experienced no or mild pain but 9% judged their pain to be severe. In four patients, temporary ambulatory disability occurred but resolved spontaneously in 7 to 10 days. We conclude that the described outpatient bone biopsy procedure is safe, efficient, and generally acceptable to patients.

Aged↗

PubMed1999

A prospective study of bone loss and turnover after allogeneic bone marrow transplantation: effect of calcium supplementation with or without calcitonin.

Transplantation of solid organs including heart, kidney, and liver is associated with rapid bone loss and increased rate of fracture; data on bone marrow transplantation recipients (BMT) are scarce. The purpose of the present study was to examine the magnitude, timing, and mechanism of bone loss following allogeneic BMT, and to study whether bone loss can be prevented by calcium with or without calcitonin. Sixty-nine patients undergoing allogeneic BMT for malignant blood diseases were enrolled into the study. Forty-four (22 women, 22 men) completed 6 months, and 36 patients 1 year follow-up. They were randomized to receive either no additional treatment (n = 22), or oral calcium 1 g twice daily for 12 months (n = 12) or the same dose of calcium plus intranasal calcitonin 400 IU/day for the first month and then 200 IU/day for 11 months (n = 10). Bone mineral density (BMD) at the lumbar spine and three femoral sites (femoral neck, trochanter, Ward's triangle) was measured by dual-energy X-ray absorptiometry (DXA). Bone turnover rate was followed with markers of bone formation and resorption (serum bone-specific alkaline phosphatase (B-ALP), type I procollagen carboxyterminal (PICP) and aminoterminal propeptide (PINP), serum type I collagen carboxyterminal telopeptide (ICTP)). Serum testosterone was assayed in men. Calcium with or without calcitonin had no effect on bone loss or bone markers; consequently the three study groups were combined. During the first 6 post-transplant months BMD decreased by 5.7% in the lumbar spine and by 6.9% to 8.7% in the three femoral sites (P < 0.0001 for all); no significant further decline occured between 6 and 12 months. Four out of 25 assessable patients experienced vertebral compression fractures. Markers of bone formation reduced: B-ALP by 20% at 3 weeks (P = 0.027), PICP by 40% (P < 0.0001) and PINP by 63% at 6 weeks (P < 0.0001), with a return to baseline by 6 months. The marker of bone resorption, serum ICTP was above normal throughout the whole observation period, with a peak at 6 weeks (77% above baseline, P < 0.0001). In male patients serum testosterone decreased reaching a nadir (57% below baseline) at 6 weeks (P = 0.0003). In conclusion, significant bone loss occurs after BMT. It results from imbalance between reduced bone formation and increased bone resorption; hypogonadism may be a contributing factor in men. Bone loss can not be prevented by calcium with or without calcitonin.

Administration, Inhalation↗

PubMed1975

[Chronic spinal epidural abscess (author's transl)].

A case of 58 year old female with chronic spinal epidural abscess demonstrating rapid progression of complete spinal cord paralysis without remarkable recovery by laminectomy was reported. Patient had a large subcutaneous abscess on left back, ten years ago. Three months before admission she fell down from stairs and had a compression fracture on the seventh thoracic vertebra. She has been troubled with slight spinal ache and left lower back pain since the fall accident. One month before admission she suddenly noted severe lower back pain with radiation to left side and the pain became more severe. Three weeks after she noted fecal retention without urinary retention. Five days before admission she noted gait disturbance accompanied by numbness of both foots. Three days later she developed inability to urinate and the same day, over the coure of a few hours, she became total paraplegia and anesthesia below the waist. On admission neurological examination and myelography disclosed complete spinal subarachnoid block with flaccid total paraplegia and anesthesia below the lower chest. The clinical diagnosis was spinal epidural mass lesion, probably neoplasm. Laminectomy from Th-6 through Th-9 was performed the next day: three days after complete paralysis. The epidural abscess included pus and soft granulation tissue was found and totally removed. Staphylococcus aureus sensitive to penicillin, chloramphenicol etc. was isolated on becteriologic culture. On seven months after operation, sensory and deep reflexes were considrable improved, but she remained paraplegic without sphincter control. Dicussion were made on the incidence, pathogenesis.

Abscess↗

PubMed1999

A prospective study of bone loss and turnover after cardiac transplantation: effect of calcium supplementation with or without calcitonin.

Cardiac transplantation exposes recipients to osteoporosis and increased risk of consequent fractures. The purpose of the present study was to examine the magnitude, timing and mechanism of bone loss following cardiac transplantation, and to establish whether bone loss can be prevented by calcium with or without calcitonin. Thirty patients (29 men, 1 woman), aged 26-68 years (mean 48 years), were randomized into three groups of 10 to receive either no additional treatment, oral calcium 1 g twice daily for 12 months or the same dose of calcium plus intranasal calcitonin 400 IU/day for the first month and then 200 IU/day for 11 months. Bone mineral density (BMD) at the lumbar spine and three femoral sites (femoral neck, trochanter, Ward's triangle) was measured by dual-energy X-ray absorptiometry (DXA) at the time of transplantation and 6 and 12 months later. Markers of bone formation [serum bone-specific alkaline phosphatase (B-ALP), type I procollagen carboxyterminal propeptide (PICP) and aminoterminal propeptide (PINP)] and resorption [serum type I collagen carboxyterminal telopeptide (ICTP)], as well as serum testosterone in men, were assayed before transplantation and at 1 week and 1, 3, 6 and 12 months after transplantation. During the first 6 post-transplant months BMD calculated as a percent change from baseline decreased in the control group by 6.4% (p = 0.014) in the lumbar spine, by 6.0% (p = 0.003) in the femoral neck, by 5.0% (p = 0.003) in the trochanter and by 5.5% (p = 0.130) in Ward's triangle. Between 6 and 12 months a further decline in BMD occurred only at the three femoral sites, ranging from 2.2% to 9.8% (p = 0.004-0.079). In comparison with the control group, the group receiving calcium alone lost less bone in the trochanter between 0 and 6 months (p = 0.019), and the group receiving calcium together with calcitonin lost less bone in the femoral neck (p = 0.068) and Ward's triangle (p = 0.076) between 0 and 12 months. Seven (28%) of 25 assessable patients experienced vertebral compression fractures. Calcium with or without calcitonin had no effect on changes in biochemical parameters; consequently, the three study groups were combined. The markers of bone formation increased, the elevations in mean values being 59% for B-ALP at 1 month (p = 0.009), 152% for PICP at 1 week (p < 0. 0001) and 27% for PINP at 1 week (p = 0.021). After a temporary decline at 3 months B-ALP (p = 0.0002) and PINP (p < 0.0001) at 1 year were nearly doubled compared with baseline values. Throughout the study the marker of bone resorption, serum ICTP, was above normal, with a peak (mean values 67-69% above baseline) at 1 week (p = 0.0002) to 1 month (p < 0.0001). The mean concentration of total testosterone was decreased by 48% (p < 0.0001) 1 week and by 28% (p = 0.0005) 1 month after transplantation, but this was mainly explained by the concomitant drop in serum albumin. High bone turnover underlies bone loss after cardiac transplantation. Bone loss is most rapid during the first 6 post-transplant months. In the upper femur this bone loss may be reduced by treatment with calcium and calcitonin.

Adult↗

PubMed1989

Nonunion of a midshaft clavicle fracture associated with subclavian vein compression. A case report.

Fractures of the clavicle are usually treated by closed means and heal uneventfully. In this report, we present an unusual case in which the subclavian vein was compressed by a fracture callus that had formed around a clavicular nonunion. Treatment included dissection of the subclavian vein from the fracture callus and compression plating with autogenous bone grafting of the fracture. Symptoms from the patient's venous obstruction slowly resolved without further treatment. The fracture united postoperatively.

Bony Callus↗

PubMed1981

Hypercalcemia in patients with breast cancer. Osseous metastases, hyperplastic parathyroid tissue, or pseudohyperparathyroidism?

Breast cancer is the malignant neoplasm most commonly associated with hypercalcemia. At the University of Texas M. D. Anderson Hospital, Houston, during the fiscal year 1977 to 1978, of 16,887 patients having calcium determinations, 7.8% had hypercalcemia. From 1969 to 1979, 13 patients had proved and three had presumed primary hyperparathyroidism associated with breast cancer. Two other patients had pseudohyperparathyroidism. Selective neck vein catheterization was used in 17 of the 18 patients and helped localize and confirm the diagnosis of primary hyperparathyroidism. Chloride-phosphate ratios were elevated in 13 of the 14 patients with proved or presumed primary hyperparathyroidism. This condition may mimic osseous metastases by producing brown tumors or compression fractures. In patients with breast cancer and hypercalcemia, particularly without osseous metastases, a careful diagnostic evaluation is warranted to rule out primary hyperparathyroidism.

Adenoma↗

PubMed1999

Solitary vertebral collapse: distinction between benign and malignant causes using MR patterns.

Differentiation of benign from malignant causes of vertebral compression fracture can be difficult at a single location. We studied 37 patients with solitary vertebral collapse (SVC) in the spine using magnetic resonance imaging (MRI). Sixteen of them were found to have a benign cause of SVC, while the remaining 21 were found to have malignancy. The following four MRI characteristics were investigated: ill- or well-defined margin of the intravertebral lesion (P < 0.005); pedicle involvement (P < 0.05); MR enhancement pattern (P < 0.005); and paravertebral soft tissue lesion (PSL) (P < 0.025). It was found that cases of malignant SVC tended to have an ill-defined margin, abnormal signal involvement of the pedicle, a marked and heterogenous MR enhancement pattern, and irregular nodular-type PSL. Pedicle change with expansile lesion totally excluded a benign cause. By using these criteria, we were able to differentiate benign or malignant causes of SVC accurately.

Aged↗

PubMed1984

Remission and exacerbation of tumor-related nephrotic syndrome with treatment of the neoplasm.

A 61-year-old man presented with nephrotic syndrome in March 1978. Renal biopsy revealed mesangial and endocapillary proliferation with no underlying cause found. One year later, evaluation of back pain resulted in the finding of undifferentiated adenocarcinoma with compression fracture of the T-11 vertebra. Local irradiation relieved the pain and ameliorated the nephrotic syndrome. In 1981 the nephrotic syndrome recurred. Evaluation revealed metastases to the right pelvis and to the brain without an identifiable primary lesion. Irradiation of these lesions reduced protein excretion to 50 to 150 mg/day. A gastric carcinoma was later found. Exacerbation of nephrotic syndrome may herald exacerbation of tumor activity as occurs in Hodgkin's disease. Survival with tumor-related nephrotic syndrome is not invariably poor, and treatment of metastases may be worthwhile in similar patients in whom only partial tumor reduction is possible.

Adenocarcinoma↗

PubMed1987

The spectrum of metabolic bone disease in lymphoblastic leukemia.

Eight patients with childhood acute lymphoblastic leukemia (ALL) and hypercalcemia, osteopenia, or vertebral compression fractures seen at our institution during the last 12 years were evaluated for biochemical evidence of bone disease. Five patients were hypercalcemic, three had abnormal phosphorous levels, and four had elevated alkaline phosphatase values. Parathyroid hormone (PTH) was measured by a polyvalent radioimmunoassay in five patients and these levels were abnormally high in three patients. Four of these five patients also had PTH measured by a midregion-specific radioimmunoassay. One patient had a high PTH value. Two patients had low levels and one patient had a normal PTH level. Although these studies suggest diverse biochemical mechanisms may be contributing to the bone changes and hypercalcemia seen in childhood ALL, ectopic PTH production as well as ectopically produced fragments of PTH may have a role in mediating bone resorption and hypercalcemia.

Adolescent↗

PubMed1979

Gerodermia osteodysplastica hereditaria: report of three affected brothers and literature review.

Gerodermia osteodysplastica hereditaria was diagnosed in three Mexican brothers 6, 7, and 8 years old, respectively, who had the distinct facial appearance with sagging cheeks, premature wrinkling of the skin of face, abdomen, and dorsum of hands and feet; malocclusion, span greater than height; hyperextensibility; winging of the scapulae; stooped posture with kyphoscoliosis; protuberant abdomen; and pes planus. Radiologically they had generalized osteoplorosis, platyspondily due to multiple compression fractures, pseudoepiphyses of second metacarpals, and dislocated hips. Three other families with a total of 14 affected individuals have been reported. Inter- and intrafamilial variability can be recognized, particularly regarding the tendency to fractures, upper:lower segment ratio abnormalities, and results of skin biopsies, which have shown fragmentation of the elastic fibers in some cases (including the present family) and not in others. Although inheritance was considered to be X-linked recessive in the first reported family, an analysis of that pedigree together with those of the other reported families, including the present one, suggests that gerodermia osteodrysplastica is inherited in an autosomal recessive manner.

Abnormalities, Multiple↗

PubMed2003

Bone mineral density in juvenile dermatomyositis: assessment using dual x-ray absorptiometry.

OBJECTIVE: To determine the bone mineral density (BMD) status of our juvenile dermatomyositis (DM) population and to compare the frequency of osteopenia in patients with active disease requiring corticosteroids with that in patients with inactive disease who are not receiving corticosteroids. METHODS: Medical charts of all children diagnosed as having juvenile DM at our institution between 1989 and 1999 were reviewed for demographic and clinical data, including disease activity and duration of corticosteroid therapy. BMD measurements of the lumbar spine (L1-L4) were performed using dual x-ray absorptiometry (DXA). Z scores were calculated from the BMD data for comparison with published normative data. RESULTS: A total of 15 patients were assessed: 10 with active disease, and 5 with inactive disease who had not taken corticosteroids for an average of 6.0 years (range 3.4-8.1 years). Baseline BMD measurements demonstrated osteopenia or frank osteoporosis in the majority of patients, including 6 of the 10 patients with active disease and 4 of the 5 patients whose disease was in remission. Fourteen patients had serial BMD measurements. Persistent or worsening osteopenia was documented in all patients who had ongoing active disease, except for 3 patients who had been treated with bisphosphonates because of vertebral compression fractures. CONCLUSION: Osteopenia is common in patients with juvenile DM, and it usually worsens with ongoing disease. It can persist for many years after the disease enters remission. Bisphosphonates appeared to beneficially affect bone mineralization in our patients. Treatment to prevent the long-term complications of osteoporosis in patients with juvenile DM should be considered and requires further study.

Absorptiometry, Photon↗

PubMed1992

Appendicular and vertebral bone mass in ankylosing spondylitis. A comparison of plain radiographs with single- and dual-photon absorptiometry and with quantitative computed tomography.

OBJECTIVE: We assessed the prevalence, severity, and anatomic distribution of ankylosing spondylitis (AS)-related osteopenia (OP). METHODS: We studied 70 patients (60 males, 10 premenopausal females) with AS (according to the New York criteria) to determine the frequency of OP. Bone mass was measured by plain radiographs of the spine, by single-photon absorptiometry (SPA) of the distal and midshaft of the radius on the nondominant side, by dual-photon absorptiometry (DPA) of the lumbar spine (L2-L4), and by quantitative computed tomography (QCT) of the lumbar spine. RESULTS: SPA values for the radius mass were normal in males and in females, both at the distal and midshaft sites. In contrast, spine radiographs showed diminished density of the vertebral bodies in 69% of the males and 50% of the premenopausal females. Two male patients had had a vertebral compression fracture, and one female patient had had two. DPA values for the spine mass were significantly diminished in the male patients compared with the controls, but not in the female patients. Males with less severe AS also had the largest reduction in lumbar bone mineral content. In patients with more severe disease, lumbar bone mineral content was not statistically different from that in controls. QCT of the lumbar spine performed in 10 patients disclosed low density of the trabecular bone of the vertebral bodies, more so in those with more severe AS and syndesmophyte formation and/or apophyseal joint fusion, which contrasts with the normal values on DPA in these patients. CONCLUSION: Male patients with AS have axial osteopenia. In those who have very severe AS with new bone formation, DPA demonstrates normal values as a result of two opposite trends: central osteopenia (as assessed from QCT) and peripheral new-bone formation, which transforms vertebral bodies into long bones. This could modify the mechanical resistance of the spine and account for the propensity for anteroposterior transvertebral and transdiscal fractures after trauma in AS.

Absorptiometry, Photon↗

PubMed1995

A longitudinal study of functional disability in a national cohort of patients with polymyositis/dermatomyositis.

OBJECTIVE: To analyze changes in functional status and the factors contributing to disability in a national inception cohort of 257 patients with polymyositis/dermatomyositis (PM/DM). METHODS: Data were gathered from patients' self-reports on questionnaires: one concerning disease- and treatment-related complications, and the other concerning disability, as reflected by a disability index (DI) derived from the Health Assessment Questionnaire (HAQ). RESULTS: Based on certain characteristics that differentiated disability patterns, 3 groups of patients were identified. Group 1 patients (n = 153) were < or = 60 years old and never had avascular necrosis (AVN) or a vertebral compression fracture (CF), Group 2 patients were > 60 and never had AVN or a vertebral CF, and Group 3 patients reported AVN or a vertebral CF irrespective of age. As measured by the HAQ DI, disability increased very gradually over time in Group 1 patients and more rapidly in Group 2 and Group 3 patients. The increase in disability in patients experiencing AVN was greater than that in patients with similar pre-AVN disease characteristics who did not develop AVN (P = 0.003). CONCLUSION: In this prospective study of disease course and iatrogenic factors related to functional disability in PM/DM, the HAQ DI increased with disease duration. Corticosteroid-related morbidity, as reflected by the development of AVN or CF, significantly contributed to patient-reported functional disability.

Adult↗

PubMed2006

Injectable bone cements for use in vertebroplasty and kyphoplasty: state-of-the-art review.

Vertebroplasty (VP) and kyphoplasty (KP) are minimally invasive surgical procedures that have recently been introduced for the medical management of osteoporosis-induced vertebral compression fractures. The aim of VP is to stabilize the fractured vertebral body, while the goals of KP are to stabilize the fractured vertebral body and to restore its height to as near its prefracture level as possible. Both procedures involve injection of the setting dough of an injectable bone cement (IBC) into the fractured vertebral body, thereby highlighting the indispensable role that the IBC plays. Although there is a very large literature on IBCs, no detailed critical review of it has been published. Such a review is the subject of the present work, which is in seven parts. The review opens with a succinct introduction to VP and KP. The topics covered in the parts that follow are: (1) a listing of the 18 most desirable properties of an IBC (e.g., easy injectability, high radiopacity, and a resorption rate that is neither too high nor too low); (2) descriptions of the four classes of IBCs (calcium phosphates, acrylic bone cements, calcium sulfates, and composites); (3) concerns that have been raised with regard to the use of IBCs (such as the potential for thermal necrosis of tissue at the peri-augmentation site, when an acrylic bone cement is used); (4) explicative summaries of the main findings of literature studies on the influence of nine factors (such as powder particle size, powder-to-liquid ratio, and the method used to mix the powder and the liquid) on the values of various properties of IBCs; (5) explicative summaries of the main findings of literature studies on five fundamental matters, such as the aging mechanism of the powder, the thermokinetics of a setting dough, and the influence of the type of IBC used on various ex vivo biomechanical performance measures of VP- and KP-augmented vertebral bodies; and (6) descriptions of topics in six areas for future research, such as the determination of an overall index of the fatigue performance of an IBC and the development of internationally recognized standardized testing protocols to employ when a synthetic cancellous bone void model is used in the rapid in vitro screening of IBCs. The review ends with a summary of the most salient points and observations made.

Bone Cements↗

PubMed1989

Noninvasive axial and peripheral assessment of bone mineral content: a comparison between osteoporotic women and normal subjects.

We compared different methods of bone densitometry in women with spinal osteoporosis and normal subjects to assess their discriminatory capability. The methods used included: quantitative computed tomography of the spine (QCT) specified as to trabecular (QCTtrab) and cortical bone (QCTcort), dual-photon absorptiometry of the spine (DPAspine), single-photon absorptiometry of the distal and proximal forearm (SPAdist and SPAprox), and quantitative roentgen microdensitometry of the phalanx (QMD). A total of 25 postmenopausal osteoporotic women and 24 healthy comparison subjects matched for age and years since menopause were studied. In the osteoporotic group an average decrement of the axial bone mineral density of -50% (p less than 0.001) and -20% (p less than 0.001) were observed for QCTtrab and QCTcort, respectively. For DPAspine, SPAdist, SPAprox, and QMD the difference between normal and osteoporotic subjects was -20% (p less than 0.001), -12% (p less than 0.05), -7% (NS), and -6% (NS), respectively. With the peripheral measurements (SPA and QMD), alone or in combination, no adequate discrimination between women with or without vertebral compression fractures could be obtained. Although QCTtrab showed the highest diagnostic sensitivity (81%), it appears not to be superior to DPAspine. Combinations of the various axial and peripheral measurements did not result in an essentially better sensitivity. In normal women as well as in osteoporotic individuals the trabecular and cortical QCT measurements showed two opposite trends, suggesting an increase in cortical and a decrease in trabecular density from L1 to L3.

Absorptiometry, Photon↗

PubMed1990

Osteoporosis as the sole presentation of bone marrow mastocytosis.

Three (young) adults with severe generalized osteopenia and vertebral compression fractures were studied. Extensive clinical and laboratory investigations were not contributory. Undecalcified bone biopsies demonstrated multiple mast cell granulomas in the marrow in two patients and numerous mast cells diffusely distributed throughout the bone marrow in the third patient. Mast cells may serve as a pathogenic agent in osteoporosis. Therefore, we conclude that isolated skeletal mastocytosis without clinical evidence of mast cell mediator release should be sought in the evaluation of a patient with unexplained severe bone loss.

Adult↗