A 45-year-old woman reported the development of thigh pain followed within a year by proximal muscle weakness. Clinical findings included short stature, prominent kyphoscoliosis, proximal weakness, and brisk reflexes. Recognition of an increased level of serum alkaline phosphatase and hypophosphatemia led to the diagnosis of osteomalacia. Identification of iron deficiency anemia and hypocholesterolemia implicated previously unrecognized gluten-sensitive enteropathy with associated vitamin D malabsorption as the cause of the osteomalacia. Adherence to a gluten-free diet and treatment with vitamin D2 resulted in weight gain, resolution of pain, and improvement in strength within 3 months. Painful proximal weakness and hyperreflexia may be the initial and primary manifestations of osteomalacia, a readily treatable cause of muscle and bone disease.

Osteoarticular complications, which are characterized by osseous pain, pathologic fractures, and decreased articular mobility, represent one of the major problems affecting long-term (over 15 years) hemodialysis patients. These changes seem to have a multifactorial etiology; they include osteomalacia, secondary hyperparathyroidism, and dialysis-related amyloidosis. Ten patients (5 males and 5 females, mean age 55 +/- 7 years) on long-term (over 15 years) hemodialysis were submitted to X-ray examinations of the skull, spine, shoulders, wrists, pelvis, and knees. Serum calcium, phosphorous, parathyroid hormone, alkaline phosphatase, and basal aluminium levels were also calculated. Osteopenia was demonstrated in all patients. Seven of them had alterations due to hyperparathyroidism. Six patients exhibited signs related to dialysis spondyloarthropathy; in 9 cases amyloid lesions, geodes, and erosions were present in wrists, humeral heads, or hips. One patient exhibited osteomalacic changes. Most long-term dialysis patients presented multifactorial osteoarticular changes due to hyperparathyroidism, osteomalacia, and dialysis-related amyloidosis. Clinical symptoms and decreased articular mobility appeared to be due mainly to amyloid osteoarthropathy.

Three cases of contracted pelvis in Bedouin women, appearing after two and three previous normal vaginal deliveries, are presented. In these three cases cesarean section had to be performed to deliver the babies. A roentgenray screening revealed osteomalacic pelves in all cases with typical psuedo-fractures (Milkman) and Looser zones. Pelvic deformities of the osteomalacic type are considered rare medical curiosities, and elective cesarean section is usually indicated. It has been found that Bedouins consume large quantities of "raghif", an unleavened bread with high content of phytic acid, very similar to Indian "chapati". Phytic acid impairs the absorption of calcium from the intestine by the precipitation of an amorphous calcium phytate and causes probably some interference with the action of vitamin D. Withdrawal of this alimentation improves the illness. There is emphasis on the fact that vaginal delivery is not granted from a pelvic point of view for multiparous women who have delivered normally in the past. Bedouin women constitute a rather important fraction of the obstetric population admitted to our hospital, the only one in the Negev area. Almost 15 per cent of the deliveries in our Obstetrics Department belong to Bedouin women. The sudden appearance of three consecutive cases of contracted pelvis in which we had to perform ceasarean section on women who had previously delivered vaginally at least twice, produced this investigation, whose interesting results we describe herewith.