Paget’s Disease of Bone (PDB)

Paget’s Disease of Bone (PDB) is relatively uncommon in India compared to Western countries. However, its prevalence appears to be increasing in recent years.

Prevalence:

While large-scale epidemiological studies on PDB in India are limited, several smaller studies and case reports suggest that the prevalence is significantly lower than in Western populations. Some estimates place the prevalence at around 0.1% to 0.5% of the population, compared to 1.5% to 8.3% in Western countries. However, it’s important to note that these numbers may underestimate the true prevalence due to underdiagnosis and reporting.

References:

• A study published in ResearchGate in 2008 titled "Does Paget’s Disease Exist in India?: A series of 21 patients" reported a prevalence of 2.8 cases per 1 million persons in India.[1]
• Another study published in ResearchGate in 2009 titled "Paget’s disease in India" analyzed 48 cases and found that the disease often presents with polyostotic involvement (affecting multiple bones).[2]

Factors influencing prevalence:

Several factors might contribute to the lower prevalence of PDB in India, including:

• Genetic predisposition: Paget’s disease is more common in people of European descent and less common in Asian populations, including those in India.
• Environmental factors: While the exact cause of PDB is unknown, environmental factors may play a role, and these may differ between India and Western countries.
• Awareness and diagnosis: Lack of awareness among healthcare professionals and the general public, as well as limited access to diagnostic facilities, may contribute to underdiagnosis of PDB in India.

It’s important to note that research on Paget’s disease in India is ongoing, and a better understanding of the epidemiology and risk factors is crucial for effective prevention and management strategies.

Types

1. Number of Bones Affected:

• Monostotic: Involves a single bone. This is less common, accounting for about 15% of cases.
• Polyostotic: Involves multiple bones. This is more common, accounting for about 85% of cases.

2. Stage of Disease:

• Active: Characterized by increased bone turnover (formation and breakdown), leading to bone pain, deformity, and increased risk of fractures.
• Inactive: Characterized by decreased bone turnover, with less pain and deformity.

3. Location of Affected Bones:

PDB can affect any bone, but it’s most commonly found in the:

• Pelvis
• Spine
• Skull
• Long bones of the legs (femur, tibia)

Book References:

Several books provide detailed information on Paget’s disease of bone, including its classification and clinical features:

• Primer on the Metabolic Bone Diseases and Disorders of Mineral Metabolism (9th Edition): This comprehensive textbook offers a chapter dedicated to Paget’s disease, covering its epidemiology, etiology, pathophysiology, clinical manifestations, diagnosis, and treatment.[3]
• Endocrine and Metabolic Diseases: A Practical Approach: This book provides a practical guide to the diagnosis and management of endocrine and metabolic disorders, including Paget’s disease.[4]
• The Paget’s Foundation Introduction to Paget’s Disease of Bone: This book is a patient-friendly guide to Paget’s disease, providing information on symptoms, diagnosis, treatment options, and living with the condition.[5]

These references can help you understand the various ways Paget’s disease of bone can present and be classified. It’s important to consult with your doctor for accurate diagnosis and personalized treatment recommendations.

Pathogenesis 

Paget’s disease of bone is characterized by abnormal bone remodeling, leading to structurally disorganized and weakened bone. The process involves three main phases:  

1. Osteolytic Phase: Excessive osteoclastic activity leads to increased bone resorption. Osteoclasts in Paget’s disease are often larger and contain more nuclei than normal.  
2. Mixed Phase: Both osteoclastic and osteoblastic activity occur. The osteoblasts attempt to compensate for the bone loss by rapidly laying down new bone, but this new bone is haphazard and structurally weak, often described as "woven bone."
3. Osteosclerotic Phase: The osteoblastic activity dominates, leading to thickened, but still structurally abnormal, bone. This bone is more prone to fractures and deformities.  

Key Factors in Pathogenesis:

• Genetic Predisposition: Multiple genes have been implicated in Paget’s disease, including SQSTM1 and VCP. Familial cases suggest an autosomal dominant inheritance pattern in some families.
• Environmental Triggers: Viral infections, particularly paramyxoviruses, have been suggested as possible triggers for the disease, but this remains controversial.  
• Osteoclast Dysfunction: The primary driver of Paget’s disease is abnormal osteoclast function. These cells become hyperactive and over-responsive to signals that promote bone resorption.

Note: The specific page numbers regarding Paget’s disease may vary slightly between different editions of the book.

Remember: Paget’s disease is a complex disorder with multiple contributing factors. The exact interplay of these factors is still under investigation.  [7]

Pathophysiology 

Paget’s disease of bone (PDB) is characterized by excessive and abnormal bone remodeling. The process involves three phases:

1. Initial Osteolytic Phase: This phase is marked by increased osteoclastic activity. The osteoclasts are abnormally large and have numerous nuclei. They cause excessive bone resorption, leading to lytic lesions and focal areas of bone weakness.

2. Mixed Osteolytic-Osteoblastic Phase: In this phase, there’s a compensatory increase in osteoblastic activity in an attempt to repair the damage. However, the new bone formation is haphazard and disorganized, leading to the characteristic "mosaic" pattern of woven and lamellar bone. The bone marrow is replaced by highly vascular fibrous tissue.

3. Final Osteosclerotic Phase: In this phase, osteoblastic activity continues, leading to excessive bone deposition and thickening of the affected bone. The new bone is structurally weak and prone to fractures.

Key Points:

• Etiology: The exact cause of PDB is unknown. However, both genetic and environmental factors are thought to play a role.
  
  • Genetic: Familial clustering is seen in about 15-30% of cases. Mutations in the SQSTM1 gene have been identified in some families.
  • Environmental: Viral infections (particularly paramyxoviruses) have been implicated, but the evidence is not conclusive.
• Clinical Features: The clinical manifestations depend on the extent and location of the affected bone.
  
  • Bone Pain: The most common symptom is bone pain, which is often described as deep and aching.
  • Bone Deformity: Enlargement and bowing of the affected bones can occur.
  • Fractures: The abnormal bone is prone to fractures.
  • Neurological Complications: Nerve compression can occur if the skull or spine is involved.
  • High-Output Cardiac Failure: In severe cases, the increased vascularity of the affected bone can lead to high-output cardiac failure.
  • Osteosarcoma: A rare but serious complication is malignant transformation to osteosarcoma.[7].

Clinical Examination of Paget’s Disease of Bone

Patients with Paget’s disease may be asymptomatic or present with a variety of symptoms depending on the affected bones. Common presenting complaints include:

• Bone Pain: This is the most common symptom and can be localized to the affected bone or referred. The pain may be constant or intermittent, dull or aching, and may worsen with activity or at night.
• Bone Deformity: Enlargement and bowing of long bones, especially the tibia and femur, can occur. Skull involvement can lead to an enlarged head (leontiasis ossea) and hearing loss.
• Fractures: The abnormal bone in Paget’s disease is more susceptible to fractures.
• Neurological Complications: Nerve compression can occur due to bone enlargement, leading to symptoms such as hearing loss, facial palsy, or spinal cord compression.
• Secondary Osteoarthritis: Joint degeneration can occur in joints adjacent to affected bones.

Physical Examination Findings:

• Affected Bone:

  • Warmth: Increased vascularity in the affected bone can lead to warmth and increased skin temperature over the area.
  • Tenderness: The bone may be tender to palpation.
  • Enlargement: Enlarged bones may be visible or palpable, especially in the skull, tibia, or femur.
  • Deformity: Bowing of long bones or other deformities may be apparent.

• Neurological Examination:

  • Cranial Nerves: Assess for hearing loss, facial palsy, or other cranial nerve deficits if the skull is involved.
  • Sensory & Motor Function: Evaluate for sensory changes, muscle weakness, or other neurological deficits if spinal cord or nerve compression is suspected.

• Joint Examination:

  • Range of Motion: Assess for decreased range of motion and crepitus in joints adjacent to affected bones.

Additional Considerations:

• Cardiovascular: High-output heart failure can occur in severe cases due to increased vascularity in affected bones.
• Laboratory Findings:
  
  • Elevated Alkaline Phosphatase: This is a hallmark of Paget’s disease and reflects increased bone turnover.
  • Normal Calcium and Phosphate: Serum calcium and phosphate levels are usually normal.
  • Elevated Urine Hydroxyproline: This reflects increased bone resorption.

Remember:

• The clinical examination is just one part of the diagnostic process for Paget’s disease.
• Imaging studies (X-rays, bone scans) are crucial for confirming the diagnosis and assessing the extent of bone involvement.
• It is essential to rule out other conditions that can mimic Paget’s disease, such as metastatic bone disease or primary bone tumors.[3]

Diagnosis of Paget’s Disease of Bone

The diagnosis of Paget’s Disease of Bone (PDB) involves a combination of clinical presentation, laboratory tests, and imaging studies:

1. Clinical Presentation:

   • Bone pain (most common symptom)
   • Skeletal deformities (e.g., enlarged skull, bowing of legs)
   • Pathological fractures
   • Hearing loss (if skull involved)
   • Neurological symptoms (if spine or skull involved)

2. Laboratory Tests:

   • Elevated serum alkaline phosphatase (ALP) – a marker of increased bone turnover
   • Normal calcium and phosphate levels (usually)
   • Elevated urine markers of bone resorption (e.g., N-telopeptide, C-telopeptide)

3. Imaging Studies:

   • X-rays: Characteristic findings include osteolytic (bone destruction) and osteosclerotic (bone thickening) areas, bone enlargement, and deformities.
   • Bone scan: Shows increased uptake in affected areas, helpful for identifying extent of disease.[6]

Important Considerations:

• Asymptomatic patients: PDB is often discovered incidentally on X-rays or blood tests done for other reasons.
• Differential Diagnoses: Other conditions that can mimic PDB include bone metastases, osteomyelitis, and primary bone tumors.
• Early Diagnosis and Management: Early diagnosis and appropriate management are crucial to prevent complications such as fractures, deformities, and neurological problems.

Differential Diagnoses for Paget’s Disease of Bone

1. Osteoarthritis:

   • While PDB can cause joint pain, osteoarthritis is a more common cause, particularly in older individuals.
   • In osteoarthritis, joint space narrowing and osteophyte formation are typical imaging findings, whereas in PDB, the bone itself is enlarged and has a disorganized appearance.

2. Metastatic Bone Disease:

   • Bone pain and elevated alkaline phosphatase levels are seen in both PDB and metastatic bone disease.
   • Imaging findings can sometimes overlap, but metastatic disease often presents with multiple lytic or sclerotic lesions, while PDB typically involves a single bone or a few contiguous bones with a characteristic mixed lytic and sclerotic pattern.

3. Primary Bone Tumors:

   • Certain primary bone tumors, such as osteosarcoma or giant cell tumor, can cause bone pain and localized bone enlargement, mimicking PDB.
   • Biopsy and histopathological examination are essential to differentiate these conditions.

4. Fibrous Dysplasia:

   • This benign bone disorder can cause bone pain, deformity, and fractures, especially in young individuals.
   • Radiographically, fibrous dysplasia typically shows a "ground-glass" appearance, distinct from the mixed lytic-sclerotic pattern seen in PDB.

5. Osteoporosis:

   • Although both PDB and osteoporosis can lead to fractures, osteoporosis typically causes diffuse bone loss with decreased bone density on imaging, whereas PDB shows localized areas of increased bone turnover and abnormal bone remodeling.

6. Hyperparathyroidism:

   • Elevated serum calcium and parathyroid hormone levels are seen in hyperparathyroidism, which can cause bone pain, fractures, and osteolytic lesions.
   • Unlike PDB, hyperparathyroidism usually affects multiple bones and shows a more generalized pattern of bone resorption on imaging.[6]

Important Note:

• It’s essential to perform a thorough clinical evaluation, including a detailed history, physical examination, and appropriate imaging studies, to arrive at the correct diagnosis.
• In some cases, a bone biopsy may be necessary to confirm the diagnosis of Paget’s disease or rule out other conditions.

Complications of Paget’s Disease of Bone

• Bone Fractures and Deformities: Paget’s disease weakens bones, making them more prone to fractures. The excessive bone growth can also lead to deformities, such as bowing of the legs or enlargement of the skull.

• Osteoarthritis: The abnormal bone remodeling in Paget’s disease can place stress on nearby joints, leading to the development of osteoarthritis, a painful degenerative joint disease.

• Neurological Problems: When Paget’s disease affects the skull or spine, it can compress nerves, causing pain, numbness, tingling, or even paralysis. Hearing loss can also occur if the bones of the inner ear are involved.

• Heart Failure: In rare cases, the increased blood flow to the affected bones can put a strain on the heart, potentially leading to heart failure.

• Bone Cancer (Osteosarcoma): While rare, Paget’s disease can increase the risk of developing a type of bone cancer called osteosarcoma.[6]

Investigations for Paget’s Disease of Bone

1. Blood Tests:

   • Serum Alkaline Phosphatase (ALP):
     
     • This is the most sensitive marker for Paget’s disease.
     • Elevated levels indicate increased bone turnover.
     • The degree of elevation often correlates with the extent and activity of the disease.
   • Serum Calcium:
     
     • Usually normal, unless the patient is immobilized or has concurrent hyperparathyroidism.
   • Urinary N-telopeptide (NTx) and C-telopeptide (CTx):
     
     • These are markers of bone resorption and may be elevated in active Paget’s disease.

2. Imaging Studies:

   • X-rays:
     
     • Often the first imaging test performed.  
     • Can show characteristic findings like bone enlargement, cortical thickening, lytic lesions, and osteosclerosis.
     • May also reveal complications like fractures, osteoarthritis, and bone deformities.
   • Bone Scan:
     
     • Highly sensitive for detecting areas of increased bone turnover.
     • Useful for assessing the extent and activity of the disease, especially in patients with normal ALP levels.
     • Can also help identify complications like fractures and bone tumors.

3. Other Investigations:

   • Bone Biopsy:
     
     • Rarely needed for diagnosis but may be considered in atypical presentations or to rule out other bone diseases.
     • Histologic examination shows characteristic mosaic pattern of lamellar bone.  
   • Computed Tomography (CT) or Magnetic Resonance Imaging (MRI):
     
     • May be helpful for evaluating specific complications, such as spinal stenosis, nerve compression, or bone tumors.  

Interpretation of Findings

• Elevated ALP with normal calcium suggests Paget’s disease.  
• Characteristic X-ray findings confirm the diagnosis.  
• Bone scan shows increased uptake in affected areas.
• Bone biopsy, if performed, shows mosaic pattern of bone.  

Important Considerations

• Asymptomatic patients with incidentally detected elevated ALP should be investigated further to confirm or rule out Paget’s disease.
• The extent of investigations may vary depending on the patient’s symptoms and clinical presentation.
• A multidisciplinary approach involving rheumatologists, endocrinologists, and orthopedic surgeons may be needed for optimal management of Paget’s disease and its complications.[8]

Treatment of Paget’s Disease of Bone

Primary Treatment Modality: Bisphosphonates

• Mechanism: These drugs inhibit osteoclast activity, thereby reducing bone resorption and turnover, leading to a decrease in pain and normalization of bone markers (alkaline phosphatase).
• Administration:
  
  • Oral: Alendronate, risedronate
  • Intravenous: Zoledronic acid, pamidronate  

Choice of Bisphosphonate and Regimen

• Asymptomatic patients: Often no treatment is necessary, but if alkaline phosphatase is significantly elevated, or there’s a risk of complications, oral bisphosphonates may be considered.
• Symptomatic patients: Intravenous zoledronic acid is often the preferred initial therapy due to its efficacy and ease of administration.
• Monitoring: Alkaline phosphatase levels and bone-specific markers are checked periodically to assess treatment response.

Other Treatment Options:

• Calcitonin: A less commonly used option for patients who cannot tolerate bisphosphonates. It is given by injection or nasal spray.  
• Surgery: May be necessary in cases of severe bone deformity, fractures, or nerve compression.
• Pain Management: Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used for pain relief.

Important Considerations:

• Calcium and Vitamin D Supplementation: Adequate intake is crucial for optimal bone health.
• Dental Care: Patients should maintain good oral hygiene and have any necessary dental work done before starting bisphosphonate therapy due to the rare risk of osteonecrosis of the jaw.
• Monitoring for Complications: Regular follow-up with a physician is essential to monitor for complications such as hearing loss, fractures, and neurological symptoms.

Key Points:

• Bisphosphonates are the mainstay of treatment for Paget’s disease of bone.  
• Treatment decisions are individualized based on the patient’s symptoms, disease severity, and potential complications.
• Regular monitoring and follow-up are crucial for optimizing treatment outcomes and managing potential complications.[8]

Prevention of Paget’s Disease of Bone

Unfortunately, the exact cause of Paget’s disease of bone remains unknown, which makes primary prevention challenging. There are no specific lifestyle changes or preventative measures that are guaranteed to prevent the onset of this condition. However, some recommendations can promote overall bone health and potentially reduce the risk of complications associated with Paget’s disease if it does develop.

• Maintain a Healthy Lifestyle:

  • A balanced diet rich in calcium and vitamin D is essential for bone health.
  • Regular weight-bearing exercise can also help maintain bone density and strength.
  • Avoiding smoking and excessive alcohol consumption is crucial for overall health, including bone health.

• Early Detection and Management:

  • While there is no way to prevent Paget’s disease itself, early diagnosis and management can significantly improve outcomes. If you have a family history of Paget’s disease or experience any symptoms such as bone pain, fractures, or deformities, consult your doctor for evaluation.[3]

Homeopathic Treatment for Paget’s Disease of Bone

Homeopathy offers a holistic approach to managing Paget’s disease of bone by focusing on the individual’s unique symptoms and constitutional tendencies. While conventional medicine primarily aims to control pain and slow the progression of the disease, homeopathy aims to stimulate the body’s inherent healing capabilities and address the underlying imbalances that contribute to the condition.

Key Considerations:

• Individualization: Homeopathic treatment is highly individualized. A detailed case analysis considers the patient’s physical, mental, and emotional symptoms, as well as their medical history and family background.

• Constitutional Remedy: The goal is to find the patient’s "constitutional remedy," a single medicine that matches their overall symptom picture and underlying predisposition.

• Symptom Management: Homeopathic remedies can also be used to target specific symptoms such as bone pain, deformities, or neurological complications.

Potential Homeopathic Remedies:

Calcarea carbonica:

This remedy is often considered for patients with Paget’s disease who experience bone pain, deformities, and a tendency towards obesity.

Calcarea fluorica:

This remedy is indicated for patients with bone hardening, exostoses (bony growths), and joint stiffness.

Phosphorus:

This remedy may be helpful for patients with bone pain, weakness, and a tendency towards anxiety and restlessness.

Silicea:

This remedy is often considered for patients with brittle bones, deformities, and a tendency towards coldness and sensitivity.

Symphytum:

This remedy is known for its bone-healing properties and may be used to support fracture healing in Paget’s disease.

Important Considerations:

• Consultation with a Homeopath: It is essential to consult a qualified homeopath for a proper diagnosis and individualized treatment plan.
• Conventional Treatment: Homeopathy can be used as a complementary therapy alongside conventional treatment for Paget’s disease.
• Ongoing Management: Homeopathic treatment is often an ongoing process that requires regular follow-ups and adjustments as the patient’s condition evolves.

Disclaimer: Homeopathy is a complementary therapy and should not be considered a substitute for conventional medical treatment for Paget’s disease. It is crucial to consult with your doctor before starting any new treatment, including homeopathy.  

Remember:

• Homeopathy offers a personalized approach to managing Paget’s disease.
• Consult a qualified homeopath for a comprehensive assessment and individualized treatment plan.
• Use homeopathy as a complementary therapy alongside conventional medical care.

Diet and Regimen for Paget’s Disease of Bone

A balanced diet and healthy lifestyle are essential components in managing Paget’s Disease of Bone, alongside medical treatment. While there’s no specific diet to cure the disease, certain recommendations help maintain bone health and manage symptoms.

Dietary Recommendations

• Calcium & Vitamin D: Adequate intake is crucial for bone health. Include dairy products, leafy greens, fortified foods, and consider supplements if dietary intake is insufficient.
• Protein: Supports muscle and bone health. Choose lean sources like poultry, fish, beans, and lentils.
• Fruits & Vegetables: Provide essential vitamins, minerals, and antioxidants. Aim for a variety of colorful options.
• Limit Sodium: High sodium intake can lead to calcium loss. Avoid processed foods and excessive salt.
• Hydration: Adequate water intake is essential for overall health, including bone health.

Lifestyle Recommendations

• Weight-bearing Exercise: Helps maintain bone density and strength. Consult your doctor for suitable activities like walking, dancing, or tai chi.
• Avoid Smoking & Excessive Alcohol: These habits negatively impact bone health and overall well-being.
• Manage Pain: Use heat therapy, gentle stretching, or relaxation techniques to alleviate pain. Consult your doctor for appropriate pain medication if needed.
• Assistive Devices: Use canes, walkers, or braces as recommended by your doctor to improve mobility and prevent falls.
• Regular Checkups: Monitor the progression of the disease and adjust treatment as needed. [3]

Do’s and Don’ts of Paget’s Disease of Bone

Managing Paget’s disease involves a combination of medical treatment and lifestyle modifications. Here are some key do’s and don’ts to help you navigate the condition effectively:

Do’s

• Consult Your Doctor Regularly: Regular check-ups are vital to monitor disease progression, adjust medication as needed, and address any emerging complications.
• Follow Medical Advice: Adhere to your doctor’s prescribed treatment plan, including medication and any recommended physical therapy or assistive devices.
• Maintain a Healthy Diet: Prioritize a balanced diet rich in calcium and vitamin D, crucial for bone health.
• Exercise Regularly: Engage in weight-bearing exercises as recommended by your doctor or physical therapist to maintain bone strength and improve mobility.
• Manage Pain: Use heat therapy, gentle stretching, or relaxation techniques. If needed, discuss appropriate pain medication with your doctor.
• Use Assistive Devices: Utilize canes, walkers, or braces as recommended to improve mobility and prevent falls.
• Prevent Falls: Take precautions to avoid falls, such as removing tripping hazards at home and using grab bars in bathrooms.
• Stay Informed: Educate yourself about the disease, its potential complications, and treatment options.
• Communicate: Discuss any concerns or questions you have with your healthcare team.

Don’ts

• Ignore Symptoms: Don’t dismiss persistent bone pain, deformities, or other symptoms. Seek medical attention for prompt diagnosis and treatment.
• Self-Treat: Avoid self-medicating or relying solely on alternative therapies without consulting your doctor.
• Overexert: Avoid high-impact activities or exercises that could put undue stress on affected bones.
• Smoke or Drink Excessively: These habits can worsen bone health and negatively impact overall well-being.
• Neglect Mental Health: Paget’s disease can affect emotional well-being. Don’t hesitate to seek support or counseling if you’re feeling anxious or depressed.

Additional Considerations

• Protect Your Joints: If Paget’s disease affects your joints, be mindful of protecting them from excessive strain.
• Listen to Your Body: Pay attention to your body’s signals and adjust your activity levels as needed.
• Be Patient: Managing Paget’s disease is a long-term process. Be patient with yourself and your body’s healing journey.

Terminology

• Paget’s Disease of Bone: A chronic bone disorder characterized by abnormal bone remodeling, leading to enlarged, weakened, and deformed bones.
• Osteoclasts: Cells responsible for breaking down old bone tissue.
• Osteoblasts: Cells responsible for building new bone tissue.
• Bone Remodeling: The continuous process of bone breakdown and rebuilding.
• Osteolytic Phase: The initial phase of Paget’s disease where osteoclasts become overactive, leading to excessive bone breakdown.
• Mixed Phase: The phase where both osteoclasts and osteoblasts are overactive, resulting in rapid, chaotic bone turnover and the formation of disorganized bone.
• Osteosclerotic Phase: The final phase where osteoblasts dominate, leading to the formation of dense, but weak and brittle, bone.
• Bisphosphonates: A class of drugs that inhibit osteoclast activity and slow down bone breakdown.
• Calcitonin: A hormone that can also help reduce bone breakdown.
• Pain Management: Strategies to reduce pain associated with Paget’s disease, including medication, physical therapy, and assistive devices.
• Bone Deformities: Changes in bone shape, such as bowing of the legs or enlargement of the skull.
• Osteoarthritis: Joint pain and inflammation that can occur when Paget’s disease affects bones near joints.
• Neurological Complications: Nerve compression or damage that can occur when Paget’s disease affects the skull or spine.
• Osteosarcoma: A rare but serious complication of Paget’s disease, where bone cancer develops in affected areas.

Paget’s Disease Of Bone Also Search As

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Homeopathic Websites and Databases:

National Center for Homeopathy (NCH): The NCH website features a searchable database of articles and resources related to homeopathy.

Homeopathy Plus: This website offers a collection of articles and research papers on various health conditions, including Paget’s Disease.

The American Institute of Homeopathy: Their website provides information about homeopathy and may have links to relevant articles.  

Homeopathic Journals and Publications:

The Journal of the American Institute of Homeopathy

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