Characterisation of Patients with Postmenopausal Osteoporosis in French Primary Healthcare [Optimization of calcium intake for the prevention of osteoporosis and osteoporotic fractures: a review of the evidence]. The effect of homocysteine-lowering with B-vitamins on osteoporotic fractures in patients with cerebrovascular disease: substudy of VITATOPS, a randomised placebo-controlled trial Treatment with denosumab reduces secondary fracture risk in women with postmenopausal osteoporosis Probability of fractures predicted by FRAX® and observed incidence in the Spanish ECOSAP Study cohort. Cost-equivalence of different osteoporotic fractures Randomized controlled trial of a primary care–based screening program to identify older women with prevalent osteoporotic vertebral fractures: Cohort for skeletal health in Bristol and Avon (COSHIBA) Effect of daily vitamin B-12 and folic acid supplementation on fracture incidence in elderly individuals with an elevated plasma homocysteine concentration: B-PROOF, a randomized controlled trial. Use of Calcium Supplements, Vitamin D Supplements and Specific Osteoporosis Drugs Among French Women Aged 75–85 Years: Patterns of Use and Associated Factors Prescribing by general practitioners after an osteoporotic fracture A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures Ten-year risk of osteoporotic fractures in postmenopausal Chinese women according to clinical risk factors and BMD T-scores: a prospective study. Extra virgin olive oil consumption reduces the risk of osteoporotic fractures in the PREDIMED trial. Osteoporosis prevalence and levels of treatment in primary care: the Australian BoneCare Study. Effect of raloxifene combined with monofluorophosphate as compared with monofluorophosphate alone in postmenopausal women with low bone mass: a randomized, controlled trial Targeted intervention reduces refracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study Predicting risk of osteoporotic fracture in men and women in England and Wales: prospective derivation and validation of QFractureScores Effects of risedronate alone or combined with vitamin K2 on serum undercarboxylated osteocalcin and osteocalcin levels in postmenopausal osteoporosis Cost-effectiveness of bisphosphonate therapies for women with postmenopausal osteoporosis: implications of improved persistence with less frequently administered oral bisphosphonates
Background The public health burden of osteoporosis is high , principally because of increased risk of fractures and associated morbidity , h and icap and mortality . Osteoporotic fracture prevention is therefore an important public health goal . General practitioners ( GPs ) play a key role in the management of osteoporosis , both in ensuring timely diagnosis and in providing treatment . Little information is available on st and ards of care for postmenopausal women with osteoporosis in general practice . Objectives The primary objective of this study was to describe risk factors and treatment in postmenopausal women with osteoporosis . Secondary objectives were to evaluate treatment compliance and to assess the impact of osteoporosis on quality of life . Methods This observational , cross-sectional , pharmacoepidemiological study was performed in a primary -care setting in France . A r and om sample of GPs recruited postmenopausal women with a diagnosis of osteoporosis who had been followed by the investigator for at least 2 years . At inclusion , investigators completed a question naire providing information on patient age , osteoporosis duration , risk factors and treatment history . The first three patients recruited by each investigator completed a question naire providing information on sociodemographic features , osteoporosis treatments and quality of life . Treatment compliance was quantified using the Test d’Evaluation de l’Observance and quality of life evaluated using the 12-item Short Form Health Survey ( SF-12 ) . Results Overall , 389 physicians included 3097 patients , of whom 1053 completed the patient question naire . Risk factors for osteoporotic fracture were identified in 2148 patients ( 69.4 % ) , most frequently personal or maternal antecedents of osteoporotic fracture and a low body mass index . Of these , 946 ( 44.0 % ) presented more than one risk factor . At the time of diagnosis , 629 patients ( 59.7 % ) presented fractures , which involved the vertebrae in 51.7 % of cases , the wrist in 40.5 % and the hip in 5.4 % . Older patients were more likely to have fractures at the time of diagnosis and to have multiple fractures . After diagnosis , at least one new fracture occurred in 201 patients ( 19.2 % ) . Multivariate logistic regression analysis identified age > 70 years , diagnosis at least 10 years previously , diagnosis based on the presence of a fracture , biochemical and haematological evaluation at the time of diagnosis , and a change in osteoporosis treatment in the previous 2 years as being significantly associated with incident fracture risk . At inclusion , 1019 patients ( 97.4 % ) were receiving treatment for osteoporosis , most frequently weekly bisphosphonates ( 71.6 % of treatments ) . Most patients ( 81.0 % ) had been treated for at least 1 year . Treatment compliance was high in 61 % of patients and low in < 5 % . Patient variables associated with high compliance were being retired , prescription of bisphosphonates and , among the bisphosphonate users , prescription of weekly formulations . SF-12 quality -of-life scores were low , ranging from 38.6 ( energy/vitality ) to 65.1 ( social functioning ) out of a possible maximum score of 100 . Baseline variables associated with SF-12 physical component summary scores included age , height loss since menopause , diagnosis following a fracture , fracture incidence since diagnosis , time since diagnosis and treatment with bisphosphonates . Conclusions In this study of postmenopausal osteoporosis in the French primary healthcare setting , many women with osteoporosis were diagnosed following a fracture . Although most were treated with bone-consolidating drugs , compliance was suboptimal in a significant minority . Osteoporotic fracture was associated with reduced quality of life One of the main focuses of lifestyle modification for the prevention of osteoporosis and osteoporotic fractures  in Japan is improvement in dietary calcium intake . However , virtually no r and omized controlled trial to assess the preventive effects of administration of calcium on the risk of fractures has been conducted in Japan . In this study , we review ed all the scientific papers currently available from medical literature data bases to propose evidence -based recommendations on the preventive procedures for osteoporosis . The result of the present systematic review gives the evidence showing that calcium supplementation or optimal dietary calcium intake increases bone density in childhood and adolescence and reduces the risk of fracture due to osteoporosis in the elderly people regardless of the gender . The evidence also supports the current health policy guiding the elderly to increase their dietary calcium intake in daily life Background Homocysteine has been postulated as a novel , potentially reversible risk factor for osteoporosis and related fractures . We evaluated whether homocysteine-lowering therapy with B-vitamins in patients with symptomatic cerebrovascular disease reduced the incidence of osteoporotic fractures . Methods VITAmins To Prevent Stroke ( VITATOPS ) was a prospect i ve r and omised double-blind placebo-controlled trial in which 8,164 patients with recent ( within 7 months ) stroke or transient ischemic attack were r and omly allocated to double-blind treatment with one tablet daily of either placebo ( n = 4,075 ) or B-vitamins ( folic acid 2 mg , vitamin B6 25 mg , vitamin B12 500 μg ; n = 4,089 ) . Patients were review ed every six months . Any osteoporotic fracture and osteoporotic hip fractures were secondary outcome events , and were review ed by a masked adjudication committee . Analysis was by intention to treat . Logistic regression was used to identify independent predictors of fracture . Results Participants had a mean age of 62.6 years ( SD 12.5 years ) and 64 % were male , 42 % of Western European descent and 75 % were functionally independent ( Oxford H and icap Scale of two or less ) . After a median duration of 2.8 years therapy and 3.4 years follow-up , there was no significant difference in the incidence of any osteoporotic fracture between participants assigned B-vitamins ( 67 [ 1.64 % ] ) and placebo ( 78 [ 1.91 % ] ; risk ratio [ RR ] 0.86 , 95 % confidence interval [ CI ] 0.62 - 1.18 ) or the incidence of hip fractures ( 34 [ 0.83 % ] B-vitamins vs. 36 [ 0.88 % ] placebo ; RR 0.94 , 95 % CI 0.59 - 1.5 ) . There was no significant impact of B-vitamin therapy on time to first fracture . Baseline homocysteine levels did not predict any osteoporotic fracture ( p = 0.43 ) . Independent predictors of any osteoporotic fracture were female sex , age > 64 years , Western European ethnicity and use of anti-osteoporosis medication at r and omization ( all p < 0.01 ) . Conclusions Once daily treatment with B-vitamins had no effect on incidence of osteoporotic fractures during a median of 3.4 years follow-up in patients with cerebrovascular disease . A modest effect of B-vitamin therapy is not excluded due to the low numbers of fracture outcome events . Trial registration Clinical trials.gov number : NCT00097669 and is rct n.org number : IS RCT N74743444 Objectives A history of prior fracture is one of the strongest predictors of a future fragility fracture . In FREEDOM , denosumab significantly reduced the risk of new vertebral , non-vertebral , and hip fractures . We carried out a post-hoc analysis of FREEDOM to characterize the efficacy of denosumab in preventing secondary fragility fractures in subjects with a prior fracture . Methods A total of 7808 women aged 60–90 years with a bone mineral density T-score of less than − 2.5 but not less than − 4.0 at either the lumbar spine or total hip were r and omized to subcutaneous denosumab 60 mg or placebo every 6 months for 36 months . The anti-fracture efficacy of denosumab was analyzed by prior fracture status , to assess secondary fragility fracture , and by subject age , prior fracture site and history of prior osteoporosis medication use . Results A prior fragility fracture was reported for 45 % of the overall study population . Compared with placebo , denosumab significantly reduced the risk of a secondary fragility fracture by 39 % ( incidence , 17.3 % vs. 10.5 % ; p < 0.0001 ) . Similar results were observed regardless of age or prior fracture site . In the overall population , denosumab significantly reduced the risk of a fragility fracture by 40 % ( 13.3 % vs. 8.0 % ; p < 0.0001 ) , with similar results observed regardless of history of prior osteoporotic medication use . Conclusions Denosumab  reduced the risk of fragility fractures to a similar degree in all risk subgroups examined , including those with prior fragility fractures . Identifying and treating high-risk individuals could help to close the current care gap in secondary fracture prevention PURPOSE To assess the ability of the Spanish version of the WHO fracture risk assessment tool ( FRAX ® ) to predict the observed incident fractures in the ECOSAP Study cohort . METHODS 5201 women , aged 65 or older , were enrolled in a three-year , prospect i ve study by a non-r and omized sampling of consecutive cases in 58 primary care centers in Spain . Participants completed an osteoporosis and fracture risk question naire and attended follow-up visits every 6 months . All radiologically or surgically confirmed low-trauma , non-spinal fractures were collected . The individual 10-year absolute risks of hip and major osteoporotic fractures were calculated with the FRAX ® algorithms for Spain without the inclusion of the bone mineral density ( BMD ) measurements . Calibration was evaluated by comparing the three-year estimated ( E ) fractures predicted with FRAX ® with the number of observed ( O ) fractures , and their discriminative ability for the probability of new fractures with the area under the receiving operating characteristic ( ROC ) curves . RESULTS Fifty ( 0.96 % ) women sustained an incident hip fracture , and 201 ( 3.81 % ) women presented with major osteoporotic fractures ( hip , forearm or humerus ) . The E/O ratios for hip and major osteoporotic fractures were 1.10 and 0.66 respectively . Clinical vertebral fractures were not collected ; therefore , the E/O ratio for major fractures should be expected to be lower . The difference between E and O cases reached statistical significance ( χ(2 ) , p<0.001 ) . Areas under the ROC curves were 0.640 and 0.615 for hip and major osteoporotic fractures respectively . CONCLUSIONS The Spanish FRAX ® underestimates the risk for major osteoporotic fractures . The estimated risk for hip fractures was similar to the observed fractures ; however the algorithm had only modest discriminative ability . These results should be interpreted in the context of the relatively low number of observed fractures , especially at the hip Methods Among 985 Olmsted County , Minnesota , residents who experienced an osteoporotic fracture ( distal forearm , humerus , clavicle/scapula/sternum , ribs , vertebrae , pelvis , hip , other femur or tibia/fibula [ the latter in women only ] ) , we estimated the incremental cost of direct medical care in the following year compared with age- and sex-matched controls without a fracture r and omly sample d from the same community . Results The overall median incremental ( case minus control ) cost in the succeeding year was $ 2390 , with a particularly high incremental cost for hip fractures ( $ 11,241 ) . There was fair concordance between the incremental cost of the different fractures , relative to hip fracture alone , and the previously published disutility associated with each fracture type relative to hip fracture . Overall , the incremental cost for all osteoporotic fractures combined was 46 % greater than that for hip fractures alone in women and 47 % greater in men . This is consistent with the earlier report that overall morbidity from all osteoporotic fractures combined is 47 % and 39 % greater in women and men , respectively , than the morbidity attributable solely to hip fractures . Conclusion These data lend support to the notion that other osteoporotic fractures can be quantified relative to hip fracture on the basis of their cost , as well as their morbidity and mortality . This may simplify health economic analyses by allowing all fracture outcomes to be modeled relative to hip fractures ( i.e. , hip fracture ' equivalents ' ) and will provide a more comprehensive assessment of osteoporosis outcomes than is possible by focusing only on hip fractures Approximately 12 % of postmenopausal women have osteoporotic vertebral fractures ( VFs ) ; these are associated with excess morbidity and mortality and a high risk of future osteoporotic fractures . Despite this , less than one-third come to clinical attention , partly due to lack of clear clinical triggers for referral for spinal radiographs . The aim of this study was to investigate whether a novel primary care – based screening tool could be used to identify postmenopausal women with osteoporotic VFs and increase appropriate management of osteoporosis . A r and omized controlled trial was undertaken in 15 general practice s within the Bristol area of the UK . A total of 3200 women aged 65 to 80 years were enrolled , with no exclusion criteria . A simple screening tool was carried out by a nurse in primary care to identify women at high risk of osteoporotic VFs . All identified high-risk women were offered a diagnostic thoracolumbar radiograph . Radiographs were reported using st and ard National Health Service ( NHS ) reporting , with results sent back to each participant 's general practitioner ( GP ) . Participants in the control arm did not receive the screening tool or radiographs . The main outcome measure was self-reported prescription of medication for osteoporosis at 6 months with a r and om 5 % sub sample verified against electronic GP records . Secondary outcome was self-reported incidence of new fractures . Results showed that allocation to screening increased prescription of osteoporosis medications by 124 % ( odds ratio [ OR ] for prescription 2.24 at 6 months ; 95 % confidence interval [ CI ] , 1.16 to 4.33 ) . Allocation to screening also reduced fracture incidence at 12-month follow-up ( OR for new fracture 0.60 ; 95 % CI , 0.35–1.03 ; p = 0.063 ) , although this did not reach statistical significance . This study supports the use of a simple screening tool administered in primary care to increase appropriate prescription of medications for osteoporosis in postmenopausal women in the UK . © 2012 American Society for Bone and Mineral BACKGROUND Elevated plasma homocysteine concentrations are a risk factor for osteoporotic fractures . Lowering homocysteine with combined vitamin B-12 and folic acid supplementation may reduce fracture risk . OBJECTIVE This study [ B-vitamins for the PRevention Of Osteoporotic Fractures ( B-PROOF ) ] aim ed to determine whether vitamin B-12 and folic acid supplementation reduces osteoporotic fracture incidence in hyperhomocysteinemic elderly individuals . DESIGN This was a double-blind , r and omized , placebo-controlled trial in 2919 participants aged ≥65 y with elevated homocysteine concentrations ( 12 - 50 μmol/L ) . Participants were assigned to receive daily 500 μg vitamin B-12 plus 400 μg folic acid or placebo supplementation for 2 y. Both intervention and placebo tablets also contained 600 IU vitamin D3 . The primary endpoint was time to first osteoporotic fracture . Exploratory prespecified subgroup analyses were performed in men and women and in individuals younger than and older than age 80 y. Data were analyzed according to intention-to-treat and per- protocol principles . RESULTS Osteoporotic fractures occurred in 61 persons ( 4.2 % ) in the intervention group and 75 persons ( 5.1 % ) in the placebo group . Osteoporotic fracture risk was not significantly different between groups in the intention-to-treat analyses ( HR : 0.84 ; 95 % CI : 0.58 , 1.21 ) or per- protocol analyses ( HR : 0.81 ; 95 % CI : 0.54 , 1.21 ) . For persons aged > 80 y , in per- protocol analyses , osteoporotic fracture risk was lower in the intervention group than in the placebo group ( HR : 0.27 ; 95 % CI : 0.10 , 0.74 ) . The total number of adverse events ( including mortality ) did not differ between groups . However , 63 and 42 participants in the intervention and placebo groups , respectively , reported incident cancer ( HR : 1.56 ; 95 % CI : 1.04 , 2.31 ) . CONCLUSIONS These data show that combined vitamin B-12 and folic acid supplementation had no effect on osteoporotic fracture incidence in this elderly population . Exploratory subgroup analyses suggest a beneficial effect on osteoporotic fracture prevention in compliant persons aged > 80 y. However , treatment was also associated with increased incidence of cancer , although the study was not design ed for assessing cancer outcomes . Therefore , vitamin B-12 plus folic acid supplementation can not be recommended at present for fracture prevention in elderly people . The B-PROOF study was registered with the Netherl and s Trial Register ( trialregister.nl ) as NTR1333 and at clinical trials.gov as NCT00696414 Background Despite the availability of effective preventive and curative medications for osteoporosis , and guidelines for its diagnosis and management , few individuals are treated for osteoporosis , even among those who have already had a fracture . Objectives Our objective was to describe the patterns of use of medication for osteoporosis , i.e. , calcium supplements , vitamin D supplements , and specific anti-osteoporotic drugs , such as bisphosphonates , in a large sample of French older women living at home , and to identify individual factors associated with use of these medications overall and in two specific clinical situations . Methods Cross-sectional analysis of data from 4,221 women aged 75–85 years who participated in a balance and mobility examination as part of the screening procedure for the Ossébo study , a r and omized controlled trial testing the effectiveness of exercise for the prevention of fall-related injuries .  Electoral rolls  were used to invite women in 16 towns to participate ( participation rate 10.3 % ) . Information collected through question naires included current medication use and , in particular , use of osteoporosis medications ( specific osteoporosis drugs , calcium and vitamin D supplementation ) in the past 6 months , and history of fracture since the age of 50 , including fracture locations . Fractures were categorized in three groups : no fracture , major osteoporotic fracture ( hip , humerus , wrist , pelvis , and vertebra ) , and other fracture . Results Nearly 48 % of the participants reported they did not take calcium or vitamin D supplements or any specific  osteoporosis drugs  . Of the 2,133 women who reported using osteoporosis medication , 85 % used  vitamin D supplements ( 25 % as the sole medication against this disease ) , 59 % calcium supplements , and 42 % a specific anti-osteoporotic drug ( 75 % of them combining it with vitamin D supplementation ) . The use of any osteoporosis medication was significantly associated ( p < 0.001 ) with a history of a major osteoporotic fracture , lower weight , dual-energy X-ray absorptiometry ( DXA ) bone-density measurement in the past 5 years , a cancer-screening examination in the past 5 years , and a positive attitude toward medication use in general . Living alone was associated with a lower likelihood of using a specific anti-osteoporotic drug  , and a higher education level was associated with a higher likelihood of vitamin D supplementation . Of the 1,553 women who had already had a major osteoporotic fracture , one-third ( 34.8 % ) were not taking any osteoporosis medication . In this subgroup , use of this medication was associated with the same factors as in the overall study population . In particular , neither older age nor a history of falls in the previous 12 months was associated with a higher likelihood of using osteoporosis medication . Among the 909 women who reported using a specific osteoporosis drug , vitamin D use was associated with a higher educational level and a more frequent preventive attitude . Conclusion In France , as in other western countries , women aged 75 years and over are not managed according to guidelines . Further studies should address the barriers encountered in improving quality of care in osteoporosis management OBJECTIVES Osteoporosis is a major cause of morbidity and cost . Patients sustaining one osteoporotic fracture are at increased risk of having another fracture . The objective of this study was to examine the use of “ bone drugs ” for the prevention of further osteoporotic fractures among patients who have had a “ typical ” osteoporotic fracture . METHODS This study took a r and om sample of 300 women aged 50 and over who had sustained either a vertebral , hip or Colles fracture in 1995 from the General Practice Research Data base ( GPRD ) and compared their use of bone drugs with 300 age and practice matched controls . RESULTS Compared with age and practice matched control patients only vertebral fracture patients showed a statistically significant increase in the use of bone drugs in the year after fracture ( 39 % and 2 % for cases and controls respectively ; 95 % CI of difference 27 % to 47 % ) . Etidronate was the most commonly used compound . CONCLUSION The majority of patients sustaining an osteoporotic fracture are not prescribed any pharmaceutical agents for the secondary prevention of fracture one year after a primary fracture Introduction Despite the high risk for subsequent fracture following an initial osteoporotic fracture , the majority of subjects with minimal trauma fractures receive no treatment for osteoporosis . The primary aim of this investigation was to determine whether an information-based intervention could change post-fracture management of osteoporosis . A secondary aim was to define participant- and doctor-related barriers to osteoporosis management . Methods Consecutive fracture patients ( n=254 ) from the outpatient fracture clinic at St Vincent ’s Hospital , Sydney were interviewed over a 15-month period ( February 2002–July 2003 ) . Fracture risk factors , prior investigation and treatment for osteoporosis were collected at baseline . Participants were initially contacted after 3 months to ascertain follow-up management . All those not investigated or treated by their primary care physician were then r and omized to either a personalized letter or the same letter plus an offer of a free bone mineral density ( BMD ) test . Participants were contacted after 9 months to record further investigations or treatment for osteoporosis . Results Less than 20 % of the participants had a primary care physician follow-up 3 months after the fracture , leaving 159 who were r and omized to a personalized letter ( n=79 ) and a personalized letter plus the offer of a free BMD test ( n=80 ) . There was a significant increase in the number of people investigated for osteoporosis in the group receiving the letter plus BMD offer [ 38 % ( letter + BMD ) vs. 7 % ( letter only ) ; p=0.001 ) . A high proportion of those tested had low BMD ( 49 % osteopenia and 17 % osteoporosis ) . However , the rates of treatment in both groups were very low ( 6 % ) . Furthermore , even among the few individuals ( 23 % ) who contacted their primary care physician , only 25 % were recommended treatment . The belief that the fracture was osteoporotic was an independent predictor of having a BMD test , a primary care physician follow-up and treatment . Other independent predictors were age over 50 years for a primary care physician follow-up , female sex for having a BMD test and having had a BMD test for treatment . Conclusion This study demonstrates that an information-based intervention led to a modest increase in the proportion of people investigated for osteoporosis ; however . there was no significant effect on treatment rates . The offer of a free BMD assessment was associated with a significantly higher rate of investigation than a personalized letter alone ( odds ratio : 8.5 ; 95 % confidence interval : 3.1–24.5 ) , but this investigation did not affect treatment rate . The low uptake of either a BMD or a visit to a primary care physician together with low rates of treatment recommendation even among people who contacted their primary care physician reflects significant participant and doctor-related barriers to osteoporosis management UNLABELLED Independent risk factors for osteoporotic fracture were identified for a Southern Chinese postmenopausal population .  Clinical risk factor assessment with or without BMD measurement was shown to be an effective predictor of 10-yr risk of osteoporotic fracture and provides a more accessible tool for patient evaluation . INTRODUCTION Asian-specific data on risk factors for osteoporosis remain sparse . However , risk factor assessment , in addition to BMD measurement , is increasingly recognized as a reliable predictor of absolute osteoporotic fracture risk . The purpose of this prospect i ve study was to determine the specific independent risk factors for osteoporotic fracture and to predict the 10-yr risk of osteoporotic fracture in the postmenopausal Southern Chinese population . MATERIAL S AND METHODS A total of 1435 community-dwelling , postmenopausal , treatment-naive women were recruited . Baseline demographic characteristics and clinical risk factors were obtained , and  BMD at the spine and  hip  was measured . Subjects were followed for outcomes of incident low trauma fracture . Ten-year risk of osteoporotic fracture was predicted from the risk factor assessment and BMD measurement by Cox proportional hazards models . RESULTS The mean age of subjects was 63.4 + /- 8.3 yr . After 5.0 + /- 2.3 yr ( range , 1.0 - 11.0 yr ) of follow-up , 80 nontraumatic new fractures were reported during follow-up . Eight independent clinical risk factors identified at baseline were found to be significant predictors of osteoporotic fracture , with the most important being use of walking aids ( RR , 4.2 ; 95 % CI , 2.7 - 6.7 ; p < 0.001 ) and a history of fall ( RR , 4.0 ; 95 % CI , 2.5 - 6.2 ; p < 0.001 ) . Other predictive factors included being homebound , calcium intake < 400 mg/d , age > 65 yr , history of fracture , and BMI < 19 kg/cm(2 ) . Subjects with three to eight clinical risk factors had a predicted 10-year risk of osteoporotic fracture of 25 % , which increased to 30 % if they also had total hip BMD T-score < or= -2.5 . CONCLUSIONS Clinical risk factor assessment , with or without BMD measurement  , is a reliable predictor of 10-year risk of osteoporotic fracture and may be particularly useful in regions or primary care clinics without access to bone densitometry equipment BACKGROUND & AIMS The incidence of osteoporotic fractures is lower in countries in the Mediterranean basin .  Virgin olive oil , a key component of the Mediterranean Diet ( MDiet ) , with recognised beneficial effects on metabolism and cardiovascular health , may decrease the risk of osteoporotic fractures . The aim to this study was to explore the effect of chronic consumption of total olive oil and its varieties on the risk of osteoporosis-related fractures in a middle-aged and elderly Mediterranean population . METHODS We included all participants ( n = 870 ) recruited in the Reus ( Spain ) centre of the PREvención con DIeta MEDiterránea ( PREDIMED ) trial . Individuals , aged 55 - 80 years at high cardiovascular risk , were r and omized to a MedDiet supplemented with extra-virgin olive oil , a MedDiet supplemented with nuts , or a low-fat diet . The present analysis was an observational cohort study nested in the trial . A vali date d food frequency question naire was used to assess dietary habits and olive oil consumption . Information on total osteoporotic fractures was obtained from a systematic review of medical records . The association between yearly repeated measurements of olive oil consumption and fracture risk was assessed by multivariate Cox proportional hazards . RESULTS We documented 114 incident cases of  osteoporosis-related fractures during a median follow-up of 8.9 years . Treatment allocation had no effect on fracture risk . Participants in the highest tertile of extra-virgin olive oil consumption had a 51 % lower risk of fractures ( HR:0.49 ; 95 % CI:0.29 - 0.81 . P for trend = 0.004 ) compared to those in the lowest tertile after adjusting for potential confounders . Total and common olive oil consumption was not associated with fracture risk . CONCLUSIONS Higher consumption of extra-virgin olive oil is associated with a lower risk of osteoporosis-related fractures in middle-aged and elderly Mediterranean population at high cardiovascular risk UNLABELLED The level of recognition and treatment of osteoporosis is not well characterized in primary care . In data from a large sample of postmenopausal women attending 927 primary care physicians , 29 % of women reported one or more fractures after menopause . The great majority ( 72 % ) were not on any osteoporosis-specific therapy . INTRODUCTION Osteoporosis is often first recognized at the time of a low-trauma fracture . However , by this stage , the risk of subsequent fractures has already risen substantially . Moreover , in many countries , only a small proportion of women , who have already sustained fractures , receive a treatment shown to reduce this increased risk of further fractures . MATERIAL S AND METHODS This project was initiated to examine the prevalence of osteoporotic fractures , risk factors for osteoporosis , and use of antifracture therapy among postmenopausal Australian women . More than 88,000 women from 927 primary care physicians returned over 69,358 surveys . Of these , 57,088 reported the presence of a postmenopausal fracture or risk factors . RESULTS Among these r and omly selected postmenopausal women , 29 % reported having had one or more low-trauma fractures after menopause ( 44 % substantiated in current records ) . One-third of these women reported multiple fractures . The prevalence of all types of fractures , except rib and ankle , increased with age and low body weight . Those who reported fractures were also more likely to report early menopause , corticosteroid use , and a family history of osteoporosis . Moreover , those with vertebral fractures were more likely to record height loss , kyphosis , and back pain . Physical inactivity , low calcium intake , and smoking had no consistent relationship with any fracture outcome . Of the women who reported a fracture after menopause , only 28 % were on any specific therapy for osteoporosis , and 7 % were on calcium alone . Of those who had been told they had osteoporosis by a doctor , 40 % were receiving specific osteoporosis therapy . CONCLUSIONS In this large study of postmenopausal Australian women attending primary care physicians , 29 % reported at least one low-trauma fracture after menopause . Less than one-third of these women were on specific treatment for osteoporosis , and only 40 % were ever told they had osteoporosis . Therefore , osteoporotic fractures are common in postmenopausal Australian women , and few , despite their substantially increased risk of further fractures , are on any specific anti-osteoporotic therapy . These data support the need for more effective education for the community and medical practitioners of the clinical significance of osteoporotic fractures and alternatives for treatment Raloxifene effectively reduces the incidence of vertebral fractures in patients with postmenopausal osteoporosis . Recent data suggest that low-dose monofluorophosphate ( MFP ) plus calcium reduces the vertebral fracture rate in postmenopausal women with moderate osteoporosis . The objective of this study was to evaluate the combination of raloxifene and MFP in the treatment of postmenopausal women with osteopenia , osteoporosis and severe osteoporosis . A total of 596 postmenopausal women with osteopenia , osteoporosis and severe osteoporosis ( mean femoral neck T-score of –2.87 SD ) were r and omized to treatment with 60 mg/day raloxifene HCl and 20 mg/day fluoride ions ( as MFP ) or 20 mg/day fluoride and placebo for 18 months . All patients received calcium ( 1000 mg/day ) and vitamin D ( 500 IU/day ) supplements . Changes in bone mineral density ( BMD ) , as primary endpoint , and the rate of osteoporotic fractures and biochemical markers , as secondary endpoints , were assessed . As compared with MFP , raloxifene plus MFP was associated with significantly greater mean increases in the BMD of the femoral neck ( 1.37 % versus 0.33 % ; P=0.004 ) , total hip ( 0.89 % versus −0.42 % ; P<0.001 ) and lumbar spine ( 8.80 % versus 5.47 % P<0.001 ) . In the raloxifene plus MFP group , 16 patients sustained 17 osteoporotic fractures , as compared with 22 patients sustaining 34 incident osteoporotic fractures in the MFP group ( P=0.313 ) . One patient in the raloxifene plus MFP group sustained multiple osteoporotic fractures , as compared with eight patients in the MFP group ( P=0.020 ) . MFP alone significantly increased the serum bone alkaline phosphatase ( bone ALP ) and the urinary C-terminal crosslinking telopeptide of type I collagene ( U-CTX ) . The addition of raloxifene in the combination arm blunted the rise in bone ALP , which remained nevertheless significant , and abolished the increase in U-CTX . The combination of raloxifene with MFP was generally well tolerated . This study demonstrates that , in postmenopausal women with osteopenia , osteoporosis and severe osteoporosis , the combination therapy of raloxifene plus MFP favorably influences the BMD and the bone formation and resorption balance , and may reduce the risk of multiple osteoporotic fractures compared to MFP alone Summary In the present prospect i ve controlled observational study , we investigated the effect of a coordinated intervention program on 4-year refracture rates in patients with recent osteoporotic fractures . Compared to st and ard care , targeted identification , and management significantly reduced the risk of refracture by more than 80 % . Introduction The risk of refracture following an incident osteoporotic fracture is high . Despite the availability of treatments that reduce refracture and mortality rates , most patients with minimal trauma fracture ( MTF ) are not managed appropriately . The present prospect i ve controlled observational study investigated the effect of a coordinated intervention program on 4-year refracture rates and time to refracture in patients with recent osteoporotic fractures . Methods Patients presenting with a non-vertebral MTF were actively identified and offered referral to a dedicated intervention program . Patients attending the clinic underwent a st and ardized set of investigations , were treated as indicated and review ed at 12-monthly intervals ( ‘ MTF group ’ ) . Patients who elected to follow-up with their primary care physician were assigned to the concurrent control group . Results Groups were balanced for baseline anthropometric , socio-economic , and clinical risk factors . Over 4 years , 10 out of 246 patients ( 4.1 % ) in the MTF group and 31 of 157 patients ( 19.7 % ) in the control group suffered a new fracture , with a median time to refracture of 26 and 16 months , respectively ( p < 0.01 ) . Compared to the intervention group , the risk of refracture was increased by 5.3-fold in the control group ( 95 % CI : 2.8–12.2 , p < 0.01 ) , and remained elevated ( HR 5.63 , 95%CI 2.73–11.6 , p < 0.01 ) after adjustment for other significant predictors of refracture such as age and body weight . Conclusions In patients presenting with a minimal trauma non-vertebral fracture , active identification and management significantly reduces the risk of refracture ( Australian New Zeal and Clinical Trials Registry ACTRN 12606000108516 ) Objective To develop and vali date two new fracture risk algorithms ( QFractureScores ) for estimating the individual risk of osteoporotic fracture or hip fracture over 10 years . Design Prospect i ve open cohort study with routinely collected data from 357 general practice s to develop the scores and from 178 practice s to vali date the scores . Setting General practice s in Engl and and Wales . Participants 1 183 663 women and 1 174 232 men aged 30 - 85 in the derivation cohort , who contributed 7 898 208 and 8 049 306 person years of observation , respectively . There were 24 350 incident diagnoses of osteoporotic fracture in women and 7934 in men , and 9302 incident diagnoses of hip fracture in women and 5424 in men . Main outcome measures First ( incident ) diagnosis of osteoporotic fracture ( vertebral , distal radius , or hip ) and incident hip fracture recorded in general practice records . Results Use of hormone replacement therapy ( HRT ) , age , body mass index ( BMI ) , smoking status , recorded alcohol use , parental history of osteoporosis , rheumatoid arthritis , cardiovascular disease , type 2 diabetes , asthma , tricyclic antidepressants , corticosteroids , history of falls , menopausal symptoms , chronic liver disease , gastrointestinal malabsorption , and other endocrine disorders were significantly and independently associated with  risk of osteoporotic fracture in women . Some variables were significantly associated with risk of osteoporotic fracture but not with risk of hip fracture . The predictors for men for osteoporotic and hip fracture were age , BMI , smoking status , recorded alcohol use , rheumatoid arthritis , cardiovascular disease , type 2 diabetes , asthma , tricyclic antidepressants , corticosteroids , history of falls , and liver disease . The hip fracture algorithm had the best performance among men and women . It explained 63.94 % of the variation in women and 63.19 % of the variation in men . The D statistic values for discrimination were highest for hip fracture in women ( 2.73 ) and men ( 2.68 ) and were over twice the magnitude of the corresponding values for osteoporotic fracture . The ROC statistics for hip fracture were also high : 0.89 in women and 0.86 for men versus 0.79 and 0.69 , respectively , for the osteoporotic fracture outcome . The algorithms were well calibrated with predicted risks closely matching observed risks . The QFractureScore for hip fracture also had good performance for discrimination and calibration compared with the FRAX ( fracture risk assessment ) algorithm . Conclusions These new algorithms can predict risk of fracture in primary care population s in the UK without laboratory measurements and are therefore suitable for use in both clinical setting s and for self assessment ( www.qfracture.org ) . QFractureScores could be used to identify patients at high risk of fracture who might benefit from interventions to reduce their risk Risedronate decreases osteoporotic fracture incidence ; however , its effects remain unclear in elderly osteoporotic patients . Vitamin K mediates carboxylation of osteocalcin ( OC ) , and high undercarboxylated osteocalcin ( ucOC ) levels indicate vitamin K deficiency and increased osteoporotic fracture risk . We aim ed to evaluate the effects of risedronate alone or combined with vitamin K2 on serum ucOC , OC , and incidence of vertebral fractures in elderly osteoporotic patients . A total of 101 women with postmenopausal osteoporosis aged > 60 years were r and omly stratified into two groups — R group ( n = 51 ) , treated with risedronate alone ; and R + K group ( n = 50 ) , treated with risedronate and vitamin K2 .  Serum ucOC , OC and incidence of vertebral fractures were evaluated before treatment and at 6 and 12 months post-treatment . Decreased ucOC rates at 6 and 12 months were not significant between groups . However , at 6 and 12 months , decreased OC rates in the R group ( p < 0.01 and 0.05 , respectively ) were significantly higher than in the R + K group , and ucOC/OC change rates in the R group ( p < 0.05 and 0.001 , respectively ) were significantly lower than in the R + K group . Vertebral fracture incidence was not significantly different between the groups at 6 and 12 months . ucOC levels in patients with incident vertebral fractures were significantly higher than in patients without incident vertebral fractures in the R group at 6 months ( p < 0.05 ) . Although no significant difference was observed for ucOC decrease rate and incidence of vertebral fractures between treatments , ucOC levels in patients with incident vertebral fractures were significantly greater than in patients without when using risedronate alone ABSTRACT Objective : Studies have shown that weekly bisphosphonate dosing results in improved persistence compared to daily dosing among patients with postmenopausal osteoporosis , yet more than 50 % of patients discontinue therapy within a year . An oral , less frequent administration bisphosphonate provides an opportunity to improve persistence , a parameter not well modeled in previous cost-effectiveness analyses of osteoporosis therapies . Research design and methods : We developed a Markov model to estimate the effect of improved persistence on the cost-effectiveness of bisphosphonates among postmenopausal women with established osteoporosis ( vertebral fracture and bone mineral density T-score ≤ –2.5 ) and an average age of 78 years .  Fracture risks , clinical efficacy , mortality , re source use , costs , and utilities were obtained from the published literature . Persistence rates were derived primarily from a published clinical trial . Approximately 50 % greater persistence with a monthly versus a weekly therapy was assumed on the basis of the PERSIST study , a 6-month , r and omized , head-to-head prospect i ve study that investigated treatment persistence in postmenopausal osteoporotic women on monthly versus weekly bisphosphonate therapy . Persistence was extrapolated to a maximum of 5 years . Following discontinuation , treatment benefit declined linearly and proportionally to the duration of active treatment . Results : Based on model estimates , more fractures were avoided ( versus no treatment ) with monthly bisphosphonate ( 58.1 per 1000 treated women ) than with weekly bisphosphonates ( 33.8 per 1000 treated women ) , result ing in lower fracture care costs per woman ( $ 7317 and $ 7548 , respectively ) . The incremental cost per quality -adjusted life-year gained was lower with a monthly bisphosphonate ( $ 13 749 ) than with weekly bisphosphonates ( $ 16 657 ) when compared to no treatment . The incremental cost per quality -adjusted life-year of a monthly bisphosphonate was $ 9476 when compared to a weekly bisphosphonate . Conclusions : In postmenopausal women with established osteoporosis , improvement in persistence with a less frequently administered oral bisphosphonate therapy could augment the fracture benefit and thereby improve cost-effectiveness . Further studies are required to refine the estimates of cost-effectiveness in order to address limited availability of adherence and fracture risk data
One type A service with a valid control group showed a significant decrease in re-fractures .
Types A and B services were cost-effective , although definition of cost-effectiveness varied between studies .
Fully coordinated , intensive models of care for secondary fracture prevention are more effective in improving patient outcomes than approaches involving alerts and /or education only
Most people presenting with incident osteoporotic fractures are neither assessed nor treated for osteoporosis to reduce their risk of further fractures , despite the availability of effective treatments .
We evaluated the effectiveness of published models of care for the secondary prevention of osteoporotic fractures .