Primary Prevention Of Fractures Research Articles

Incorporating postmenopausal women's perspectives into osteoporosis clinical guidelines: a systematic review

ObjectivesTo assess the inclusion of individuals’ perspectives in the development of osteoporosis Clinical Practice Guidelines (CPGs) for primary fracture prevention in postmenopausal women. Study Design and SettingWe performed a comprehensive systematic search across guideline databases and (CPGs) developing organizations websites. Using the AGREE II tool, we assessed the quality of the guidelines, with particular emphasis on the inclusion of patients, or representatives in the development process. We also examined if women's perspectives were considered at the recommendations level and explored the potential association between the inclusion of patients' values and preferences with the quality of the CPGs. ResultsWe retrieved a total of 491 eligible CPGs, of which 33 were finally included. The majority of the CPGs were developed by scientific societies (63.6%), primarily from Europe (39.4%) and North America (30.3%). One in every four (24.2%) guidelines explicitly included individuals' perspectives in their development, and one in ten (12.1%) included research evidence about this aspect to support their recommendations. The domains with the lowest mean scores in the quality assessment were applicability (42.4%), rigor of development (44.7%), and stakeholder involvement (45.7%), and 61% were recommended for use according to our assessment. Guidelines of higher quality were more likely to include women's perspective in their development (mean difference 39.31, P = .003). ConclusionThe incorporation of women's perspectives into the process of developing guidelines for primary fracture prevention in osteoporosis remains inadequate. Our findings serve as a call for guideline developers to improve this situation, and for users, and policymakers to be aware of these limitations, when using or implementing guidelines in this field.

Postfracture survival in a population-based study of adults aged ≥66yr: a call to action at hospital discharge.

Postfracture survival rates provide prognostic information but are rarely reported along with other mortality outcomes in adults aged ≥50yr. The timing of survival change following a fracture also needs to be further elucidated. This population-based, matched-cohort, retrospective database study examined 98 474 patients (73% women) aged ≥66yr with an index fracture occurring at an osteoporotic site (hip, clinical vertebral, proximal non-hip non-vertebral [pNHNV], and distal non-hip non-vertebral [dNHNV]) from 2011 to 2015, who were matched (1:1) to nonfracture individuals based on sex, age, and comorbidities. All-cause 1- and 5-yr overall survival and relative survival ratios (RSRs) were assessed, and time trends in survival changes were characterized starting immediately after a fracture. In both sexes, overall survival was markedly decreased over 6yr of follow-up after hip, vertebral, and pNHNV fractures, and as expected, worse survival rates were observed in older patients and males. The lowest 5-yr RSRs were observed after hip fractures in males (66-85yr, 51.9%-63.9%; ≥86yr, 34.5%), followed by vertebral fractures in males (66-85yr, 53.2%-69.4%; ≥86yr, 35.5%), and hip fractures in females (66-85yr, 69.8%-79.0%; ≥86yr, 52.8%). Although RSRs did not decrease as markedly after dNHNV fractures in younger patients, relatively low 5-yr RSRs were observed in females (75.9%) and males (69.5%) aged ≥86yr. The greatest reduction in survival occurred within the initial month after hip, vertebral, and pNHNV fractures, indicating a high relative impact of short-term factors, with survival-reduction effects persisting over time. Therefore, the most critical period for implementing interventions aimed at improving post-fracture prognosis appears to be immediately after a fracture; however, considering the immediate need for introducing such interventions, primary fracture prevention is also crucial to prevent the occurrence of the initial fracture in high-risk patients.

Underlying motivations hampering Flemish primary care physicians from overcoming the barriers in osteoporosis care: an EMR-facilitated clinical reasoning study

BackgroundOver half of the European population aged minimum 65 years presents with at least two chronic diseases. Attention towards these diseases exhibits disparities, with limited primary care physician (PCP) attention for osteoporosis. This was confirmed in a previous integrated osteoporosis care (IOC) project in which notable difficulties to enlist PCPs arose. Consequently, this study was initiated in Flemish PCPs for in-depth analysis of underlying mechanisms hampering PCPs to fully commit to osteoporosis care.MethodsA qualitative Electronic Medical Record (EMR)-facilitated clinical reasoning study was conducted. A semi-structured interview guide was employed to guide PCPs from reflections on their own patients to broader views regarding osteoporosis care. An inductive thematic analysis was performed using NVivo 12.ResultsThirteen PCPs were interviewed. They stated that osteoporosis patients often had complex (medical) profiles. PCPs emphasised the ongoing necessity for prioritisation within this context. This leads to a competition for PCP attention during consultations at three levels: i. between acute versus preventive care; ii. between primary fracture prevention and other preventive services and iii. between secondary fracture prevention and other preventive services; spanning eight areas of competition: disease significance, perceived impact, PCP awareness, the patient agenda, PCP competence, PCP support, perceived patient burden, and efficiency of care provision. Applicability of these areas of competition differed between levels.ConclusionThe intricate context in which PCPs operate, creates a competition for PCP attention leading to a lack of attention for fracture prevention. To preserve efforts in fracture prevention, areas of competition should be systematically addressed.Trial registrationApproval for the study has been provided by the Ghent University Hospital Ethics Committee (BC-09797).

Osteoporosis and Fracture Risk among Older US Asian Adults.

This review summarizes the current knowledge regarding osteoporosis and fracture among older US Asian adults. Asian adults have lower (areal) bone density than non-Hispanic White adults and thus are more likely to be diagnosed and treated for osteoporosis, despite their lower risk of hip fracture. The latter may relate to favorable characteristics in hip geometry, volumetric bone density, and bone microarchitecture; lower risk of falls; and other clinical factors. The fracture risk calculator FRAX accounts for the lower risk of hip fracture among US Asian adults. However, data on major osteoporotic fracture risk remain limited. Fracture rates also vary by Asian subgroup, which may have implications for fracture risk assessment. Furthermore, among women receiving bisphosphonate drugs, Asian race is a risk factor for atypical femur fracture, an uncommon complication associated with treatment duration. Recent clinical trial efficacy data pertaining to lower bisphosphonate doses and longer dosing intervals may be relevant for Asian adults. More research is needed to inform osteoporosis care of US Asian adults, including risk-benefit considerations and the optimal duration of bisphosphonate treatment. Greater evidence-based guidance for primary fracture prevention among US Asian adults will ensure health equity in the prevention of osteoporotic fractures.

Use of Clinical Practice Guidelines and Quality Metrics to Assess Primary Care Management of Osteoporosis.

Background: Clinical practice guidelines and quality measures provide recommendations for physicians addressing osteoporosis management. This study explored the alignment of osteoporosis clinical practice in a primary care geriatric clinic with recommended guidelines. Methods: This retrospective chart review included 388 patients 65 or older from a primary care geriatric clinic diagnosed with osteopenia or osteoporosis, with or without a fragility fracture. Data included history of falls and use of DXA scans, FRAX® fracture risk assessment tool, osteoporosis medication, and fall risk mitigation plans. Results: For age-related primary fracture prevention, 68% of women and 87% of men had documented DXA scans, and 45% of patients diagnosed with osteoporosis and 42% determined at high risk were prescribed osteoporosis medication. For secondary fracture prevention, 72% of women aged 67 to 85 had DXA scans and 21% were prescribed osteoporosis medication. Only 10% of patients with a history of falls had documented fall risk management plans. Conclusion: Although showing higher rates of primary and secondary prevention outcomes than did research results from general primary care, gaps were identified for high fracture risk patients and fall risk management documentation. Medical record review may not provide sufficient data to capture factors influencing decision-making for fracture prevention.

Long-Term Treatment of Postmenopausal Osteoporosis.

Osteoporosis is an incurable chronic condition, like heart disease, diabetes, or hypertension. A large gap currently exists in the primary prevention of fractures, and studies show that an estimated 80% to 90% of adults do not receive appropriate osteoporosis management even in the secondary prevention setting. Case finding strategies have been developed and effective pharmacological interventions are available. This publication addresses how best to use the pharmacological options available for postmenopausal osteoporosis to provide lifelong fracture protection in patients at high and very high risk of fracture. The benefit of osteoporosis therapies far outweighs the rare risks.

Associations between stroke type, stroke severity, and pre-stroke osteoporosis with the risk of post-stroke fracture: A nationwide population-based study

BackgroundRecognizing the post-stroke fracture risk factors is crucial for targeted intervention and primary fracture prevention. We aimed to investigate whether stroke types, stroke severity, and pre-stroke osteoporosis are associated with post-stroke fracture.MethodsIn a nationwide cohort, we identified previously fracture-free patients who suffered from first-ever stroke, either acute ischemic stroke (AIS) or intracerebral hemorrhage (ICH), between 2003 and 2015. Information regarding stroke severity, osteoporosis, comorbidity, and medication information was collected. The outcomes analyzed included hip fracture, spine fracture, and other fractures. Cumulative incidence functions (CIFs) were used to estimate the cumulative incidence of fractures over time after accounting for competing risk of death. Multivariable Fine and Gray models were used to determine the adjusted hazard ratio (HR) and 95% confidence interval (CI).ResultsOf the 41,895 patients with stroke, the 5-year CIFs of any incident fracture, hip fracture, spine fracture, and other fractures were 8.03%, 3.42%, 1.87%, and 3.05%, respectively. The fracture risk did not differ between patients with AIS and ICH. While osteoporosis increased the risk of post-stroke fracture (adjusted HR [95% CI],1.42 [1.22–1.66]), stroke severity was inversely associated with post-stroke fracture (moderate, 0.88 [0.81–0.96] and severe, 0.39 [0.34–0.44], compared with mild stroke severity).ConclusionsStroke survivors had an over 8% fracture risk at 5 years after stroke. Mild stroke severity and osteoporosis were significantly associated with post-stroke fracture risk, whereas stroke type was not. Our results call for effective measures for bone health screening and fracture prevention in patients with stroke.

The Utilization and Costs of USPSTF Grade D Services in Medicare, 2007‐2016

Research ObjectiveLow‐value care (LVC), or patient care that offers no net benefit in specific clinical scenarios, leads to unnecessary spending and patient harm in certain circumstances. The U.S. Preventive Services Task Force (USPSTF) Grade D Recommendations exemplify LVC, given the very high certainty that the expected clinical benefits of these services do not exceed the expected harms. We estimate the utilization and related costs of ten USPSTF Grade D Services among U.S. Medicare beneficiaries.Study DesignWe conducted a cross‐sectional analysis of data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative survey of U.S. outpatient visits. NAMCS uses a multistage probability sampling design, and data are abstracted directly from the medical record. Eligible visits included those by beneficiaries 18 years of age or older for whom Medicare was listed as the primary expected payer. Ten USPSTF Grade D Services were selected based on feasibility of case identification using diagnosis codes and recorded symptoms. These included the following: (1) cervical cancer screening for women older than 65, (2) prostate cancer screening for men 75 and older, (3) colonoscopy for adults older than 85, (4) vitamin D screening, (5) screening for cardiovascular disease among low‐risk adults, (6) COPD screening among asymptomatic adults, (7) screening for asymptomatic bacteriuria, (8) vitamin D supplementation for primary prevention of fractures among postmenopausal women, (9) hormone therapy for primary prevention of chronic conditions among postmenopausal women, and (10) vitamin E or beta‐carotene supplements for primary prevention of cardiovascular disease or cancer. The annual volume of these services was determined and then multiplied by per unit costs obtained from separate claims and actuarial sources to calculate annualized costs.Population StudiedOffice‐based visits by Medicare beneficiaries, 2007 to 2016.Principal FindingsFor the 10 services measured, over 30 million were provided to Medicare beneficiaries annually. The direct costs ranged from $649,604,514 to $862,159,707 annually. The three most frequently used services were (1) screening for asymptomatic bacteriuria, (2) vitamin D supplementation, and (3) screening for vitamin D deficiency screening, comprising 83% of the measured services and 46% of the calculated LVC spending. Three services (1) screening for asymptomatic bacteriuria, (2) cervical cancer screening among women older than 65, and (3) colonoscopies among adults older than 85 comprised 53% of measured LVC spending.ConclusionsThe USPSTF provides a D rating for services for which there is a moderate or high certainty that the service has no benefits or that the harms outweigh the benefits. Ten Grade D Services were provided frequently to Medicare beneficiaries, costing nearly $1 billion in Medicare spending annually. The negative clinical impact and total costs associated with the use of D‐rated services are likely larger as these findings do not capture all D‐rated services, as well as the downstream health care utilization after their use.Implications for Policy or PracticeThe implementation of policies that reduce LVC use offers an important opportunity to improve patient‐centered outcomes while safely reducing U.S. health care spending. Resultant savings could be used to expand access to high‐value care using value‐based insurance design.Primary Funding SourceThis study was supported by the Department of Veterans Affairs.

SUN-384 A Dedicated Primary Fracture Prevention Program Decreased Low Trauma Hip Fracture Rates over Six Years

BACKGROUND: Improvements in secondary prevention of osteoporotic fractures are widely reported following the dissemination of Fracture Liaison Services, however, few models for the primary prevention of such fractures have been described. Available published data indicates osteoporosis screening rates in the United States, most significantly in men, remain consistently less than 20% (Cheng N, Green ME). We have previously published how an interdisciplinary Bone Health Team (BHT) improves screening and treatment initiation rates in the outpatient setting. Here we describe the changes in low trauma hip fracture hospitalizations in the six years since initiation of BHT screenings.METHODS: The BHT began osteoporosis screening in February 2013. Hip fracture admission rates at our facility for each year starting in 2007 were assessed utilizing codes ICD 9 820*/ICD 10 S72.*; our facility is not a trauma center and receives no trauma injuries. Data was divided into a period from October 2007 to September 2013 and October 2013 to September 2019, the latter period based upon the average timeline from identification to treatment initiation and expected efficacy for the first screening group.RESULTS: From October 2007 to September 2013 there were 216 individuals admitted with a new hip fracture diagnosis, representing 0.54% of the averaged 40,362 individuals served by our facility during that time. Ages ranged from 48 to 94 years, with 156 (72.2% of fractures; 0.39% of all individuals) of individuals meeting age-based screening criteria (aged ≥65 for women and ≥70 for men) at time of fracture. Nine individuals with hip fractures had greater than one discrete hip fracture, confirmed as separate by chart review.From October 2013 to September 2019 there were 156 individuals admitted with a new hip fracture diagnosis, representing 0.37% of the averaged 46,327 individuals during that time. Ages ranged from 26 to 99 years. Of the hip fractures, 110 (70.5% of fractures) were in individuals meeting age-based screening criteria representing 0.24% of the averaged total individuals served and a 38.5% decrease (p<0.0001) in hip fracture admissions when compared to the prior six years. One individual had greater than one discrete hip fracture, representing an 88.9% lower rate (p<0.0001) of repeated fractures compared to the prior timeframe.Men represented 355 (95.4%) of the 372 fractures seen from 2007 to 2019. CONCLUSION: A statistically significant decrease in hip fracture admission rates in women aged ≥65 and men ≥70 and in repeat hip fractures was observed in the 6 years since BHT inception compared to the 6 years prior.

The Global Burden of Surgical Management of Osteoporotic Fractures.

Osteoporosis is an epidemic in the developed world. Fracture is a major burden associated with osteoporosis. Surgical management is recommended for particular anatomical areas, whilst other fracture patterns have a less defined and controversial role for surgery. This review aims to highlight increase in the global burden of osteoporosis and subsequent fragility fractures. As health and life expectancy improves, osteoporotic fracture fixation will constitute a significant physical and economic burden. The surgical management of osteoporotic fractures involves awareness on all levels from government to the individual, from primary prevention of fracture to surgical aftercare in the community.

Budget impact analysis of osteoporosis medications for primary prevention of fractures in Taiwan.

Taiwan's national health insurance currently only covers the use of osteoporosis drugs for the secondary prevention of fractures and does not provide coverage for primary prevention. The purpose of this study is to develop a model for analyzing the budgetary impact of the use of osteoporosis medications of primary prevention. The budget impact model in this study is the "actual medication cost" minus the "medical expenses for all types of fractures that can be avoided by taking osteoporosis medications." We developed six possible insurance payment plans for primary prevention based on the age of the patients and T-scores and performed eleven steps to estimate the budget impact of each payment plan. The results of this study indicated that there may be 71,220 (T-score ≤ - 3.0, 75 + y/o) to 157,515 (T-score ≤ - 2.5, 65 + y/o) people using the drugs, and the budget impact may be US$26.28-58.98 million in 2019. However, the payment plans may avoid 492-766 fracture events and save medical expenditures for fracture treatment by US$1.30-2.02 million. The average costs for primary prevention within a year will be US$53,386-77,006. The budget impact of using osteoporosis medications to primary prevention of fractures is significant, but it can be compensated due to savings in fracture treatment costs.

Vitamin D Supplementation in Older Adults: istheHypeDefinitelyOver?

Four meta-analyzes on the effect of vitamin D on fracture prevention were published between 2016 and 2018. Two of these meta-analyzes focused on the primary prevention of fractures in adults aged 50 and over who were not at risk for fractures or vitamin D deficiency. Another meta-analysis focused on the combination of vitamin D plus calcium and the most recently published meta-analysis focused on the individual effect of vitamin D without calcium. In terms of current guidelines, it is important to note that only 1 out of the 3 most recent meta-analyzes were predominantly directed at adults over the age of 65 with an increased risk of falls, fractures, and vitamin D deficiency.What can we recommend now? Based on our critical review of the meta-analyzes on vitamin D and fracture prevention, vitamin D supplementation with or without calcium is still useful in older adults, ages 65 and older, with an increased risk of vitamin D deficiency and an increased risk of fracture.

Diagnostics and fracture risk prediction

Diagnostics in osteoporosis and fracture risk prediction should never rely on bone mineral density (BMD) measurements alone. Data from the National Osteoporosis Risk Assessment (NORA) in the USA revealed some 15 years ago that only 6.4% of postmenopausal women with new fragility fractures had T-scores of −2.5 or less (WHO definition of osteoporosis) in BMD tests performed one year before the event. The majority of fractures occurs in patients with osteopenia or normal BMD. Many of them are middle-aged women, 40 to 65 years old, an age group not much attended to in most studies on osteoporosis. A study on 100.000 women treated in a specialized Viennese menopause and osteoporosis clinic showed that 66.8% of patients with non-vertebral fractures were less than 65 years of age. Such results point to the urgent need of moving away from the preoccupation with BMD alone to a multi-causal risk-of-fracture approach for improving identification of women at risk. Fracture risk assessment tools as FRAX® may be of great help to ease the handling of anamnestic information, weight clinical risk factors and spot secondary causes of osteoporosis. Beside the medical history and physical examination of patients more attention should be paid to x-ray imaging of the spine for detection of vertebral fractures, which otherwise are overlooked to a great extent, to measuring muscle mass and -strength for diagnosing sarcopenia, and to laboratory tests for evaluating the impact of a wide array of diseases and functional disorders on the bone and mineral metabolism. Both, primary fracture prevention by identification of women at risk as early as age 40, and secondary prevention in patients with preexisting fractures, preferably by fracture liaison services, will be of crucial importance to avoid detrimental sequelae for the affected patients and associated costs to the health-care system.

SAT-534 How Has Bisphosphonate Prescribing Changed in the Past Decade for Primary Fracture?

INTRODUCTION: The importance of bisphosphonate drugs (BP) in preventing fractures is well known. Initial guidelines focused on early primary prevention of fracture for postmenopausal women using a BMD T-score -2.0 or lower, regardless of age (T-score < -1.5 with risk factors). In 2008, national guidelines focused treatment on osteoporosis (T-score < -2.5) or osteopenia (-1 > T-score > -2.5) with high fracture risk based on FRAX. This study examines whether there has been a shift in the characteristics of women initiating BP therapy for primary prevention (no previous fracture) over time from 2002 to 2013. METHOD: We included female members age within an integrated healthcare delivery system who were age 50-79y, initiated oral BP in 2002-2013, and had BMD measured within the 2 previous years. Women with fracture history (except head, fingers, toes), metastatic cancer, and advanced kidney disease were excluded. Age at BP initiation, race/ethnicity, and the proportions with normal BMD (T-score > -1), osteopenia, and osteoporosis each year and within earlier (2002-2007) and later (2008-2013) treatment eras were examined. Analyses were also stratified by race/ethnicity. RESULTS: 28,495 women age 50-79y (mean age 66y; 56% non-Hispanic White, 27% Asian, and 17% all others) met inclusion criteria. For each year from 2002-2013, the proportions of women <65y declined as the proportions >65y increased among those initiating BP. By age decade, the proportion 50-59y declined from 31% to 12%, while the proportion 60-69y and 70-79y increased from 39% to 54% and 29% to 34%, respectively, from 2002-2013. In 2013, the predominant age group initiating BP was 60-69y (54% overall; 51% in whites, 63% in Asians). During this same period, the percentage of women initiating BP who had osteoporosis progressively increased from 62% in 2002 to 79% in 2013. For whites, the overall percentage with osteoporosis was 65%, increasing from 58% in 2002 to 71% in 2013; for Asians, the percentage with osteoporosis was higher at 82%, increasing from 74% to 95% in these same years. Only among older women (70-79y) there appeared to be no temporal change (71% in 2002-2007 vs 69% in 2008-2013, p=0.1). DISCUSSION: Over time, there has been a remarkable shift in the type of woman initiating BP for primary prevention, from younger to older and from those with osteopenia to osteoporosis. By 2013, over half of the women initiating BP were 60-69y, and compared to 2002, there was a 27% higher prevalence of osteoporosis among women starting BP. Within the health plan, 13-15% of older women are Asian compared to 27% of our study population, indicating that Asians appear to be more likely to begin BP for primary prevention. Future studies should assess the impact of the observed shift in BP prescribing on fracture outcomes, focusing on the possible impact of age, race/ethnicity, and cost-effectiveness.

Re: Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: An Evidence Review for the U.S. Preventive Services Task Force.

Re: Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults: An Evidence Review for the U.S. Preventive Services Task Force.

Guideline: Insufficient evidence for vitamin D and/or calcium to prevent fractures in community-dwelling adults.

Source Citation US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults...

Issues of trial selection and subgroup considerations in the recent meta-analysis of Zhao and colleagues on fracture reduction by calcium and vitamin D supplementation in community-dwelling older adults.

We discuss the recent meta-analysis by Zhao and colleagues on the primary prevention of fractures of calcium and vitamin D as well as their combination among community-dwelling adults age 50+. Zhao and colleagues included 33 trials that recruited a total of 51,145 community-dwelling participants age 50years and older, including any randomized clinical trial with a placebo or no treatment in the control group. The authors found no significant association of calcium and/or vitamin D with risk of hip fracture compared with placebo or no treatment and concluded that the routine use of calcium, vitamin D, and the combination in community-dwelling older people is not supported by their findings. We discuss four concerns regarding this meta-analysis, including the target population, the selection of trials with regard to blinding and duration of follow-up, and the lack of adjustment for adherence to the interventions and subgroup analysis by bolus versus daily dosing for vitamin D. Based on the four concerns raised in this letter and the fact that there will be a manyfold increase in the data on vitamin D supplementation in community-dwelling senior adults from large ongoing trials, we believe that it is too early to recommend the cessation of vitamin D with or without calcium for the prevention of fractures among community-dwelling adults.

Vitamin D supplementation: Hypothetical effect on medication-related osteonecrosis of the jaw

Vitamin D is an important nutrient for bone health and skeleton growth. Few foods are natural sources of this secosteroid; this is the reason why the consumption of vitamin D as a dietary supplement is becoming common in developed countries. For many years vitamin D has been considered crucial in the treatment and prevention of the Global Burden of Disease and in a reduction in mortality among elder people. Many health care providers prescribe these supplements in the management of osteoporosis and metabolic bone diseases; specifically in the primary prevention of fractures. Recently medication-related osteonecrosis of the jaw (MRONJ) has been reported as severe late sequelae of antiresorptive therapies (i.e., bisphosphonates and some monoclonal antibodies). Although MRONJ-related pathophysiology is not fully understood, there are three fundamental theories to explain it: (1) the inhibition of osteoclasts, (2) the inhibition of angiogenesis and (3) the processes of inflammation-infection. Recent advances in Vitamin D research have shown that this secosteroid can play a potential pivotal role in many of the different etiological pathways of MRONJ. Furthermore, there are a large number of co-morbidities between the deficit of this vitamin and other MRONJ concomitant outcomes. Our hypothesis argues that the low-risk and low-cost vitamin D dietary supplementation may prove to be suitable for use as a practical MRONJ prevention strategy. The described framework gives more insight into the study of disease mechanisms, search of potential biomarkers, and therapeutic targets in MRONJ.

Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures.

This narrative review considers the key challenges facing healthcare professionals and policymakers responsible for providing care to populations in relation to bone health. These challenges broadly fall into four distinct themes: (1) case finding and management of individuals at high risk of fracture, (2) public awareness of osteoporosis and fragility fractures, (3) reimbursement and health system policy and (4) epidemiology of fracture in the developing world. Findings from cohort studies, randomised controlled trials, systematic reviews and meta-analyses, in addition to current clinical guidelines, position papers and national and international audits, are summarised, with the intention of providing a prioritised approach to delivery of optimal bone health for all. Systematic approaches to case-finding individuals who are at high risk of sustaining fragility fractures are described. These include strategies and models of care intended to improve case finding for individuals who have sustained fragility fractures, those undergoing treatment with medicines which have an adverse effect on bone health and people who have diseases, whereby bone loss and, consequently, fragility fractures are a common comorbidity. Approaches to deliver primary fracture prevention in a clinically effective and cost-effective manner are also explored. Public awareness of osteoporosis is low worldwide. If older people are to be more pro-active in the management of their bone health, that needs to change. Effective disease awareness campaigns have been implemented in some countries but need to be undertaken in many more. A major need exists to improve awareness of the risk that osteoporosis poses to individuals who have initiated treatment, with the intention of improving adherence in the long term. A multisector effort is also required to support patients and their clinicians to have meaningful discussions concerning the risk-benefit ratio of osteoporosis treatment. With regard to prioritisation of fragility fracture prevention in national policy, there is much to be done. In the developing world, robust epidemiological estimates of fracture incidence are required to inform policy development. As the aging of the baby boomer generation is upon us, this review provides a comprehensive analysis of how bone health can be improved worldwide for all.

Primary fracture prevention through the Osteoporosis Liaison Service.

It is difficult to prevent primary fragility fractures because the subjects have not yet experienced a fracture. The offers of the community Osteoporosis Liaison Service are important for primary prevention of fragility fractures. The prevention, education, enlightenment, and the offer of osteoporosis examinations are included in this service. It is necessary to deliver the prevention services and osteoporosis education according to the age of the subjects. Hence, for young people, it is effective to include in school education that getting high peak bone mass is important, and for the middle-aged population, it is necessary to include education on the maintenance of bone quantity and the impact on risk factors such as smoking and excessive alcohol consumption. Furthermore, early detection of osteoporosis is important, with an osteoporosis check-up being one of the few opportunities for assessing the bone mineral density(BMD)in elderly women. However, there are some problems with osteoporosis check-ups in Japan. First, the implementation and participation rates of osteoporosis check-ups are low. Second, only BMD is set as the most important value for the assessment. Third, the subjects are limited to women in the range of 40-70 years of age with the knot age set at every 5 years. Finally, the setting of the BMD measuring apparatus is low. We adopted Fracture Risk Assessment Tool(FRAX)and loco-check for check-ups at Asahi-machi in the Toyama Prefecture to resolve the above problems and have reported its usefulness. Action by the Osteoporosis Liaison Service to enforce osteoporosis check-ups is expected. Various types of professional medical staff participate in the Osteoporosis Liaison Service as osteoporosis managers. It is desired that the managers will cooperate and function as an osteoporosis project team in the community.