Original Article
Results of a Model of Secondary Prevention for Osteoporotic Fracture Coordinated by Rheumatology and Focused on the Nurse and Primary Care Physicians
Resultados de un modelo de prevención secundaria de fractura osteoporótica coordinado por reumatología centrado en la enfermera y el médico de atención primaria
Antonio Naranjoa,b,
, Soledad Ojeda-Brunoa, Ana Bilbao Cantareroa, Juan Carlos Quevedo Abeledoa, Luis Alberto Henríquez-Hernándezc,d, Carlos Rodríguez-Lozanoa
Corresponding author
a Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
b Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
c Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
d Servicio de Oncología Radioterápica, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain
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"afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Ciencias Médicas y Quirúrgicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Ciencias Clínicas, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Oncología Radioterápica, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Resultados de un modelo de prevención secundaria de fractura osteoporótica coordinado por reumatología centrado en la enfermera y el médico de atención primaria" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Fractures and their complications will be a health problem of the first order in the coming years due to the aging population. In Spain it is estimated that osteoporosis (OP) affects 32% of women aged 50 years and above to 52% of those aged 70 years.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition, between 53% and 92% of fractures in women older than 50 years are attributed to OP.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Fragility fractures are more common in patients who have had previous fractures. Wrist fracture, for example, increases the risk of hip and<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> vertebral fracture. It is estimated that one of 4 patients with vertebral fracture suffer a second vertebral fracture during the next 2 years and 26% will suffer a non-vertebral fracture in the year following. At the same time, a fractured femur is the leading cause of disability and mortality in the elderly.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In terms of costs, one study estimated that hip fracture, within 5 years, involves a cost of $36,929 U.S. dollars for women and $39,479 for men.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The consequences of hip fracture were comparable to those of acute myocardial infarction and stroke.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These data justify the need for an effective program to prevent fragility fractures.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Although treatment of patients with an OP fracture is cost effective in order to prevent new fractures,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> less than 20% of patients who have suffered a fragility fracture receive antiresorptive bisphosphonate treatment.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Thus, 60% of cases of vertebral fractures diagnosed in primary care receive no treatment to prevent new vertebral fractures.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Moreover, a high rate of treatment with antiresorptive bisphosphonates abandonment was found in these patients.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Therefore, programs are needed for the detection and study of fractured patients, establishing management guidelines.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Coordination between hospitals and primary care is very important in these cases because once the fracture is healed there is no clear reference on who should undertake the study and monitoring of the patients. Existing models for secondary prevention of fractures are mostly Anglo-Saxon<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> and should be adapted to our healthcare environment. In this study we present the results of a strategy for secondary prevention of osteoporotic fracture, the first multidisciplinary study of its type in Spain.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">This is an observational study, conducted in the area of Gran Canaria north, with 2 distinct parts: (1) prospective intervention study and (2) retrospective study. The structure of the health area in 2012 was as follows: 332,650 inhabitants older than 14 years of age, 21 health centers and 255 primary care physicians.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Prospective Study</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Health Centers Training Plan</span><p id="par0030" class="elsevierStylePara elsevierViewall">The study included the training on OP and fragility fracture of primary care physicians in the health area through a session lasting 60<span class="elsevierStyleHsp" style=""></span>min given by rheumatologists. The key points of the meeting were (1) the need to treat patients at high risk for fracture and maintain treatment, (2) explanation of the study protocol and patient flow from the densitometry unit to primary care and (3) presentation of the model report issued by the fractures unit and the offer of communication channels to resolve questions (telephone, fax and email).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Selection of Patients</span><p id="par0035" class="elsevierStylePara elsevierViewall">Patients were seen in the emergency department of the hospital between March 2012 and March 2013 with a diagnosis of fracture. The first step was obtaining a mail list, followed by a screening of patients and application of the inclusion criteria based on the data platform. This work was carried out by the coordinators (AN and SOB) and took about 3<span class="elsevierStyleHsp" style=""></span>h every month. The new listing was given to a secretary trained for the study, who, by telephone, informed the patient about the convenience of assessment from the bone metabolism point of view.</p><p id="par0040" class="elsevierStylePara elsevierViewall">If after telephone contact the patient met the inclusion criteria and agreed to participate in the study, an appointment was made for the baseline visit, which was scheduled at least 2 months after the fracture and patient recovery. At baseline, a densitometry (DXA) followed by a consultation with the nurse was performed. This task entailed a nurse workday each week.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The selection criteria of patients were adults over 50 years with fragility fracture at any site except facial bones and skull, ribs and bones of the hands and feet. Fragility fracture was defined as a fracture that occurs as a result of a fall from the height of the person or lower.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Patients with pathological fracture or severe functional disability, as well as patients with advanced liver disease or renal failure, or any serious medical illness criteria were excluded.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Study Protocol</span><p id="par0055" class="elsevierStylePara elsevierViewall">The study was approved by the ethics and research committee of the hospital and follows the Helsinki Declaration of 1975. All patients gave written consent.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The nurse recorded the following data for each patient: OP family history of fracture (broken hip in parents), personal history of fragility fracture, active smoking, alcohol consumption, rheumatoid arthritis, previous use of any medication for OP (including bisphosphonates) and use of corticosteroids. Other secondary causes of OP were also recorded, including type 1 diabetes mellitus, osteogenesis imperfecta in adults, untreated hypothyroidism, hypogonadism or premature menopause (<45 years), chronic malnutrition or malabsorption, and chronic liver disease. Also, the height and weight of each patient were recorded to calculate the body mass index.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Bone mineral density was measured with DXA Hologic QDR-4500 (Hologic, Waltham, MA, USA. UU) equipment. Normal bone, osteopenia and OP were defined according to WHO criteria.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> The FRAX<span class="elsevierStyleSup">®</span> index was calculated using the tool available online for the Spanish population (<a id="intr0010" class="elsevierStyleInterRef" href="http://www.shef.ac.uk/FRAX/tool.jsp">http://www.shef.ac.uk/FRAX/tool.jsp</a>).</p><p id="par0070" class="elsevierStylePara elsevierViewall">Laboratory tests recommended for all patients included complete blood count, ESR, biochemical profile, serum calcium and phosphorus, alkaline phosphatase, serum 25 OH vitamin D, and thyroid and parathyroid hormone determinations. In patients with urolithiasis history, a determination of calciuria and phosphaturia was added. In males, we recommended including serum free testosterone levels in addition to LH and FSH.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Treatment and Follow-up</span><p id="par0075" class="elsevierStylePara elsevierViewall">Patients received specific education by a nurse trained in OP. Treatment was explained, including tips for exercise, improving calcium intake with diet, avoiding alcohol and tobacco use, and measures to prevent falls. Patients were informed about the benefits of drug treatment with bisphosphonates. The nurse emphasised particularly on how to take the tablets and the importance of maintaining the prescribed treatment.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Recommendations to indicate bisphosphonate treatments were based on the guidelines for treatment published by the NOF (web site for detailed information: <a id="intr0015" class="elsevierStyleInterRef" href="http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009_v7.pdf">http://www.nof.org/professionals/pdfs/NOF_ClinicianGuide2009_v7.pdf</a>). The treatment protocol was agreed on between rheumatology and primary care. The first choice of treatment was alendronate or risedronate. The decision to treat was based on the type of fracture (indicated in all hip and vertebral fractures), the result of the DXA (indicated in all OP) and fracture risk estimated by FRAX<span class="elsevierStyleSup">®</span> (the rest of patients were treated if the risk of hip fracture was >3%). Regardless of the use of bisphosphonate, calcium supplements (1000<span class="elsevierStyleHsp" style=""></span>mg/d) and vitamin D (800<span class="elsevierStyleHsp" style=""></span>IU/d) were advised for all patients.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Patients treated at baseline were referred to primary care with the results of the DXA and a treatment decision algorithm, whether or not they were given a bisphosphonate. This report was issued by the nurse and signed by a medical coordinator. More serious cases such as vertebral fractures, multiple fractures and those with digestive problems receiving oral treatments were referred to rheumatology (see metabolic diseases) in order to assess not only bisphosphonate use, but also other treatments for OP.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The main outcome variable was the percentage of patients with confirmed onset of bisphosphonate therapy at 3 months from baseline, both proven through electronic records (medical coordinator) and by telephone (nurse). Follow-up work was done by the nurse in the weekday devoted to fractures while the medical coordinator employed three monthly hours.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Retrospective Study</span><p id="par0095" class="elsevierStylePara elsevierViewall">A sample of patients with the same inclusion criteria as that in the prospective phase, treated in the emergency department 6 months before the start of the study were analyzed. Prescription of antiresorptive treatment was documented in electronic health records 6 months after the fracture occurred. The retrospective group was included for routine clinical practice in the health area and bias in primary care training talks on treatments at baseline were eliminated in the intervention group.</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical Analysis</span><p id="par0100" class="elsevierStylePara elsevierViewall">The characteristics of patients who refused the study and of those finally included, as well as of patients who started bisphosphonate and of those not taking it 3 months from the baseline visit were compared. Possible differences between the groups were analyzed by Student's <span class="elsevierStyleItalic">t</span> test for continuous variables and chi-square test for categorical variables. SPSS version 15.0 for data analysis was used. Statistical significance was set at <span class="elsevierStyleItalic">P</span><.05.</p></span></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><p id="par0105" class="elsevierStylePara elsevierViewall">In this paper we present the results of the first 12 months of the program.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the retrospective study, 167 patients met the criteria for evaluation; 70% women, with an average age of 71 years, were reviewed. The percentage of distribution of fractures in this group was as follows: forearm 30%, femur 24%, humerus 15%, and other fractures 29% (<span class="elsevierStyleItalic">P</span>=.57 compared with the prospective intervention group). In reviewing the 6 months after fracture treatment, 23 patients (13.7%) were prescribed an antiresorptive.</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the prospective study, a total of 532 patients met the inclusion criteria and were invited to participate, of whom 202 (38%) did not accept. Compared with the patients who agreed to participate, those who refused had a higher mean age (73 vs 70 years, <span class="elsevierStyleItalic">P</span><.01) and a higher frequency of hip fracture (27 vs 21%, <span class="elsevierStyleItalic">P</span><.01).</p><p id="par0120" class="elsevierStylePara elsevierViewall">We included 330 patients for intervention, 254 of them women (77%). The mean age was 71 years, 64 patients were less than 60 years, 87 patients were between 60 and 69 years, 103 patients were between 70 and 79 years and 76 patients were over 79 years of age (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The most common fracture was that of the forearm (34%) followed by the femur (21%). A total of 68 patients (20%) were receiving calcium and/or vitamin D, and 45 patients (13%) were taking bisphosphonate or other effective drugs for reducing fractures at baseline (59 of them, 18% in the past). The DXA study showed osteopenia or OP in 80% of cases. The FRAX<span class="elsevierStyleSup">®</span> for hip fracture was >3% in 153 patients (46%). After baseline, 213 patients were referred to the primary care physician (64%) and 117 patients to the hospital clinic (35%). In total, bisphosphonate treatment was recommended to 223 patients (67%): 109 of those sent to primary care (51%) and 114 of those sent to the hospital clinic (97%). The remaining 107 patients, presenting a low risk of fracture, received only general advice and supplements of calcium and vitamin D.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">At follow-up at 3 months, from the data from 169 patients who were prescribed bisphosphonate treatment, 133 (78%) were undergoing the prescribed treatment. Twelve of the 133 patients started treatment after forwarding the DXA report to the PCP or after a new appointment in the hospital clinic. Extrapolating data to the entire sample of 223 patients receiving bisphosphonate (multiplied by 5 compared to baseline), 174 patients had started treatment 3 months after the visit (multiplied by 4 with respect to the baseline visit). Comparing the group of patients who started treatment at 3 months with those who did not, patients who started it were on average older (74 vs 70 years, <span class="elsevierStyleItalic">P</span>=.007). However, there were no significant differences in relation to gender, type of fracture, fracture risk measured by FRAX<span class="elsevierStyleSup">®</span> or the type of physician to whom the patient (primary care or hospital rheumatology) was submitted.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Although there are moderately effective prophylactic treatments, most patients with fragility fracture are not studied or treated.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10</span></a> In the present study, both in the retrospective group as at baseline and in the intervention group, fewer than 15% of patients were taking a bisphosphonate after fracture. We know it is more effective to treat with alendronate those patients with previous fracture since the number of patients needed to treat to prevent an OP vertebral fracture was 50 when no previous fracture was present (primary prevention), while it was an estimated 16 patients if a fragility fracture history was present.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Different secondary prevention of fracture strategies published can be summarized as follows<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">(a)</span><p id="par0140" class="elsevierStylePara elsevierViewall">On the patient: information by telephone and/or letter, education and summons to visit with or without performing DXA or, in case of hospitalization, a report with treatment recommendations.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">(b)</span><p id="par0145" class="elsevierStylePara elsevierViewall">On primary care physicians: report with treatment recommendations including DXA results if available. Performing DXA alone increases the prescription of treatment to prevent new fractures.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">(c)</span><p id="par0150" class="elsevierStylePara elsevierViewall">Specific units fracture: it has been observed that units that include specific personnel, especially nurses supervised by physicians experienced in OP and fractures, are the most effective in secondary prevention.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> The model of coordinated care systems of attention to fractures is officially recommended by the American Society for Bone and Mineral Research.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">Furthermore, because adherence to treatment for OP is low, estimated at 40%–50% in the first year,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,19</span></a> patients who have suffered a fracture should be followed up in order to increase adherence to treatment. It has been found that when the patient takes more than 80% of the prescribed medication, future fractures reduce significantly.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">In a study conducted in Spain by orthopedic surgeons, an increase in the diagnosis and treatment of OP after discharge due to a fracture was observed.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> The authors analyzed the usefulness of specific software in 70 hospitals,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> attaining 61% correct treatments for OP in the discharge report. Although this is a simple model that requires little infrastructure and no additional staff, it has the disadvantage of not including DXA or confirmation by the prescribing physician or primary monitor.</p><p id="par0165" class="elsevierStylePara elsevierViewall">In a previous study by our group on fragility fractures, all patients were referred to the outpatient clinic for clinical evaluation, undergoing a DXA and treatment, with clinical follow-up for 12 months. After 4 years, the persistence of bisphosphonate therapy was 71%,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> which for this model is appropriate, yet it does not seem very effective because all patients must be assessed in hospital clinics with the consequential reviews.</p><p id="par0170" class="elsevierStylePara elsevierViewall">We believe that the model presented here, regarding the care of fragility fractures, is a reasonable approach, adapted to the characteristics of the Spanish health system, integrating primary care physicians and other related OP specialists such as rheumatologists. This strategy covers performing a DXA, evaluation and patient education by the nurse and tracks treatment control, all known factors associated with an increase in fracture treatments. The time taken to carry it out is one day a week for the nurse and one day a month for the medical coordinator.</p><p id="par0175" class="elsevierStylePara elsevierViewall">Results from the first year of our program are similar to those of other published models.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,17</span></a> The percentage of patients who were prescribed bisphosphonate increased from 13% at baseline to 67% after the evaluation. In the study by Harrington and Lease held in Madison (USA), after 3 years of experience with a coordinated unit fractures nurse and rheumatologist, they evaluated and advised treatment to 61% of patients with<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> fractures. However, the most successful model is that done in Glasgow, which achieves 80% of patients participating in the program, 74% received treatment, with 96% of treatments prescribed by the GP and with patient compliance at one year of 86%.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Thus, the Glasgow model appears to be cost effective, so it was taken as a reference for other centers in the UK.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Our experience with these patients is that some of them are reluctant to participate in the study or take medication, assuming that only trauma was involved and they do not require more visits once the fracture is consolidated. It is therefore important that all health services involved in the patient's fracture remember the need for bone metabolic evaluation, starting with emergency medical and trauma care, to the primary care physician and musculoskeletal related specialists, endocrinology and other medical specialties. The main weakness we found in our study is not so much related to the model per se as the insufficient awareness of other medical specialties, such as primary care and trauma, on the importance of secondary prevention of fractures. When we reviewed the treatments at 3 months of the baseline visit, about a quarter of patients who were indicated or prescribed a bisphosphonate was not taking it; reasons such as fear of adverse effects or becoming a polymedicated patient were common. Therefore, we will try to strengthen the relationship with other specialties through training campaigns.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Rheumatology plays an important role in the secondary prevention of fractures because a good number of DXA units are managed by rheumatologists. In this regard, we believe that active uptake of fractured patients should be a priority of DXA units.</p><p id="par0190" class="elsevierStylePara elsevierViewall">Our results show that, in the short-term, the strategy works as it involves the use of a small staff. If confirmed in the long term, this will allow the implementation of the model as a consolidated portfolio of services in the area of health care offerings.</p><p id="par0195" class="elsevierStylePara elsevierViewall">In summary, we present the first multi-disciplinary and multi-professional program for secondary prevention of fractures in Spain, coordinated by rheumatologists. The number of patients who were prescribed and initiated bisphosphonate is multiplied 4 times compared with standard treatment.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Ethical Responsibilities</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Protection of people and animals</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that the study procedures conformed to the ethical standards of the responsible committee on human experimentation and are in accordance with the World Medical Association and the Declaration of Helsinki.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Confidentiality of data</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their workplace on the publication of data from patients and that all patients included in the study have received sufficient information and gave written informed consent to participate in the study.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Right to privacy and informed consent</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors state that no patient data appear in this article.</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Financing</span><p id="par0215" class="elsevierStylePara elsevierViewall">This study is funded as a national research project by the Ministry of Science and Innovation, Carlos III Health Institute (reference PI11/01429).</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of Interest</span><p id="par0220" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:2 [ "identificador" => "xres368269" "titulo" => array:5 [ 0 => "Abstract" 1 => "Objective" 2 => "Patients and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec347440" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres368268" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivo" 2 => "Pacientes y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec347441" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and Methods" "secciones" => array:2 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Prospective Study" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Health Centers Training Plan" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Selection of Patients" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Study Protocol" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Treatment and Follow-up" ] ] ] 1 => array:3 [ "identificador" => "sec0040" "titulo" => "Retrospective Study" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Statistical Analysis" ] ] ] ] ] 6 => array:2 [ "identificador" => "sec0050" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:3 [ "identificador" => "sec0060" "titulo" => "Ethical Responsibilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0065" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0070" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0075" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0080" "titulo" => "Financing" ] 10 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflict of Interest" ] 11 => array:2 [ "identificador" => "xack92228" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-17" "fechaAceptado" => "2013-12-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec347440" "palabras" => array:4 [ 0 => "Osteoporosis" 1 => "Fragility fracture" 2 => "Secondary prevention" 3 => "Bisphosphonates" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec347441" "palabras" => array:4 [ 0 => "Osteoporosis" 1 => "Fractura por fragilidad" 2 => "Prevención secundaria" 3 => "Bisfosfonatos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To assess the influence of the implementation of a program for secondary prevention of osteoporotic fractures on prescribing bisphosphonates and persistent short-term treatment.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Patients >50 years of age with fragility fracture attended in the emergency department were enrolled in an observational study. The program consisted of (1) training of primary care physicians, (2) baseline visit: questionnaire on osteoporosis, bone densitometry and patient education, (3) patient referral to primary care, except those with multiple fractures or requiring special study or therapy, who were referred to a specialist, and (4) follow-up by checking prescriptions in electronic records, and a telephone survey. The outcome variable was the percentage of patients who, on having been prescribed bisphosphonates, still adhered to the treatment at 3 months.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 532 patients with inclusion criteria, 202 (39%) refused to participate. Those who refused to take part had a higher mean age (<span class="elsevierStyleItalic">P</span><.01) and a higher frequency of hip fracture (<span class="elsevierStyleItalic">P</span><.01) compared with patients who did participate. A total of 330 patients were included for intervention, with a mean age of 71 years, and 254(77%) were women. An antiresorptive was being used by 45 patients (13%) at baseline. After the baseline visit 223 patients (67%) were recommended a bisphosphonate. In the follow-up at 3 months 78% of patients who had been prescribed bisphosphonate were still receiving treatment.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">We present a multidisciplinary program for secondary prevention of fractures coordinated by rheumatology in which the number of patients who were receiving bisphosphonate at 3 months increased by four times compared to that at baseline visit.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la influencia de la implantación de un programa para la prevención secundaria de fracturas osteoporóticas sobre la prescripción de bisfosfonatos y la persistencia del tratamiento a corto plazo.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron pacientes con fractura por fragilidad ><span class="elsevierStyleHsp" style=""></span>50 años atendidos en el servicio de urgencias durante un año. El programa consistió en: 1) plan de formación en osteoporosis de los médicos de primaria; 2) densitometría ósea; 3) cuestionario relativo a osteoporosis y educación del paciente por la enfermera; 4) derivación al médico de primaria o, en caso de múltiples fracturas o precisar terapia parenteral, a consulta hospitalaria; y 5) seguimiento y comprobación de inicio del tratamiento prescrito a través de los registros electrónicos y encuesta telefónica. La variable principal de desenlace fue el porcentaje de pacientes que, habiéndose prescrito un bisfosfonato, cumple el tratamiento a los 3 meses.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De 532 pacientes con criterios de inclusión, 202 (38%) no aceptaron participar. Comparados con los pacientes que participaron, los que rechazaron tenían una edad promedio mayor (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,01) y una mayor frecuencia de fractura de cadera (p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,01). Así, se incluyeron 330 pacientes con una edad media de 71 años, el 77% mujeres. Cuarenta y cinco pacientes (13%) utilizaban bisfosfonato al inicio del estudio, mientras que tras la visita basal se prescribió a 223 pacientes (67%). En el seguimiento a los 3 meses, el 78% de los pacientes a los que se aconsejó bisfosfonato estaba tomando la medicación.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El programa de prevención secundaria de fracturas coordinado por reumatología consigue que el número de pacientes que inicia bisfosfonato se multiplique por 4 en comparación con la visita basal.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as: Naranjo A, Ojeda-Bruno S, Bilbao Cantarero A, Quevedo Abeledo JC, Henríquez-Hernández LA, Rodríguez-Lozano C. Resultados de un modelo de prevención secundaria de fractura osteoporótica coordinado por reumatología centrado en la enfermera y el médico de atención primaria. Reumatol Clin. 2014;10:299–303.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Gender</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">254 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(76.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(23.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Location of fracture</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Forearm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">112 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(33.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Femur \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(21.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Humerus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">611 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(18.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vertebra \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(5.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Other \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(20.3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Risk factors for fracture</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Previous fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(23.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hip fracture in parents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(12.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Active smoker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">48 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(14.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol consumption<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(7.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glucocorticoids<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(11.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Secondary Osteoporosis<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(20.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Rheumatoid Arthritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(3.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Densitometry</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Normal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(19.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Osteopenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">124 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(37.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Osteoporosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">141 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(42.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab553693.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">(SD) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Age (years)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">71.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">FRAX</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Main fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hip fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">(12) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab553692.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Three or more units daily.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Oral glucocorticoids for more than 3 months at a dose of 5<span class="elsevierStyleHsp" style=""></span>mg/d of prednisolone.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Early menopause (<45 years) in 45 cases.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the Patients Included in the Intervention Study (n=330).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:23 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The population-based prevalence of osteoporotic vertebral fracture and densitometric osteoporosis in postmenopausal women over 50 in Valencia, Spain (the FRAVO study)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Sanfelix-Genoves" 1 => "B. Reig-Molla" 2 => "G. Sanfelix-Gimeno" 3 => "S. Peiro" 4 => "M. Graells-Ferrer" 5 => "M. Vega-Martinez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.bone.2010.06.015" "Revista" => array:6 [ "tituloSerie" => "Bone" "fecha" => "2010" "volumen" => "47" "paginaInicial" => "610" "paginaFinal" => "616" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20601286" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epidemiology of falls and osteoporotic fractures: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Morrison" 1 => "T. Fan" 2 => "S.S. Sen" 3 => "L. 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To Manuel de la Torre (Service of Traumatology and Orthopedic Surgery), Sinforiano Rodríguez (Geriatric Evaluation Unit), and Vanessa Diaz (Family Physician).</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/21735743/0000001000000005/v1_201409070108/S2173574314000537/v1_201409070108/en/main.assets" "Apartado" => array:4 [ "identificador" => "17338" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Original Article" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/21735743/0000001000000005/v1_201409070108/S2173574314000537/v1_201409070108/en/main.pdf?idApp=UINPBA00004M&text.app=https://reumatologiaclinica.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173574314000537?idApp=UINPBA00004M" ]
| Year/Month | Html | Total | |
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| 2024 November | 1 | 5 | 6 |
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| 2024 August | 52 | 38 | 90 |
| 2024 July | 46 | 35 | 81 |
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| 2024 May | 45 | 35 | 80 |
| 2024 April | 35 | 17 | 52 |
| 2024 March | 46 | 27 | 73 |
| 2024 February | 14 | 32 | 46 |
| 2024 January | 22 | 26 | 48 |
| 2023 December | 31 | 27 | 58 |
| 2023 November | 38 | 39 | 77 |
| 2023 October | 32 | 22 | 54 |
| 2023 September | 89 | 38 | 127 |
| 2023 August | 35 | 18 | 53 |
| 2023 July | 32 | 23 | 55 |
| 2023 June | 38 | 26 | 64 |
| 2023 May | 41 | 24 | 65 |
| 2023 April | 21 | 15 | 36 |
| 2023 March | 62 | 30 | 92 |
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| 2023 January | 36 | 19 | 55 |
| 2022 December | 55 | 45 | 100 |
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| 2021 April | 92 | 100 | 192 |
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| 2020 December | 35 | 16 | 51 |
| 2020 November | 29 | 27 | 56 |
| 2020 October | 14 | 18 | 32 |
| 2020 September | 25 | 25 | 50 |
| 2020 August | 24 | 20 | 44 |
| 2020 July | 13 | 27 | 40 |
| 2020 June | 45 | 35 | 80 |
| 2020 May | 45 | 17 | 62 |
| 2020 April | 34 | 27 | 61 |
| 2020 March | 20 | 8 | 28 |
| 2020 February | 2 | 0 | 2 |
| 2018 May | 5 | 0 | 5 |
| 2018 April | 29 | 7 | 36 |
| 2018 March | 43 | 7 | 50 |
| 2018 February | 24 | 3 | 27 |
| 2018 January | 28 | 5 | 33 |
| 2017 December | 34 | 6 | 40 |
| 2017 November | 30 | 5 | 35 |
| 2017 October | 26 | 11 | 37 |
| 2017 September | 27 | 6 | 33 |
| 2017 August | 37 | 5 | 42 |
| 2017 July | 41 | 11 | 52 |
| 2017 June | 65 | 22 | 87 |
| 2017 May | 45 | 9 | 54 |
| 2017 April | 34 | 7 | 41 |
| 2017 March | 47 | 9 | 56 |
| 2017 February | 22 | 2 | 24 |
| 2017 January | 37 | 6 | 43 |
| 2016 December | 91 | 12 | 103 |
| 2016 November | 54 | 10 | 64 |
| 2016 October | 96 | 13 | 109 |
| 2016 September | 58 | 5 | 63 |
| 2016 August | 50 | 6 | 56 |
| 2016 July | 30 | 6 | 36 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 1 | 0 | 1 |
| 2015 September | 1 | 0 | 1 |
| 2015 August | 3 | 0 | 3 |
| 2015 July | 22 | 7 | 29 |
| 2015 June | 47 | 5 | 52 |
| 2015 May | 83 | 5 | 88 |
| 2015 April | 81 | 6 | 87 |
| 2015 March | 41 | 6 | 47 |
| 2015 February | 21 | 8 | 29 |
| 2015 January | 23 | 13 | 36 |
| 2014 December | 37 | 14 | 51 |
| 2014 November | 38 | 6 | 44 |
| 2014 October | 48 | 17 | 65 |
| 2014 September | 28 | 14 | 42 |
Show all
