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

The European Men-Who-Have-Sex-With-Men Internet Survey (EMIS): Design and Methods

Community-based opportunistic self-completion surveying for sexual health programming is common among men-who-have-sex-with-men (MSM) in Europe, being used to generate evidence of unmet prevention need, for behavioural surveillance and as a platform for advocating HIV precautions. However, comparing survey findings across Europe is difficult because of varying measures and recruitment designs, and surveying has not occurred in all countries. EMIS (the European Men-who-have-sex-with-men Internet Survey) aimed to develop a pan-European Internet survey on HIV-related male homosexual behaviours and prevention needs both to increase research capacity and to move towards harmonisation of existing systems. Six associated partners (APs) recruited another 77 collaborating partners from academia, public health and civil society across 35 countries. Partners' existing MSM surveys were collected and collated, producing a meta-survey which was discussed by all partners through rotating round-tables at a 2-day summit. Survey development continued iteratively through user piloting and partner feedback until the English language content was agreed. Transfer to an online survey application was followed by further testing before on-screen translation into 24 other languages, final testing and sign-off. The project's visual identity and promotional materials were developed in close collaboration with national leads, tailoring products to match country specific needs while maintaining an overall project identity. Five international MSM dating websites were contracted to send carefully crafted instant messages to members in a series of waves. The survey sought common ground with stakeholders and respondents by endorsing 'the best sex with the least harm' for MSM. Real-time monitoring of responses allowed targeted spending of the advertising budget to maximise coverage and depth of responses. Fieldwork occurred during June-August 2010. Over 184,469 responses were submitted of which 94.4 % were eligible. Partners in 38 countries were supplied with a national database of 100 or more respondents for national analysis and outputs, while the AP team proceeded on international comparisons among 174,209 respondents in 38 countries. EMIS demonstrated the feasibility of multi-country community-based MSM Internet surveying with limited public funding. The concept of 'the best sex with the least harm' provided a common ground for a diverse range of stakeholders to collaborate. Meaningful involvement of a large number of collaborators in the survey design, its visual identity and in promotional strategies ensured unprecedented coverage and depth of recruitment. Flexible planning was essential and a patchwork of recruitment was required across a range of commercial and community partners. Careful design, piloting and presentation ensured the survey was acceptable and had both authority and perceived community benefit. © 2013 The Author(s)

Virtual community consultation? Using the literature and weblogs to link community perspectives and health technology assessment

Copyright © 2008 The Authors The definitive version may be found at www.wiley.comBackground Community views, expressed in social impact assessments and collected through community consultation, should play an important role in health technology assessment (HTA). Yet HTA methodologists have been slow to include outcomes of these forms of inquiry in analyses, in part because collecting community views is time-consuming and resource intensive. Objective To explore how community views sourced from published studies, grey literature and informal internet web pages can inform HTA. Methods A technology reviewed by Adelaide HTA in 2004 was selected: retinal photography for detection of diabetic retinopathy. Published literature, 'grey' literature and informal web pages were searched to examine the availability of evidence about service community and user community views with respect to this technology. Particular efforts were made to source evidence relating to rural, remote and Aboriginal populations. Results We found that journal articles, reports from the grey literature and informal internet web pages (including blogs and discussion forums) can provide valuable insight into community views. Although there was little empirical evidence relating to the experience of diabetes and diabetes management in rural, remote and Aboriginal communities, there were indications that some evidence may be transferable from other populations. Conclusions Community perspectives on selected health technologies can be gauged from available resources in published and grey literature and perspectives collected in this way can provide insight into whether the introduction of the technology would be acceptable to the community. The limitations of this approach are discussed.Jackie M. Street, Annette J. Braunack-Mayer, Karen Facey, Richard E. Ashcroft and Janet E. Hille

Spelling Progress Bulletin 2. Spelling Irregularity, Spelling Reform, and Learning to Read Meaningfully, a Commentary

Purposes: 1. To promote continued research on the writing system (orthography) and word perception in reading. 2. To translate research for effective instruction in classroom situations. Topics include: perceptual learning, factors in word perception; relationships between intonation and perception, between phonic rules and word perception, between perception and other facets of reading; phonemic and morphemic bases of spellings; methodology. Dr. John Downing (Editor) announces a new national bilingual journal devoted to reading. It is called Reading-CanadaLecture, and is a refereed quarterly journal which aims to improve communication between educators within Canada and between Canadians and colleagues in other countries. R-C-L also will provide a forum between English speaking and French speaking educators whose mutual concern is the improvement of reading instruction in these two languages. We envisage that R-C-L will be read mainly by classroom teachers, but that there will be other readers such as school administrators, consultants, parents, university faculty members, etc. R-C-L will be open to all points of view regarding reading theory and practice. Articles will relate to all levels: pre-school, elementary, secondary, college and adult. We are currently particularly interested in receiving manuscripts on themes of practical concern to classroom teachers and clinicians. Articles will be published in full in the original language of the author, either English or French. In addition there will be a summary in the other language. R-C-L welcomes articles in either English or French from authors in any country in the world. The fluent reading process, according to current psycholinguistic theory (Goodman 1967, Smith 1973, involves less emphasis on graphic-visual characteristics and more emphasis on semantics and text structure. Furthermore, much research is currently being generated to demonstrate that reading involves an interaction of the various levels of language and the background knowledge of the reader in constructing meaning (Center for the Study of Reading [1]). Thus, the focus of reading instruction must be on comprehension. However, the beginning reader must learn to crack the orthographic code as part of (but not as the essence of) learning to read. [2] Yet, beginning reading would involve more spelling-sound relationships than would fluent reading (Shuy 1977). In considering spelling reform, two questions need to be answered: (1) Is the English spelling system the most "optimal" for learning to read? (2) Is spelling reform the only step toward literacy improvement? In other words, until spelling reform is achieved, how can teachers facilitate reading of traditional orthography? Chomsky (1973) claimed that the English writing system is predictable because it captures the abstract underlying phonological structure of words as well as the meaningful relationships among related words: Thus, the silent g of malign is related to the pronounced g in malignant. Likewise, the schwa sound of o in composition is related to the o in compose. The orthography preserves the meaningful relationships of these words as an assistance to the fluent reader who focuses on meaning rather than on phonetic details: While many sets of words follow predictable phonological alternations, some experimental evidence has questioned the psychological reality of some of the phonological processes claimed by Chomsky and Halle (1968). (See Steinberg (1973) and Ohala (1974).) Furthermore, many of the elements of traditional orthography have little psychological basis, as they were the result of linguistic and cultural history (Barnitz 1980). [3] Thus, English spelling is certainly not as optimal as originally claimed in Chomsky and Halle (1968). Would a more direct phonemic alphabet facilitate learning to read? Cross-cultural and crosslinguistic research suggests that the regularity of fit between phonological systems and writing systems facilitates, learning to decode spelling into sound as part of beginning reading (Downing 1973, Barnitz 1978. Furthermore, evidence from research on transitional writing systems suggests the role of regularity in learning to read (Downing 1965, Gleitman and Rozin 1973) However, an overemphasis on decoding is not the essence of reading (Goodman 1967). Yet, regularity of writing systems does greatly help the reading learning process. The second major question will be answered briefly. Until total spelling reform occurs -despite the many resistances (c.f. Stubbs 1980) -children still need to be taught the meaningful reading process, regardless of the orthography. For decoding is only a small part of the learning to read process. Goodman 1967, Shafer 1979. As traditional orthography still survives, how can teachers circumvent the problems of "irregularity." Here are only a few suggestions: (1) Emphasize the total language-meaning relationships in reading instruction. This can be done, for example, by using the Language Experience Approach (Stouffer 1980, Veatch et al. 1979. (See also the many reports from the Center for the Study of Reading). (2) Develop word attack skills within the context of meaningful comprehension. (3) Using natural language, provide as much regularity as possible in teaching beginning reading. Begin with regularities, then move to irregularities (Bloomfield 1942), but emphasize the total reading process. (4) As the meaningful relationships among many words are preserved in traditional orthography (malign-malignant), some aspects of these may be introduced for older readers. However, not all relationships have psychological reality. Instructional research is needed here. These suggestions alone will not solve all the literacy problems. Of course, spelling reform will be of assistance. However, until and even after spelling reform does occur, teachers must emphasize meaning in reading instruction. Footnotes Justification There appear to be two justifications of this study. First, studies of the phonetic pronunciation of word elements at each reader level provide the basis for determining the point at which certain phonetic elements may be introduced for systematic study. Second, studies of phonetic structure may provide s basis for deriving readability formulae. Two current reviews of readability studies indicate that this element is not a part of any such formula now available [9; 14]. Limitations The words analyzed were taken from a single vocabulary study [8]. These appeared in at least ten of the fourteen different aeries of basal readers. Only base forms and compound words were selected for analysis [8]. Reader levels studies ranged from primer through third. The syllable was the unit used for analysis. Both initial and final consonant phonograms were analyzed and tabulated. Syllabication and respellings for pronunciation were based on Webster's New International Dictionary Definitions Terminology used in this study is defined as follows: In 1950, Oaks reported "A Study of the Vowel Situations in a Primary (1) "short" vowel principle in closed syllables (2) "long" vowel principle in syllables ending with a final e (3) "long" (single) vowel principle in open accented syllables Oaks concluded that the recognition of vowel digraphs should be systematically taught at the primary level for two reasons: (1) there are several types of digraphs, and (2) two letters frequently represent diphthongs. Among the indirectly related studies are those of Spache [28], Dolch [16; Summary: The studies reviewed emphasized the unphonetic character of our language. Many different sounds were found for one phonogram. Some were found to have as many as eleven pronunciations Procedure The vocabulary used for this study was taken from the Betts' Primary Reading Vocabulary Studies [9], used also by Oaks in A Study of the Vowel Situation in a Primary Reading Vocabulary The analysis of the vocabulary entailed the following steps. First, words were listed by reader level, and the pronunciation of each consonant phonogram was recorded. Second, the position of the consonant phonogram in the syllable, whether initial or final, was then tabulated. All tabulations were made in terms of the syllable in the word. Third, from these data were obtained the incidence of consonant letters, digraphs, trigraphs, blends, and other consonant situations. (1) A total of 1,573 single letter consonants, 38.7% of the consonant situations, appeared in the initial parts of the syllables. (2) A total of 1,203 single letter consonants, 29.6% of the consonant situations, appeared in the final parts of the syllables. (3) Single letter consonants appeared at all reader levels in both initial and final parts of the syllables. b. Of the consonant situations in the study, 396, or 9.8% of all consonant situations, were consonant digraphs. Summary of Results (1) The number of consonant digraphs introduced in the initial parts of the syllables was 122, or 3% of the consonant situations. (2) The number of consonant digraphs introduced in the final parts of the syllables was 274, or 68% of the consonant situations. (3) Consonant digraphs appeared at all reader levels in both initial and final positions in the syllables, c. There were twenty-six consonant trigraphs, comprising .6% of the consonant situations, identified in the vocabulary. (1) All trigraphs appeared in the final parts of the syllables. (2) Trigraphs were introduced at first-reader level and were used at all succeeding levels. d. Consonant blends were classified as two and three-letter blends. There were 613 two-letter blends, comprising 15% of the consonant situations, in the study. Totalling 53, the three-letter blends accounted for only 1.3% of the consonant situations. (1) A total of 336 two-letter blends, 8.2% of the consonant situations, was used in the initial parts of the syllables. Only thirty-two three-letter blends, comprising .8% of the total consonant situations, were used in initial positions. (2) There were 277 two-letter blends, or 6.8% of all consonant situations in the study, in the final parts of the syllables. Twenty-one three-letter blends were tabulated in the final parts of the syllables. This was only .5% of all consonant situations. (3) Two-letter blends were identified at all reader levels, three-letter blends appeared at first-reader level and were used at all succeeding levels. e. In this study, 130 syllabic consonants and 16 syllabic blends were identified. The syllabic consonants comprised 3.3%, and the syllabic blends .4% of the total consonant situations. (1) Syllabic consonants and syllabic blends s appeared only in final syllables of words. (2) Syllabic consonants appeared at all levels; syllabic blends were introduced at firstreader level and used at all succeeding levels, f. In the "miscellaneous" situations classification, there were 52 consonant situations. (1) One "miscellaneous" phonogram, ear [3] as in earth, appeared three times in the initial syllable or parts of syllables. This total comprised .1% of the total situations. (2) Thirty, .8% of the total consonant situations, appeared in the medial parts of syllables. (3) Nineteen, .5% of the total consonant situations, appeared in final positions in the syllables. (4) "Miscellaneous" phonograms appeared in initial positions at second-reader level, and in medial and final positions at all reader levels. 2. Of the consonant and vowel-colored r situations analyzed in this study, 606 involved letter r. These accounted for 14.9% of all consonant situations tabulated. a. A total of 264 letter r phonograms, 6.5% of all consonant situations, appeared in initial syllabic positions. b. Thirty vowel-colored r [3] situations (e.g., bird), comprising .7% of the total consonant situations, appeared in medial positions. c. There were 310 letter r situations, 7.7% of all consonant situations in the vocabulary, identified in final parts of syllables. d. Letter r situations appeared at all reader levels encompassed by this study. 3. There were 281 consonant phonograms, 6.9% of the total consonant situations, containing silent letters. a. A total of 74 consonant situations, appearing in the initial parts of the syllables, contained silent letters. This was 1.9% of the total consonant situations. b. There were 207 consonant phonograms, 5% of all consonant situations appearing in the study, involving silent-letter situations which appeared in final positions