An international survey on canine urinary incontinence: case frequency, diagnosis, treatment and follow-up.

Introduction: Urinary incontinence (UI) consists of involuntary leakage of urine during the storage phase of urination. Methods: An anonymous survey was given to Spanish and Italian veterinarians about canine UI treated cases, diagnosis, treatment, follow-up, and professional interest. Results and discussion: Most veterinarians treated ≤3 cases/quarter, resulting in the percentage of incontinence males being lower than that of females (1-4% vs 0-24%). The percentage of spayed incontinent females was lower in Spain (0-24%) than in Italy (75-100%). Most diagnoses were based on a diagnostic algorithm (Spain: 88.7%; Italy: 65.3%); patient report and history, blood work, urinalysis and abdominal ultrasound. Urethral/bladder pressure measurement was unusual (Spain: 0.2%; Italy: 2.4%). In Spain, radiology with contrast medium and CT urography (26.3% and 34.4%, respectively) were more frequent than in Italy (11.6% and 22.7%, respectively). When suspecting urethral sphincter mechanism incompetence pharmacological trial (Spain: 93.2%; Italy: 78.9%). The first-choice medical treatment was Phenylpropanolamine, followed by Ephedrine and Deslorelin. When pharmacotherapy failed, the most frequent option was drug change, followed by increased drug dosage/frequency of administration, surgical therapy and colposuspension. A review was completed after the first week of treatment followed by periodic reviews. Most of the respondents participated in continuing education only if UI occurred in their everyday practice (Spain: 63.0%; Italy: 55.4%) and about 30% responders did it regardless of the number of UI cases treated (Spain: 30.5%; Italy: 37.4%). Conclusion: Some recommendations in clinical practice were made. UI can be underestimated by owners; therefore, a complete history should be obtained by veterinarians. Veterinarians should carefully evaluate if spaying is advisable considering it could increase UI risk. A step-by-step approach is recommended and a specific diagnostic-therapeutic algorithm for UI in dogs is provided. Conservative approaches (regular exercise, weight loss in overweight dogs and observing an "incontinence diary" to identify abnormal patterns of urination) are advisable.

ESMO expert consensus statements on the screening and management of financial toxicity in patients with cancer.

BACKGROUND: Financial toxicity, defined as both the objective financial burden and subjective financial distress from a cancer diagnosis and its treatment, is a topic of interest in the assessment of the quality of life of patients with cancer and their families. Current evidence implicates financial toxicity in psychosocial, economic and other harms, leading to suboptimal cancer outcomes along the entire trajectory of diagnosis, treatment, supportive care, survivorship and palliation. This paper presents the results of a virtual consensus, based on the evidence base to date, on the screening and management of financial toxicity in patients with and beyond cancer organized by the European Society for Medical Oncology (ESMO) in 2022. METHODS: A Delphi panel of 19 experts from 11 countries was convened taking into account multidisciplinarity, diversity in health system contexts and research relevance. The international panel of experts was divided into four working groups (WGs) to address questions relating to distinct thematic areas: patients with cancer at risk of financial toxicity; management of financial toxicity during the initial phase of treatment at the hospital/ambulatory settings; financial toxicity during the continuing phase and at end of life; and financial risk protection for survivors of cancer, and in cancer recurrence. After comprehensively reviewing the literature, statements were developed by the WGs and then presented to the entire panel for further discussion and amendment, and voting. RESULTS AND DISCUSSION: A total of 25 evidence-informed consensus statements were developed, which answer 13 questions on financial toxicity. They cover evidence summaries, practice recommendations/guiding statements and policy recommendations relevant across health systems. These consensus statements aim to provide a more comprehensive understanding of financial toxicity and guide clinicians globally in mitigating its impact, emphasizing the importance of further research, best practices and guidelines.

Are Italian-Polish veterinarians and breeders prepared to control an outbreak of Brucella canis infection in dogs?

Brucella canis infection is one of the most important causes of infertility in dogs and is a zoonosis for which no effective treatment or vaccines exist. It is not a mandatory notifiable disease. Following an increase of cases in Europe and worldwide, an investigation was performed to evaluate how much Italian and Polish veterinarians and breeders know about canine brucellosis and understand their perceptions of this infection. For this reason, two questionnaires were prepared, in Italian and Polish. Eighteen Italian and Polish veterinarians, specialists in canine reproduction, responded to the first survey and 44.4% of them affirmed having diagnosed canine brucellosis at least once in their clinical practice, and different perceptions emerged regarding the infection in the two countries. The second survey was completed by 145 Italian and Polish breeders; the disease was completely unknown to 22.8% of them, whereas 2.1% had diagnosed infection by B. canis in their kennels. In conclusion, knowledge of B. canis infection differs between these countries, with extremes ranging from diagnosed cases to complete underestimation of the presence of the problem. However, based on international data and reporting of a recent large outbreak in Italy, awareness of this contagious infectious disease and its management must be increased.

Low doses of prenatal ethanol exposure and maternal separation alter HPA axis function and ethanol consumption in adult male rats.

Adverse maternal behaviors during pregnancy and unfavorable postnatal experiences during development are associated with an increased risk of developing psychiatric disorders, as well as, a vulnerability to alcohol addiction in adulthood. Here, we examined the effects of combined ethanol exposure during late pregnancy and postnatal maternal separation (MS) on HPA responsiveness, anxiety behavior and preference for alcohol consumption in adult male rats. Animals exposed to both conditions revealed a decrease in blood levels of allopregnanolone accompanied by increased anxiety behavior. In addition, basal blood levels of corticosterone were markedly decreased in all experimental groups while increases in the foot-shock-induced corticosterone levels were more pronounced in MS animals. Finally, evaluating EtOH drinking behavior, MS animals exhibited a remarkable EtOH preference even at low doses (0.1-1%). Altogether, these data suggest that adverse conditions, alone or in combination, may alter anxiety-like states as well as modify behavior towards alcohol consumption.

Sex differences in the outcome of juvenile social isolation on HPA axis function in rats.

Women are more likely than men to suffer from anxiety disorders and major depression. These disorders share hyperresponsiveness to stress as an etiological factor. Thus, sex differences in brain arousal systems and their regulation by chronic stress may account for the increased vulnerability to these disorders in women. Social isolation is a model of early life stress that results in neurobiological alterations leading to increased anxiety-like and depressive-like behaviors. Here we investigated the sex difference in the effects of post-weaning social isolation on acute stress sensitivity and behavior in rats. In both sexes, social isolation at weaning reduced basal levels of the neuroactive steroid allopregnanolone in the brain and of corticosterone in plasma. Moreover, acute stress increased plasma corticosterone levels in both group-housed and socially isolated male and female rats; however this effect was greater in male than female rats subjected to social isolation. Intriguingly, group-housed female rats showed no change in plasma and brain levels of allopregnanolone after acute foot-shock stress. The absence of stress-induced effects on allopregnanolone synthesis might be due to the physiologically higher levels of this hormone in females vs. males. Accordingly, increasing allopregnanolone levels in male rats blunted the response to foot-shock stress in these animals. Socially isolated male, but not female, rats also display depressive-like behavior and increased hippocampal brain-derived neurotrophic factor (BDNF). The ovarian steroids could "buffer" the effect of this adverse experience in females on these parameters. Finally, the dexamethasone (DEX) suppression test indicated that the chronic stress associated with social isolation impairs feedback inhibition in both sexes in which an increase in the abundance of glucocorticoid receptors (GRs) in the hippocampus was found. Altogether, these results demonstrate that social isolation affects neuroendocrine reactivity to stress, plasticity and emotionality in a sexually dimorphic manner.

NPY-Y1 coexpressed with NPY-Y5 receptors modulate anxiety but not mild social stress response in mice.

The Y1 and Y5 receptors for neuropeptide Y have overlapping functions in regulating anxiety. We previously demonstrated that conditional removal of the Y1 receptor in the Y5 receptor expressing neurons in juvenile Npy1r(Y5R-/-) mice leads to higher anxiety but no changes in hypothalamus-pituitary-adrenocortical axis activity, under basal conditions or after acute restraint stress. In the present study, we used the same conditional system to analyze the specific contribution of limbic neurons coexpressing Y1 and Y5 receptors on the emotional and neuroendocrine responses to social chronic stress, using different housing conditions (isolation vs. group-housing) as a model. We demonstrated that control Npy1r(2lox) male mice housed in groups show increased anxiety and hypothalamus-pituitary-adrenocortical axis activity compared with Npy1r(2lox) mice isolated for six weeks immediately after weaning. Conversely, Npy1r(Y5R-/-) conditional mutants display an anxious-like behavior but no changes in hypothalamus-pituitary-adrenocortical axis activity as compared with their control littermates, independently of housing conditions. These results suggest that group housing constitutes a mild social stress for our B6129S mouse strain and they confirm that the conditional inactivation of Y1 receptors specifically in Y5 receptor containing neurons increases stress-related anxiety without affecting endocrine stress responses.

Maternal separation attenuates the effect of adolescent social isolation on HPA axis responsiveness in adult rats.

Adverse early life experiences that occur during childhood and adolescence can have negative impacts on behavior later in life. The main goal of our work was to assess how the association between stressful experiences during neonatal and adolescent periods may influence stress responsiveness and brain plasticity in adult rats. Stressful experiences included maternal separation and social isolation at weaning. Three hours of separation from the pups (3-14 PND) significantly increased frequencies of maternal arched-back nursing and licking-grooming across the first two weeks postpartum. Separation also induced a long-lasting increase in dams blood levels of corticosterone. Maternal separation did not modify brain and plasma allopregnanolone and corticosterone levels in adult offspring, but they demonstrate partial recovery from the reduction induced by social isolation during adolescence. Moreover, the enhancement of corticosterone and allopregnanolone levels induced by foot shock stress in socially isolated animals that were subjected to maternal separation was markedly reduced with respect to that observed in animals that were just socially isolated. All experimental groups showed a significant reduction of BDNF and Arc protein expression in the hippocampus. However, the reduction of BDNF observed in animals that were maternally separated and subjected to social isolation was less significantly pronounced than in animals that were just socially isolated. The results sustained the mismatch hypothesis stating that aversive experiences early in life trigger adaptive processes, thereby rendering an individual to be better adapted to aversive challenges later in life.

Incidence and prevalence of epilepsy among older U.S. Medicare beneficiaries.

OBJECTIVE: To determine the prevalence and incidence of epilepsy among U.S. Medicare beneficiaries aged 65 years old and over, and to compare rates across demographic groups. METHODS: We performed a retrospective analysis of Medicare administrative claims for 2001-2005, defining prevalent cases as persons with ≥1 claim with diagnosis code 345.xx (epilepsy) or 2 or more with diagnosis code 780.3x (convulsion) ≥1 month apart, and incident cases as prevalent cases with 2 years immediately before diagnosis without such claims. Prevalence and incidence rates were calculated for the years 2003-2005 using denominators estimated from a 5% random sample of Medicare beneficiaries. Results were correlated with gender, age, and race. RESULTS: We identified 282,661 per year on average during 2001-2005 (a total of 704,243 unique cases overall), and 62,182 incident cases per year on average during 2003-2005. Average annual prevalence and incidence rates were 10.8/1,000 and 2.4/1,000. Overall, rates were higher for black beneficiaries (prevalence 18.7/1,000, incidence 4.1/1,000), and lower for Asians (5.5/1,000, 1.6/1,000) and Native Americans (7.7/1,000, 1.1/1,000) than for white beneficiaries (10.2/1,000, 2.3/1,000). Incidence rates were slightly higher for women than for men, and increased with age for all gender and race groups. CONCLUSIONS: Epilepsy is a significant public health problem among Medicare beneficiaries. Efforts are necessary to target groups at higher risk, such as minorities or the very old, and to provide the care necessary to reduce the negative effects of epilepsy on quality of life.

Experimental analysis and modelling of in vitro HUVECs proliferation in the presence of various types of drugs.

OBJECTIVES: This study focuses on experimental analysis and corresponding mathematical simulation of in vitro HUVECs (human umbilical vein endothelial cells) proliferation in the presence of various types of drugs. MATERIALS AND METHODS: HUVECs, once seeded in Petri dishes, were expanded to confluence. Temporal profiles of total count obtained by classic haemocytometry and cell size distribution measured using an electronic Coulter counter, are quantitatively simulated by a suitable model based on the population balance approach. Influence of drugs on cell proliferation is also properly simulated by accounting for suitable kinetic equations. RESULTS AND DISCUSSION: The models' parameters have been determined by comparison with experimental data related to cell population expansion and cell size distribution in the absence of drugs. Inhibition constant for each type of drug has been estimated by comparing the experimental data with model results concerning temporal profiles of total cell count. The reliability of the model and its predictive capability have been tested by simulating cell size distribution for experiments performed in the presence of drugs. The proposed model will be useful in interpreting effects of selected drugs on expansion of readily available human cells.

In vitro ovine articular chondrocyte proliferation: experiments and modelling.

This study focuses on analysis of in vitro cultures of chondrocytes from ovine articular cartilage. Isolated cells were seeded in Petri dishes, then expanded to confluence and phenotypically characterized by flow cytometry. The sigmoidal temporal profile of total counts was obtained by classic haemocytometry and corresponding cell size distributions were measured electronically using a Coulter Counter. A mathematical model recently proposed (1) was adopted for quantitative interpretation of these experimental data. The model is based on a 1-D (that is, mass-structured), single-staged population balance approach capable of taking into account contact inhibition at confluence. The model's parameters were determined by fitting measured total cell counts and size distributions. Model reliability was verified by predicting cell proliferation counts and corresponding size distributions at culture times longer than those used when tuning the model's parameters. It was found that adoption of cell mass as the intrinsic characteristic of a growing chondrocyte population enables sigmoidal temporal profiles of total counts in the Petri dish, as well as cell size distributions at 'balanced growth', to be adequately predicted.

Cost-effectiveness of multifaceted evidence implementation programs for the prevention of glucocorticoid-induced osteoporosis.

SUMMARY: Using a computer simulation model, we determined that an intervention aimed at improving the management of glucocorticoid-induced osteoporosis is likely to be cost-effective to third-party health insurers only if it focuses on individuals with very high fracture risk and the proportion of prescriptions for generic bisphosphonates increases substantially. INTRODUCTION: The purpose of this study is to determine whether an evidence implementation program (intervention) focused on increasing appropriate management of glucocorticoid-induced osteoporosis (GIOP) might be cost-effective compared with current practice (no intervention) from the perspective of a third-party health insurer. METHODS: We developed a Markov microsimulation model to determine the cost-effectiveness of the intervention. The hypothetical patient cohort was of current chronic glucocorticoid users 50-65 years old and 70% female. Model parameters were derived from published literature, and sensitivity analyses were performed. RESULTS: The intervention resulted in incremental cost-effectiveness ratios (ICERs) of $298,000 per quality adjusted life year (QALY) and $206,000 per hip fracture averted. If the cohort's baseline risk of fracture was increased by 50% (10-year cumulative incidence of hip fracture of 14%), the ICERs improved significantly: $105,000 per QALY and $137,000 per hip fracture averted. The ICERs improved significantly if the proportion of prescriptions for generic bisphosphonates was increased to 75%, with $113,000 per QALY and $77,900 per hip fracture averted. CONCLUSIONS: Evidence implementation programs for the management of GIOP are likely to be cost-effective to third-party health insurers only if they are targeted at individuals with a very high risk of fracture and the proportion of prescriptions for less expensive generic bisphosphonates increases substantially.

Experimental analysis and modelling of in vitro proliferation of mesenchymal stem cells.

OBJECTIVES: Stem cell therapies based on differentiation of adult or embryonic stem cells into specialized ones appear to be effective for treating several human diseases. This work addresses the mathematical simulation of proliferation kinetics of stem cells. MATERIALS AND METHODS: Sheep bone marrow mesenchymal stem cells (phenotype characterized by flow cytometry analysis) seeded at different initial concentrations in Petri dishes were expanded to confluence. Sigmoid temporal profiles of total counts obtained through classic haemocytometry were quantitatively interpreted by both a phenomenological logistic equation and a novel model based on a one-dimensional, single-staged population balance approach capable of taking into account contact inhibition at confluence. The models' parameters were determined by comparison with experimental data on population expansion starting from single seeding concentration. Reliability of the models was tested by predicting cell proliferation carried out starting from different seeding concentrations. RESULTS AND DISCUSSION: It was found that the proposed population balance modelling approach was successful in predicting the experimental data over the whole range of initial cell numbers investigated, while prediction capability of phenomenological logistic equation was more limited.

Cell proliferation, apoptosis and mitochondrial damage in rat B50 neuronal cells after cisplatin treatment.

OBJECTIVES: Cisplatin (cisPt) is used as a chemotherapeutic agent for the treatment of a variety of human tumours; more recently, it has been demonstrated that tumour cell exposure to cisPt ultimately results in apoptosis, but the mechanism by which nuclear cisPt/DNA generates the cytoplasmic cascade of events involved has not been clarified. We have investigated the effects of cisPt on proliferation in the neuronal cell line B50, with particular attention being given to understand whether mitochondria are a target of cisPt and their involvement in the apoptotic process. MATERIALS AND METHODS: Rat neuronal B50 cells were used to investigate the mechanisms of cisPt-induced cytotoxicity; this line has been used as a model system for neurotoxicity in vivo. RESULTS: Changes in proliferation, induction of apoptosis, activation of caspase-3 and DNA fragmentation were observed in the cells, as well as morphological and biochemical alterations of mithocondria. Activation of caspase-9 confirmed that mitochondria are a target of cisPt. CONCLUSION: CisPt exerts cytotoxic effects in the neuronal B50 cell line via a caspase-dependent pathway with mitochondria being central relay stations.

Monoamine receptors and immature cerebellum cytoarchitecture after cisplatin injury.

The experimental model of cisplatin treatment provides the opportunity to identify the precise function of the neurotransmitters in some crucial events of brain development, and their interactions or modulatory roles. The serotonin and noradrenaline monoamines influence the formation of the cerebellar cortex circuitry. In this study we found changes in the expression of the serotonin and noradrenaline receptors after a single injection of cisplatin in 10-day-old rats. The growth of Pc dendrites was early altered in lobules VI-VIII of cerebellum vermis. In these lobules, at postnatal day (PD) 17, the cisplatin-induced increase of the serotoninergic receptor 5-HT2AR, a factor that inhibits Pc dendrite growth by acting post-synaptically, occurred in all cerebellar layers, suggesting also alteration of granule cell proliferation and migration. The decreased labelling of beta l adrenergic receptor (beta1AR) in the soma of some Pc at PD11 can be correlated with the altered expression of glutamate receptors and GAD65 (glutamic acid decarboxylase) of and on Pc we have previously described [Pisu, M.B., Guioli, S., Conforti, E., Bernocchi, G., 2003. Signal molecules and receptors in the differential development of cerebellum lobules. Acute effects of cisplatin on nitric oxide and glutamate system in Purkinje cell population. Dev. Brain Res. 145, 229-240; Pisu, M.B., Roda, E., Avella, D., Bernocchi, G., 2004. Developmental plasticity of rat cerebellar cortex after cisplatin injury: inhibitory synapses and differentiating Purkinje neurons. Neuroscience 129, 655-664]. Moreover, beta1AR seems to be the key factor in the cerebellar reorganization between PD17 and PD30. The expression of this receptor was maintained in the molecular layer (ML), in particular in the inhibitory interneurons, despite their different distributions. The labelling of 5-HT1AR in the ML areas lacking Pc dendrite branches could contribute to the recovery phase of the cerebellar cytoarchitecture in cisplatin-treated rats. In general these findings should be taken into consideration in therapeutic interventions for developmental CNS disorders with a morphological basis.

Reorganization of the rat cerebellar cortex during postnatal development following cisplatin treatment.

We examined the effects of the antitumor agent cisplatin on the development and plasticity of cerebellar cytoarchitecture. Since knowledge of the parallel and climbing fiber-Purkinje cell system is important in order to determine the architectural basis of cerebellar function, we used immunofluorescence for vesicular glutamate transporters (VGluT1 and VGluT2) to evaluate the trend of synaptogenesis of parallel and climbing fibers on Purkinje cells in the cerebellum vermis after a single injection of cisplatin to 10-day-old rats, i.e., during a crucial period of cerebellar development. The temporal and spatial patterns of VGluT1 and VGluT2 immunoreactivity after the early cisplatin injury provided evidence that remodeling of excitatory afferents and Purkinje cell dendrites occurs. After an early slow down of Purkinje cell dendrite growth, 7 days following the treatment, the extension of the molecular layer was reduced, as was parallel fiber innervation, but VGluT1 immunoreactive fibers contacted Purkinje cell dendrite branches extending within the external granular layer. VGluT2 immunopositive climbing fiber varicosities were still largely present on the soma and stem dendrites of Purkinje cells. Twenty days after the cisplatin injection, the thickness of the VGluT1 immunopositive molecular layer was reduced. VGluT2 climbing fiber varicosities were found on the remodeled Purkinje cell dendrites, as in controls, although at a lower density. Alterations in the immunoreactivity for polysialic acid neural cell adhesion molecule (PSA-NCAM) during the recovery phase suggest that this molecule plays a fundamental role not only during development, but also in the reorganization of neuroarchitecture. The changes were restricted to the neocerebellar vermis and were likely dependent on the different timing of lobule formation. The results of these investigations reveal the existence of vulnerability windows of the cerebellum to exposure to experimental or environmental cytotoxic agents during a critical period in development.

Mechanically induced self-propagating reactions: analysis of reactive substrates and degradation of aromatic sulfonic pollutants.

Mechanochemical reactions have been identified as a valuable alternative to conventional methodologies for the degradation of toxic pollutants as well as for their abatement in contaminated matrices. This paper discusses the application of the mechanochemical technique to the degradation of sulfonic acids in a contaminated matrix. The degradation of the pollutant compound was carried out by taking advantage of combustive reactions on a suitable reactive system ignited under mechanical treatment conditions. Two systems have been investigated as possible reactive substrates. The first one was a Mg-SiO2 powder mixture while the second system was a Ca-SiO2 powder mixture. Milling trials performed under different mechanical processing conditions allowed one to characterise the reactivity of these chemical systems, which basically undergo a reduction/oxidation reaction involving the formation of MgO and Si phases when the Mg-SiO2 system is considered and CaO and Si phases when the Ca-SiO2 system is employed, respectively. The systematic change of the stoichiometric ratios Mg:SiO2 and Ca:SiO2 permitted to identify the minimum Mg or Ca content necessary for the ignition of the combustive reactions. The experimental runs performed with such systems have shown a greater effectiveness of the Mg-SiO2 because of less energy inputs required to ignite a combustion. For this reason the Mg-SiO2 has been considered as a reactive substrate in the following trials. Since the SiO2 amount in stoichiometric excess may be regarded as inert phase, it was substituted with a different phase consisting of the matrix contaminated by sulfonic acids. This aspect permitted to ignite a combustive reaction with the minimum possible content of Mg-SiO2 reacting mixture. The chemical analyses performed after the combustive reaction proved the complete removal of the sulfonic acid from the contaminated matrix.

Ret, GFRalpha-1, GFRalpha-2 and GFRalpha-3 receptors in the human hippocampus and fascia dentata.

The immunohistochemical occurrence and localization of the receptor components of the glial cell line-derived neurotrophic factor (GDNF) family ligands, the Ret receptor tyrosine kinase and GDNF family receptor (GFR) alpha-1 to -3, is described in the human post-mortem hippocampal formation at pre- and full-term newborn, and adult age. Two different antibodies for each of the four-receptor molecules were used. Western blot analysis indicates that the availability of GFRalpha receptor proteins may vary with age and post-mortem delay. The immunohistochemical detectability of GFRalpha-1, GFRalpha-2, GFRalpha-3 and Ret receptor molecules is shown in the rat up to 72 h post-mortem. In the human specimens, labelled neuronal perikarya were detectable for each receptor protein at all examined ages, with prevalent localization in the pyramidal layer of the Ammon's horn and hilus and granular layer of the fascia dentata. In the adult subjects, abundant punctate-like structures were also present. Labelled glial elements were identifiable. Comparison of the pattern of immunoreactive elements among young and adult subjects suggests that the intracellular distribution of the GDNF family ligands may vary between pre- and perinatal life and adult age. The results obtained suggest the involvement of the Ret and GFRalpha receptors signalling in processes subserving both the organization of this cortical region during development and the functional activity and maintenance of the mature hippocampal neurons.

Fracture Reduction Affects Medicare Economics (FRAME): impact of increased osteoporosis diagnosis and treatment.

Osteoporosis is a common, debilitating disease affecting US Medicare beneficiaries, yet diagnosis and treatment lag behind medical advances. We estimated the cost of fractures to the Medicare program and the impact of increasing osteoporosis diagnosis and treatment. A Markov model was used to predict fracture incidence and costs in postmenopausal women aged 65 years and older, over 3 years (2001-2003). Only 1.80 million women were estimated to receive a Medicare-reimbursed bone mineral density (BMD) test in 2001. We evaluated the budget impact of testing an additional 1 million women from Medicare and patient perspectives. These women were stratified into high-risk (osteoporotic with prevalent vertebral fracture) and moderate-risk (without prevalent vertebral fracture) groups. During 2001-2003, an estimated 2.39 million fractures occurred among the 5.11 million women aged 65+ with osteoporosis, at a cost to Medicare of 12.96 billion dollars. We projected that BMD testing of an additional 1 million women in 2001 would result in treatment of 440,000 new patients with a bone-specific medication, preventing over 35,000 fractures over the 3 years. The decrease in fractures would produce a net discounted savings to the Medicare budget of 77.86 million dollars. Medicare's hospital inpatient cost would decrease by 115.41 million dollars and long-term care cost by 43.51 million dollars, more than offsetting incremental outpatient cost of 81.07 million dollars. Patients would benefit from fracture avoidance, but their out-of-pocket medical costs would increase by 63.49 million dollars during 2001-2003, or 1,771 dollars per fracture avoided. Sensitivity analyses showed that savings to the Medicare program varied in proportion to the unit cost of fractures, fracture risk of the populations tested, treatment rate, and adherence to therapy. Increased osteoporosis diagnosis may produce savings for the Medicare program if interventions are targeted to women at elevated risk for fracture and may be budget neutral if all older women are screened.