Fracture Risk Assessment Research Articles

Textural and geometric measures derived from digital tomosynthesis discriminate women with and without vertebral fracture.

Vertebral fractures are a common and debilitating consequence of osteoporosis. Bone mineral density (BMD), measured by dual energy x-ray absorptiometry (DXA), is the clinical standard for assessing overall bone quantity but falls short in accurately predicting vertebral fracture. Fracture risk prediction may be improved by incorporating metrics of microstructural organization from an appropriate imaging modality. Digital tomosynthesis (DTS)-derived textural and microstructural parameters have been previously correlated to vertebral bone strength in vitro, but the in vivo utility has not been explored. Therefore, the current study sought to establish the extent to which DTS-derived measurements of vertebral microstructure and size discriminate patients with and without vertebral fracture. In a cohort of 93 postmenopausal women with or without history of vertebral fracture, DTS-derived microstructural parameters and vertebral width were calculated for T12 and L1 vertebrae, as well as lumbar spine BMD and trabecular bone score (TBS) from DXA images. Fracture patients had lower BMD and TBS, while DTS-derived degree of anisotropy and vertebral width were higher, compared to nonfracture (p<0.02 to p<0.003) patients. The addition of DTS-derived parameters (fractal dimension, lacunarity, degree of anisotropy and vertebral width) improved discriminative capability for models of fracture status (AUC=0.79) compared to BMD alone (AUC=0.67). For twelve additional participants who were imaged twice, in vivo repeatability errors for DTS parameters were low (0.2% - 7.3%). The current results support the complementary use of DTS imaging for assessing bone quality and improving the accuracy of fracture risk assessment beyond that achievable by DXA alone.

Biases in the performance of FRAX without BMD in predicting fracture risk in a multiethnic population with diabetes: the Diabetes & Aging Study.

Fracture risk calculators, such as the Fracture Risk Assessment Tool (FRAX), calculate the risk of major osteoporotic (MOF) and hip fracture, but do not account for the excess risk of fracture in people with diabetes. We examined the predictive performance of FRAX without BMD in ethnically diverse, older patients with diabetes. Patients included were between ages 65-89 from the Kaiser Permanente Northern California Diabetes Registry and not already taking osteoporosis medications. Race and ethnicity were self-identified. We calculated FRAX without BMD based on baseline characteristics and assessed how well FRAX predicted MOF and hip fracture over follow-up. Predictive performance was based on measures of discrimination (area under the receiver operator curve, AUC) and calibration (observed-to-predicted ratio, O/P). We identified 96 914 patients (47.0% female), of whom 5383 (5.6%) and 1767 (1.8%) had MOF and hip fracture, respectively, over a mean follow-up of 4.3years. The AUC for MOF and hip fracture were 0.72 and 0.77, respectively. FRAX mildly underestimated MOF and hip fracture rates (O/P 1.2 for both) overall. Discrimination was similar by race and ethnicity and diabetes duration but was worse in those over age 75 (AUC < 0.7). In some groups, there were substantial calibration errors, such as Hispanic women (O/P: 1.8 and 1.5), Black men (O/P: 1.5 and 1.8), those with duration of diabetes ≥20years (O/P: 1.6 and 1.5), and those over the age of 80 (O/P: 1.4 and 1.2) for MOF and hip fracture, respectively. While the discriminatory performance of FRAX without BMD was good overall in patients with diabetes, it underestimated risk in Hispanic women, Black men, those with long duration of diabetes, and in the oldest patients with diabetes. These algorithmic biases suggest that diabetes-specific tools may be needed to stratify fracture risk in patients with diabetes.

Addressing healthcare disparities and improving osteoporosis management in rural communities: a cluster randomized control trial.

Rural communities face limited healthcare access, financial constraints, and transportation barriers leading to health disparities. This study examined interventions that reduced health disparities in increasing the outpatient attendance and treatment rate of anti-osteoporosis medication (AOM), while identifying factors contributing to therapy refusal in rural communities. A total of 567 patients were randomized at the community level into three groups: multicomponent integrated care (MIC), osteoporosis care only (OC), and usual care (UC). Fracture Risk Assessment Tool and dual-energy X-ray absorptiometry scans were used to evaluate the osteoporosis and osteoporotic fracture risk. High- and moderate-risk patients were advised to pursue further hospital-based assessments and treatment. Both the MIC and OC groups received five interventions to address rural barriers, including specialist access, disease education, overcoming transportation barriers, peer support, and dedicated case managers. However, UC excluded transportation assistance, peer support, and case management. Outcomes measured included outpatient attendance, AOM treatment rates, and factors affecting hospital assessment refusal, analyzed via multivariable logistic modeling. In the MIC group, 73.3% of patients attended the outpatient clinic and 58.6% received AOM. In the OC group, 81% patients attended and 69.3% received AOM. Conversely, in the UC group, only 4.1% attended and received AOM. Significant differences in attendance and AOM rates were found between the MIC and UC groups and between the OC and UC groups (p < .001 for both). Common barriers included beliefs that treatment was unnecessary and lack of hospital access. Risk factors hindering outpatient attendance include male sex, low education, low budget, multiple disabilities, and osteopenia diagnosis. Addressing transportation barriers and implementing dedicated case management are crucial for improving healthcare access among rural patients. ClinicalTrials.gov NCT05104034.

Effects of femoral neck width and hip Axis length on incident hip fracture risk: a registry-based cohort study.

Bone mineral density (BMD) measured with dual-energy X-ray absorptiometry (DXA) is widely used in clinical practice to assess fracture risk and guide management. DXA can also assess hip geometry, including femoral neck width (FNW) and hip axis length (HAL), which have both been associated with increased risk for hip fracture independently from BMD. Our objective was to assess if FNW predicts hip fracture independently from other factors including HAL. We performed a retrospective cohort study using the Province of Manitoba BMD registry. The study population comprised 75 095 individuals (90.8% women), mean age 64.7years, with baseline hip BMD and hip geometry parameters. Linked health records were used to ascertain subsequent hospitalization with hip fracture as a primary diagnosis. During a mean follow up of 8.3 (SD 5.1) years, 2341 incident hip fractures were recorded. Each SD increase in age- and sex-adjusted FNW was associated with incident hip fracture (HR 1.15, 95% CI 1.10-1.19) which was unchanged after adjustment for height, weight, femoral neck BMD and clinical risk factors. However, FNW showed a significant positive correlation with HAL (r = 0.68). When further adjusted for HAL, FNW was no longer associated with increased risk for hip fracture (HR 0.98, 95% CI 0.94-1.03). A similar pattern was seen for femoral neck, intertrochanteric and non hip fractures. In contrast, increased risk of hip fracture was consistently seen with each SD increase in HAL even after adjustment for all covariates including FNW (HR 1.35, 95% CI 1.28-1.42). In conclusion, FNW is a risk factor for hip fracture before but not after adjustment for HAL. HAL, on the other hand, robustly and independently predicts hip fracture, including both femoral neck and trochanteric fractures.

Preterm birth and risk of bone fractures during childhood and early adulthood.

People born preterm have reduced bone mineral density, subnormal peak bone mass, and an increased risk of osteoporosis. Whether this translates to increased risk of bone fractures is uncertain. We assessed fracture risk from childhood to early adulthood in relation to gestational age and sex by conducting a nationwide register-linkage cohort study comprising all 223 615 liveborn (1/1987- 9/1990) singletons (9161, 4.1%, preterm) in Finland. Cox regression models provided hazard ratios (HR) for fracture diagnosis in public specialty healthcare in both first and recurrent event settings during the whole follow-up (0-29yr), and during different age periods (0-4/5-9/10-29yr). Gestational age was considered categorical (full-term, 39-41weeks, reference). A total of 39 223 (17.5%) children or young adults had at least one fracture. In analyses not stratified by sex, only extremely preterm birth (<28 completed weeks' gestation) was associated with risk of bone fracture at 0-29yr; adjusted HR (aHR) 0.46 (95% CI 0.28-0.74) compared with those born full-term. Among females, gestational age was unrelated to fracture risk at 0-29yr. Among males, extremely and very preterm (28-31weeks) birth was associated with lower risk of fracture at 0-29yr compared with those born full-term: aHR 0.38 (CI 0.21-0.71) and 0.75 (CI 0.59-0.95) respectively. Restricting the analyses to the individuals without severe medical condition(s) attenuated the associations. However, the fracture risk varied according age and sex: at 10-29yr moderately preterm (32-33wk) females, and extremely- and very preterm males had a lower risk: aHR 0.63 (0.43-0.94), 0.35 (0.17-0.69), and 0.74 (0.57-0.95) respectively, while late preterm birth (34-36wk) was associated to 1.6-fold higher risk among females at 0-5yr, and 1.4-fold risk among males at 5-10yr. Analyses on recurrent fractures showed similar pattern. Children and young adults, in particular males, born extremely or very preterm may have less bone fractures, this is partly explained by severe medical conditions in this group.

Correlation Between Handgrip Strength and Bone Density and Fragility Fracture Risk Among Older Adults: A Cross-Sectional Study.

Population aging has led to a surge in elderly care needs worldwide. Bone aging, skeletal muscle degeneration, and osteoporosis pose critical health challenges for the elderly. The process of bone and skeletal muscle aging not only impacts the functional abilities but also increases fragility fracture risk. Although a negative correlation between handgrip strength and fragility fracture risk has been identified in elderly populations, there is a lack of related research in Taiwan. This cross-sectional study was designed to investigate the association between handgrip strength and two outcome variables, bone density and risk of fragility fracture, in Taiwanese individuals aged 65 years and older with low bone mass. A total of 548 older adults, including 84 men and 464 women, were recruited between August 2019 and July 2021. Bone mineral density T-scores acquired using dual-energy X-ray absorptiometry scan, the total score for the Taiwan-specific Fracture Risk Assessment (FRAX) tool, and bilateral handgrip strength acquired using a digital hand dynamometer were recorded along with other factors such as comorbidities, dietary habits, and daily activities. In this study, the mean age was 70.9 (SD = 5.6) years, mean bone mass index was 24.1 (SD = 3.5) kg/m2, mean FRAX main fracture risk score was 19.5% (SD = 8.3), and mean FRAX hip fracture risk score was 7.7% (SD = 5.7). Lumbar and hip T-scores were both significantly correlated with both dominant and nondominant handgrip strength in older woman. Older age; both lower hip and spine T-scores; both lower dominant and nondominant handgrip strengths; having Type 2 diabetes, coronary artery disease, or chronic hepatic disease; and lacking a steady job were significantly associated with a higher risk of fragility fracture. The results of this study provide important information regarding the correlation between handgrip strength and several variables, including bone mineral density T-score, FRAX score, comorbidities, and job status, among older adults. Notably, these correlations were found to be particularly strong in the female participants. This information may be used to facilitate the early identification of elderly individuals at a high risk of fragility fractures, enabling the timely development of preventive nursing strategies and the provision of targeted interventions.

An audit on the assessment and management of osteoporosis in a Parkinson's and related diseases clinic in Australia.

Patients with Parkinson's disease (PD) and atypical parkinsonian syndromes are at increased risk of falls and should be actively screened and treated for osteoporosis. In 2024, the Royal Australian College of General Practitioners (RACGP) revised their practice guidelines for diagnosing and managing osteoporosis in postmenopausal women and men aged over 50years. We conducted the first Australian study to audit these guidelines in patients with PD and atypical parkinsonian syndromes. We audited all PD, Dementia with Lewy Bodies, Progressive Supranuclear Palsy and Multiple System Atrophy cases attending our neurology service between January and March 2024 against the RACGP osteoporosis guidelines. We identified patients at risk of osteoporosis or minimal trauma fractures and assessed if they had been referred to their general practitioner (GP) for appropriate management or were already receiving appropriate osteoporosis treatment. This audit evaluated 230 patients, 199 of which had PD. We identified 78 patients over the age of 50years with risk factors that should trigger a GP bone health assessment as per the guidelines. Twenty-six of these patients were already being managed appropriately. However, only 12 of the remaining 52 'at risk' patients (23%) were directed to seek screening for osteoporosis by their GP, leaving 77% (40/52) without appropriate guidance. Our major recommendations include following the guidelines and referring patients for a bone health screen with their GP if they have risk factors for osteoporosis. This audit highlighted that assessment of osteoporosis and fracture risk by Specialists needs to be improved.

Fracture Risk Assessment as a Component of Osteoporosis Screening—Easier Said Than Done

Fracture Risk Assessment as a Component of Osteoporosis Screening—Easier Said Than Done

CAR Practice Guideline on Bone Mineral Densitometry Reporting: 2024 Update.

This practice guideline serves as an update to the Canadian Association of Radiologists' 2013 Technical Standards for Bone Mineral Densitometry Reporting. It aims to align bone mineral density testing and reporting practices in Canada with current clinical best practices, including guidelines from Osteoporosis Canada and the International Society for Clinical Densitometry. Key updates include the endorsement of both FRAX and CAROC tools for evaluating fracture risk, guidance for analyzing male patients and transgender patients, and provision of clinical management guidance of relevance to BMD reporting harmonized with that of Osteoporosis Canada. The document emphasizes the importance of accurate data collection in fracture risk assessment and provides recommendations for reporting fracture risk, T-scores, and clinical management strategies. Additionally, it outlines indications for baseline BMD testing and reassessment timelines, aiming to facilitate appropriate patient management and enhance bone health outcomes. This guideline is intended to complement existing standards and support healthcare professionals in delivering optimal care for patients undergoing BMD testing in Canada.

Fracture Risk Assessment in the 2023 Osteoporosis Canada Guideline.

Radiologists and other diagnostic imaging specialists play a pivotal role in the management of osteoporosis, a highly prevalent condition of reduced bone strength and increased fracture risk. Bone mineral density (BMD) measurement with dual-energy X-ray absorptiometry (DXA) is a critical component of identifying individuals at high risk for fracture. Strategies to prevent fractures are consolidated in the Osteoporosis Canada clinical practice guideline which was updated in 2023. In this guideline, treatment recommendations are based upon a consideration of fracture history, 10-year major osteoporotic fracture (MOF) risk, and BMD T-score in conjunction with age. The current review aims to familiarize radiologists and other diagnostic imaging specialists with the reporting requirements needed to support implementation of this guideline using the FRAX™ risk calculation tool. Fortunately, for specialists already familiar with the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool, the transition to FRAX-based reporting is readily accommodated in a radiology workflow.

How Accurately Does Bone Mineral Density Predict Bone Strength? A Clinical Observational Study of Osteoporosis Vertebral Compression Fractures in Postmenopausal Women.

Dual energy x-ray absorptiometry (DXA) provides incomplete information about bone strength. There are few data on the relationship between osteoporosis-related examinations and bone strength. The objective of the present study was to determine which osteoporosis-related examinations best predicted trabecular bone strength, and to enhance a formula for predicting bone strength on the basis of bone density examination. This observational study included postmenopausal women (aged over 50 years) who underwent unilateral percutaneous kyphoplasty (PKP) surgery in the lumbar spine between September 2021 and June 2023. The pressure within each balloon expansion circle was extracted to reflect the true bone strength. The NHANES 2013-2014 data were used to assess the performance of the formula. The performance of the formula was compared with that of the observed actual fractures. Bland-Altman analysis was used to compare the agreement between the formula and the fracture risk assessment tool (FRAX) score. A total of 40 postmenopausal women (mean age ± standard deviation, 70.90 years ± 10.30) were enrolled. The average balloon pressure was 59.23 psi (± 12.40, means ± SDs). The mean BMD of total lumbar spine (average of L1-L4) was 0.89 g/cm2 ± 0.20 (mean ± standard), and the Pearson correlation coefficient between lumbar BMD and bone strength was 0.516. After adjusting for age and BMI, the DXA response rate to bone strength reached 72%. Calibration plots of the observed actual fractures versus those estimated via the bone strength formula were considered good fits. The Bland-Altman analysis revealed a nonsignificant difference between the formula and the FRAX score in predicting fracture risk. After adjustment, the DXA response rate to bone strength reached 72%, indicating a strong correlation. In addition, Bone Strength = DXA × 27 - Age × 0.585-BMI × 0.887 + 98.

Assessment of fracture risk with FRAX and FRAXplus.

FRAX®, a risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used for fracture risk assessment since its launch in 2008. It is now incorporated into very many guidelines worldwide to inform osteoporosis management. In this review, we explore the development of FRAX and how it enhances fracture risk prediction as compared to use of bone mineral density alone, as well as approaches to utilizing FRAX in determining intervention and assessment thresholds. We also discuss the limitations of FRAX and the arithmetic adjustments that have been proposed to address these. The introduction of FRAXplus® includes these adjustments on a web-based platform for ease of application to enhance treatment decisions in osteoporosis.

Assessing and Managing Primary Hyperparathyroidism and Fracture Risk in England: A Survey of Medical Professionals.

To describe diagnostic approaches and management strategies for patients with primary hyperparathyroidism (PHPT) and recent fracture in England. We developed a survey based on a patient at high fracture risk and a new diagnosis of probable PHPT. The survey was circulated among 50 secondary care professionals identified by the Society for Endocrinology Calcium and Bone special interest group. Descriptive statistics, combinatorial, and thematic analyses were employed. In the patient with hyperparathyroidism and a recent fracture, 54% of respondents favoured a 24-hour urinary calcium: creatinine clearance ratio, with 85% opting to do so after correcting vitamin D levels. Thirty-two percent (16/50) preferred the spot urinary calcium:creatinine clearance ratio, as a random test (56%, n = 9/16). Ninety-six percent of the respondents agreed they would include a fracture risk assessment in their management plan. Eighty-five percent of the respondents selected dual-energy X-ray absorptiometry scans of the lumbar spine, total hip, and femoral neck as the most popular choice. Before initiating antiosteoporotic medications (AOMs), 94% of the respondents preferred correcting vitamin D levels with diverse regimens. IV zoledronate acid was the preferred AOM, and 58% (n = 29/50) supported cinacalcet usage if the patient was ineligible for parathyroid surgery, while 26% (n = 13/50) opposed cinacalcet use entirely. No significant correlation was found between status as an endocrinology consultant or working in a tertiary care hospital and these management preferences. This study of National Health Service medical staff identified highly-varied clinical practices in managing PHPT in the setting of high fracture risk, highlighting the need for pragmatic guidelines and wider education.

Clinical Application of a Big Data Machine Learning Analysis Model for Osteoporotic Fracture Risk Assessment Built on Multicenter Clinical Data in Qingdao City.

Osteoporotic fractures (OPF) pose a public health issue, imposing significant burdens on families and societies worldwide. Currently, there is a lack of comprehensive and validated risk assessment models for OPF. This study aims to develop a model to assess and predict the risk of OPF in Qingdao City, China. From January 2021 to January 2023, we recruited 84 osteoporotic patients diagnosed with fractures from Qingdao University Affiliated Hospital, Qingdao Municipal Hospital, Qingdao Hiser Hospital Affiliated of Qingdao University, and Qingdao Central Hospital as the experimental group. In addition, 112 osteoporotic patients without fractures were recruited as the control group. In this study, we employed seven machine learning models, namely Adaboost, random forest (RF), K-Nearest Neighbors (KNN), Support Vector Machine (SVM), Logistic Regression (LR), Naive Bayes (NB), and Gradient Boosting Decision Trees (GBDT), to analyze the risk factors influencing the occurrence of OPF. Next, we plotted receiver operating characteristic (ROC), Precision-Recall (PR), and calibration curves to evaluate the predictive values of the different risk assessment models for OPF. Among the seven models built based on the training set data, the Adaboost model showed area under the curve (AUC), sensitivity, and specificity values close to 1, indicating the best classification performance. In the test set, the AUC values for the RF, SVM, LR, KNN, NB, AdaBoost, and GBDT models were 0.936, 0.905, 0.88, 0.93, 0.862, 0.939, and 0.859, respectively (p < 0.001). All sensitivity and specificity values for these models were higher than 0.8, with sensitivity and specificity values of the Adaboost model closest to 1. Additionally, six models had an area under the Precision-Recall curve (prAUC) values higher than 0.9, except KNN at 0.284 (p < 0.001). The calibration curves of the seven models did not significantly deviate from the ideal curve, indicating acceptable discriminative ability and predictive performance of the predictive model. All results showed that trabecular bone score (TBS) was the most important variable affecting the model, followed by osteocalcin (OST) and hunchback. Given the various clinical data from patients with OPF, we assessed and demonstrated the good predictive performance of our risk predictive models. This model will enable us to take timely intervention measures to reduce the incidence of OPF and improve patient prognosis.

Cost-effectiveness of FRAX®-based intervention thresholds for management of osteoporosis in Indian women: a Markov microsimulation model analysis.

Osteoporosis represents a significant public health challenge in India, with an increasing economic burden due to the aging population. This study evaluated the cost-effectiveness of using fracture risk assessment tool (FRAX®)-based intervention thresholds (ITs) for managing osteoporosis with generic alendronate in Indian women. A Markov microsimulation model, adapted to the Indian healthcare context, was used to simulate the costs and quality-adjusted life years (QALYs) associated with different treatment strategies. The one-time gross domestic product (GDP) per capita (estimated at INR 1,97,468/QALY gained) was used as the cost-effectiveness threshold. The model revealed that generic alendronate is cost-effective for major osteoporotic fracture (MOF) ITs beginning at age 60years with full adherence-incremental cost-effectiveness ratio (ICER) of INR 102,151 per QALY gained, and age 65 with real-world adherence-ICER of INR 28,203 per QALY gained (conversion rate used is 1 US dollar (USD) = INR 83.97 and 1 EURO = INR 92.70). Hip fracture (HF) ITs showed similar cost-effectiveness at ages 60 (ICER of INR 67,144) and was the dominant strategy (i.e., more QALYs for lower costs) at ≥ 65years. Fixed ITs of 14% for MOF and 3.5% for HF proved cost-effective across all age groups (dominant strategy for ages ≥ 65years). Limitations of our study include the reliance on fracture incidence data from Singaporean Indians and variability in fracture prevalence across India. The results support the integration of FRAX®-based fixed ITs from the age of 50years and age-based ones from the age of 65years in India to optimize resource allocation and improve osteoporosis management.

Quantitative ultrasound imaging reveals distinct fracture-associated differences in tibial intracortical pore morphology and viscoelastic properties in aged individuals with and without diabetes mellitus - an exploratory study.

Diabetes mellitus (DM) is a chronic metabolic disorder that increases fragility fracture risk. Conventional DXA-based areal bone mineral density (aBMD) assessments often underestimate this risk. Cortical Backscatter (CortBS) ultrasound, a radiation-free technique, non-invasively analyzes cortical bone's viscoelastic and microstructural properties. This study aimed to evaluate CortBS's discriminative performance in DM patients compared to DXA and characterize changes in cortical bone microstructure in Type 1 and Type 2 DM (T1DM, T2DM) patients. This in-vivo study included 89 DM patients (T1DM = 39, T2DM = 48) and 76 age- and sex-matched controls. DXA measured aBMD, while CortBS measurements were taken at the anteromedial tibia using a medical ultrasound scanner with custom software. Multivariate analysis of variance assessed the impact of DM type on CortBS and DXA measurement results. Partial least squares discriminant analyses with cross-validation were used to compare the discrimination performance for vertebral, non-vertebral, and any fragility fractures, adjusting for gender, age, and anthropometric parameters (weight, height, BMI). Fractures occurred in 8/23 T1DM, 17/18 T2DM, and 16/55 controls. DXA parameters were reduced in fracture patients, with significant diabetes impact. T2DM was associated with altered CortBS parameters, reduced scatterer density, and larger pores. CortBS outperformed DXA in discriminating fracture risk (0.61 ≤ AUC(DXA) ≤ 0.63, 0.68 ≤ AUC(CortBS) ≤ 0.69). Both T1DM and T2DM showed altered bone metabolism, with T2DM linked to impaired tissue formation. CortBS provides insights into pathophysiological changes in diabetic bone and provided superior fracture risk assessment in DM patients compared to DXA.

Potential impact of obstetric history on postmenopausal fragility fracture risk: A reassessment of the Fracture Risk Assessment Tool.

This study aimed to evaluate the impact of integrating obstetric parameters into the Fracture Risk Assessment Tool (FRAX) on the precision of risk assessment. In this retrospective study, patients who experienced postmenopausal fragility fractures of the distal radius, proximal femur, or lumbar vertebrae between January 1, 2021, and December 31, 2023, were included. Obstetric histories, along with standard FRAX parameters, were obtained by phone interviews. Based on the FRAX major osteoporotic fracture risk score calculated without bone mineral density, patients were classified into high-, intermediate-, and low-risk group categories. Differences in age at menarche, age at menopause, lactation duration, gravidity, and parity were analyzed across risk categories. A total of 328 patients (mean age: 64.5±5.8 years; range, 55 to 75 years) were included. The mean FRAX score was 16±8.8 (range, 3 to 58), and 85, 191, and 52 patients were classified as high-, intermediate-, and low-risk, respectively. A positive correlation was observed between FRAX scores and both later age at menarche and earlier menopause (p<0.001 and p=0.008, respectively). The mean age at menopause was significantly different between the high- and low-risk groups (46.4 vs. 49.3 years, p=0.016). The intermediate-risk group was also evaluated, showing no significant differences in obstetric parameters compared to the low-risk group (p>0.05). Although late menarche is not explicitly included in FRAX, its association with higher fracture risk was evident. The established influence of early menopause on FRAX scores supports its role in fracture risk estimation. However, the inclusion of additional obstetric parameters did not enhance the predictive accuracy of FRAX in this cohort.

Comparative evaluation of trabecular bone density in Hounsfield units in the lumbar native CT cross-section for osteoporosis diagnosis and fracture risk determination by different examiners

An increasing loss of bone mineral density (BMD) in the axial skeleton leads to osteoporosis and fractures, with an increase found in the thoracic and thoracolumbar regions. The extent to which an examiner-independent assessment of the extent of osteoporosis and fracture risk determination is possible by determining the trabecular density in Hounsfield units (HU) in the spine should be examined. The next question was whether quantitative BMD values can be calculated from the HU values. 225 patients (pt.) with an average age of 64.9 ± 13.1 years and abody-mass-index (BMI) of 26.8 ± 6.8 kg/m2, of which 37were men and 188 were women, were examined to determine whether they had osteoporosis. The BMD was determined in mg/cm3 using quantitative computed tomography (QCT) in the lumbar region. After anonymization by three experienced radiologists, an additional measurement of the trabecular bone density in HU, was carried out in the same vertebral bodies (atotal of 675 vertebral bodies), each using aregion of interest (ROI) positioned in the midvertebral cancellous space in the sagittal reformed CT image. In additional lateral X‑rays of the thoracic and lumbar spine, vertebral fractures were detected and graded. Sacral insufficiency fractures that occurred at the same time were also recorded. The median BMD was 73.2 (57.05-104.17) mg/cm3 and the median HU was 89.93 (67.90-126.95). With acorrelation of 0.988 (p < 0.001), quantitative values in mg/cm3 can be calculated using the following formula: Xq = 12.1 + 0.68 × HU. With HU values less than 69.84 and aBMD of the lumbar spine below 59.54 mg/cm3, there was asignificantly increased number of OVF. At least one OVF was found in 137/225 pt. In 17/137 pt., sacral fractures were also found; these patients showed the significantly lowest values with amedian BMD of 41.81 (16.2-53.7) mg/cm3. Comparable HU values were determined independently of the examiners (p > 0.05). The trabecular density measurements in HU values can be converted into quantitative BMD values in mg/cm3, which enables agood assessment of osteoporosis and fracture risk. Taking the results obtained into account, an opportunistic evaluation using HU values in native CT alone seems quite possible. Experienced examiners have arrived at comparable results.

Factors influencing the survival time of patients with advanced cancer at the end of life: a retrospective study

BackgroundPredicting the survival time of patients at the end of life can provide more accurate treatment and care programs for patients. The purpose of this study was to investigate the factors impacting 14-day survival at the end of life.MethodThis was a retrospective study. Patients with advanced cancer admitted to the Department of Palliative Medicine in a tertiary hospital in China in 2021 were included and classified into group A (survival time ≤ 14 days) or group B (survival time > 14 days). Patient demographic characteristics, palliative performance scale (PPS) scores, Barthel index scores, Fracture Risk Assessment Scale (FRAIL) scale scores, clinical features and laboratory test results were extracted from medical records. Univariable and multivariable logistic regression analyses were used to identify predictors of death within 14 days. Survival time was compared between frail and nonfrail patients.ResultsA total of 261 patients were included (122 in group A and 139 in group B), with a median survival time of 17 (13.04, 20.96) days. There were significant differences in age, FRAIL score, PPS, Barthel index, dyspnea, edema, C-reactive protein and white blood cell count between the two groups. According to the multivariable logistic regression analysis, the PPS could predict the risk of death within 14 days (OR = 6.818, 95% CI = 3.944–11.785, p < 0.001). The median survival time was 48 (33.71, 62.29) days in the nonfrail group (n = 34) and 15 (12.46, 17.54) days in the frail group (n = 227) (p < 0.001).ConclusionsA lower PPS increases the risk of 14-day mortality in patients at the end of life. Frailty may shorten the survival time of patients at the end of life.

The Challenge of Fractures in Patients With Chronic Kidney Disease.

People with chronic kidney disease (CKD) are at increased risk of fractures in comparison to the non-CKD population, and fractures are associated with high mortality and worsening quality of life. However, the approach for evaluation of bone disease and fracture risk in CKD is different from the approach in the general population. The authors conducted a literature review of PubMed to include studies on pathophysiology of CKD mineral bone disorder, fracture risk assessment, and therapeutic options in the setting of CKD. The higher risk observed in the CKD population is related to the complex interplay of changes in bone turnover (T), mineralization (M), and volume (V), along with other risk factors accumulated as glomerular filtration rate declines. The diagnosis of the type of renal osteodystrophy is not based only on assessment of bone density and traditional risk factors for osteoporosis. There are limitations of currently available fracture risk tools in the CKD population. Treatment choice should take into consideration the 3 components of the TMV classification along with the stage of kidney disease and comorbidities, but the assessment of these components has not been well established. Current data are limited on efficacy and safety of treatments for fracture prevention in CKD. As new medications for the treatment of osteoporosis become available, there is an urgency to establish more clear guidelines for the diagnosis, fracture risk stratification, and treatment of bone disease in CKD.