WHO Fracture Risk Research Articles

A novel approach for assessing osteoporosis utilizing DXA, HU and VBQ

ObjectiveTo precisely assess preoperative osteoporosis in patients, a more precise method for evaluating osteoporosis is being developed to better guide the use of bone cement reinforced screws. MethodThe retrospective analysis was conducted on patients who underwent posterior lumbar decompression and fusion internal fixation at Shanghai Tongren Hospital.The general information, bone mineral density assessment data, Fracture risk prediction rate(WHO Fracture Risk Assessment Tool (FRAX)), and whether to use cement reinforced screws were collected. Definition of combination method: T value ​< ​−2.5 or HU value ​< ​110 or VBQ >3.5.The diagnostic rates of osteoporosis were compared between dual energy x-ray absorptiometry(DXA), Hounsfield Units(HU), Vertebral Bone Quality (VBQ), National Bone Health Alliance(NBHA), and combination methods, and the correlation between different methods was analyzed. Binary logistic regression was used to analyze the significant influencing factors of the use of cement-reinforced screws. ResultA total of 178 patients were enrolled in the study, aged 65.73 ​± ​14.43 years, 121 female, 57 male, Body Mass Index(BMI) was 22.88 ​± ​3.52, 57 (32.0%) used cement reinforced screws, and 14 (7.9%) had previous fracture history.The diagnostic rates of osteoporosis by DXA, HU, VBQ, NBHA and combination method were 22.5% (40/178), 47.2% (84/178), 56.2% (100/178), 64.0% (114/178) and 75.8% (135/178), respectively.HU, VBQ, NBHA, and combination methods were significantly different from DXA in the diagnosis rate of osteoporosis (P ​< ​0.001). Binary Logistics regression showed that age, T value, HU value, and VBQ value significantly influenced bone cement screw use, and the odds ratio of VBQ was 4.315. The prediction accuracy of the regression equation was 90.4%, the area under the receiver operator characteristic(ROC) curve was 0.974, and the Youden index was 0.830. ConclusionCurrently, the DXA method widely used for diagnosing osteoporosis yields false negative results and there are significant discrepancies among different diagnostic methods. The combined approach exhibits a higher detection rate (75.8%). Age, T value, HU value, and VBQ value significantly influence the use of cement screws with a regression equation accuracy of 90.4%. Cement-reinforced screws are recommended when osteoporosis is determined by a combination method.

Prediction of vertebral fractures in cancer patients undergoing hormone deprivation therapies: Reliability of WHO fracture risk assessment tool (FRAX) and bone mineral density in real-life clinical practice

Background and ObjectivePrediction of fractures in cancer survivors exposed to hormone-deprivation therapies (HDTs) is a challenge since bone loss is rapid and severe, and determinants of fractures in this setting are still largely unknown. In this study we investigated reliability of the WHO Fracture Risk Assessment Tool (FRAX) and bone mineral density (BMD) to identify subjects developing vertebral fractures during HDTs. DesignFive-hundred-twenty-seven consecutive subjects (429 females with breast cancer, 98 males with prostate cancer; median age 61 years), under HDTs for at least 6 months, were evaluated for vertebral fractures by a radiological and morphometric approach, in relationship with FRAX score, body mass index (BMI), BMD, age and duration of HDTs. ResultsVertebral fractures were found in 140 subjects (26.6%) and spine deformity index was significantly associated with duration of HDTs (rho 0.38; p < 0.001). Only in females, vertebral fractures were significantly associated with FRAX score for major fractures [OR 1.08; P < 0.001]. The best cut-off of FRAX score for major fractures, as calculated by receiving operating characteristic (ROC) analysis was 6.35%. In males, however, vertebral fractures were significantly and independently associated with BMI ≥ 25 Kg/m2 (OR 17.63; P < 0.001), BMD T-score below −1.0 SD at any skeletal site (OR 7.79; P < 0.001) and gonadotropin-releasing hormone agonists (GnRHa) plus abiraterone treatment (OR 11.51; P = 0.001). ConclusionsFRAX and BMD may be useful for predicting vertebral fractures in subjects undergoing HDTs, but the thresholds seem to be lower than those used in the general population. High BMI is a determinant of vertebral fractures in males under HDT.

Assessment of Aromatase Inhibitor-Induced Bone Loss and Appropriateness of Supportive Therapy in Postmenopausal Breast Cancer Patients at a Tertiary Care Center

Objective: To assess aromatase inhibitor-induced bone loss (AIBL) and its management in postmenopausal women (PMW) with breast cancer (BC). Materials and Methods: A cohort of 350 PMW with BC receiving aromatase inhibitors (AIs) during a span of 4 years was evaluated retrospectively. Bone mineral density (BMD) of the patients at lumbar spine (LS) and dual femur was monitored at baseline and annually for 2 years. Baseline fracture risk was evaluated using WHO fracture risk assessment tool. Results: At baseline, only 35.4% of the patients received supportive therapy such as calcium and Vitamin D supplements ± bisphosphonates. Significant decrease of mean BMD occurred at LS, left femur, and right femur (LF and RF) at 1 year (P

Expert consensus on relevant risk predictors for the occurrence of osteoporotic fractures in specific clinical subgroups \u2013 Delphi survey

BackgroundThere is an ongoing discussion about incorporating additional risk factors to established WHO fracture risk assessment tool (FRAX) to improve the prediction accuracy in clinical subgroups. We aimed to reach an expert consensus on possible additional predictive parameters for specific clinical subgroups.MethodsTwo-round modified Delphi survey: We generated a shortlist of experts from the authors’ lists of the pertinent literature and complemented the list with experts known to the authors. Participants were asked to name possible relevant risk factors besides the FRAX-parameters for the occurrence of osteoporotic fractures. Experts specified these possible predictors for specific subgroups of patients. In the second round the expert panel was asked to weight each parameter of every subgroup assigning a number between one (not important) to ten (very important). We defined the threshold for an expert consensus if the interquartile range (IQR) of a predictor was ≤2. The cut-off value of the median attributed weights for a relevant predictor was set at ≥7.ResultsEleven experts of seven countries completed both rounds of the Delphi. The participants agreed on nine additional parameters for seven categories. For the category “secondary osteoporosis”, “older adults” and “nursing home patients”, there was a consensus that history of previous falls was relevant, while for men and postmenopausal women, there was a consensus that the spine fracture status was important. For the group “primary and secondary osteoporosis” the experts agreed on the parameters “high risk of falls”, “lumbar spine bone mineral density (BMD)” and “sarcopenia”.ConclusionThis Delphi survey reached a consensus on various parameters that could be used to refine the currently existing FRAX for specific clinical situations or patient groups. The results may be useful for studies aiming at improving the predictive properties of instruments for fracture prediction.

Can Classification and Regression Tree Analysis Help Identify Clinically Meaningful Risk Groups for Hip Fracture Prediction in Older American Men (The MrOS Cohort Study)?

ABSTRACTAlthough the WHO fracture risk algorithm (FRAX) is used to predict fracture, the utility of some simple machine‐learning methods, such as classification and regression trees (CARTs) should be evaluated to determine their efficacy in fracture prediction. Follow‐up time for the hip fracture analyses of 5977 community‐dwelling American men aged ≥65 years old was truncated to 10 years. There were 172 (2.9%) men who had an incident nontraumatic hip fracture. The CARTs were developed using hip BMD and common clinical risk factors as follows: model 1 = using classification with continuous variables of age, total hip BMD, and femoral neck BMD, or together with common clinical risk factors; and model 2 = using classification with continuous variables of age, total hip BMD, femoral neck BMD, FRAX score, osteoporosis by T‐score at the hip, and common clinical risk factors. The predictive performance of risk models derived from CARTs was compared with the basic classification of FRAX at 3% (basic model). From model 1, discriminators selected by CART were total hip BMD, age, and femoral neck BMD; no other clinical risk factors were selected. From model 2, discriminators selected by CART were FRAX score, femoral neck BMD, and age. Compared with the basic model using only a high‐risk group by FRAX ≥3%, no significantly improved predictive performance was demonstrated by model 1 or model 2 as identified by CART with the area under the receiver‐operating characteristic curve for each model of 0.714 (95% CI, 0.676 to 0.751) or 0.726 (95% CI, 0.690 to 0.762) versus 0.703 (95% CI, 0.667 to 0.740), respectively. The improved overall net reclassification improvement index was 0.02 (95% CI, –0.04 to 0.08) and 0.05 (95% CI, –0.01 to 0.10), respectively. Although a FRAX category is a good clinical indicator for hip fracture risk, a simple classification by age and BMD may provide an alternative way to estimate a clinical risk level of 3.0%. © 2019 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

Are other feasible options available for screening of risk assessment of osteoporosis in postmenopausal women at community level in Southern Coastal India

Background: Osteoporosis is a chronic debilitating condition which exhibits iceberg phenomenon. Identification at an early stage of disease will enable preventive measures to reduce the incidence of disease and complications. Owing to the cost of diagnostic test, this study, various screening tools such as WHO fracture risk assessment tool, osteoporosis self-assessment tool for Asians, simple calculated osteoporosis risk estimation and osteoporosis risk assessment instrument have been used for assessment, in order to screen postmenopausal women in the preliminary stages.Methods: A facility-based cross-sectional study was conducted among 107 postmenopausal women carried over a period of five months.Results: Prevalence of osteoporosis and osteopenia was 24.3% and 69.2%. The area under the curve for osteoporosis self-assessment tool for Asians (OSTA), simple calculated osteoporotic risk estimation (SCORE) and osteoporotic risk assessment instrument (ORAI) was 0.731, 0.407 and 0.172 respectively. OSTA proved to be effective in differentiating normal BMD from low BMD score (i.e., osteopenia and osteoporosis) with a cut off of 1.1, SCORE to be more effective in screening osteoporosis than the other tools because it had a higher positive probability with a cut off 22. FRAX tool predicted probability of five and three percent probability of major fracture and hip fracture risk in ten yearsConclusions: Various tools assessed in the studies can be utilized at community level for identifying high risk women in post-menopausal stage but with different cut offs. This will reduce the cost of screening and also facilitate non pharmacological measures to reduce the progression of disease.

Prevalence of Osteoporosis and Risk of Developing Fragility Fracture in Post-Menopausal Women

Introduction: Osteoporosis and fragility fracture pose major health concern and cause significant financial burdens in healthcare system. The objectives of this study were to determine the prevalence of osteoporosis among post-menopausal women and to predict the risk of having the major osteoporotic and hip fracture in 10 years using the WHO Fracture Risk Assessment Tool. Materials and Methods: This was a cross-sectional study spanning over a two-year period (from June 2015 to June 2017) investigating post-menopausal women who did their Bone Mass Density (BMD) test at Hospital Melaka. Collected BMD data and parameters were used for analysif of the prevalence of osteoporosis among the study population and FRAX calculation was used to predict the average risk of fragility fracture in 10 years. Statistical analysis was done using SPSS statistical package. Results: Prevalence of osteoporosis among 388 post-menopausal women age 45 to 90 years old was 29.9%. More than half of patients had osteoporosis were Chinese (51%) followed by Malay (43%), Indian (5%) and others (1%). The 10 years average percentage of developing major osteoporosis was 10.81 ± 9.55 %, while the average percentage of developing hip fracture was 4.20 ± 6.53. Conclusion: Prevalence of the post-menopausal women who were osteoporotic was about 30% which is comparable to other countries (Japan, Egypt, Australia, Mexico, Argentina and India). The 10 years average percentage of developing major osteoporosis and hip fracture in our study is quite high, approximately around 20% and 10%, respectively.

Fracture risk prediction in post-menopausal women with osteopenia and osteoporosis: preliminary findings

The study aims to identify the risk of obtaining a fracture among post-menopausal women with osteopenia and osteoporosis. This work was a cross-sectional study involving a purposive sample of 87 post-menopausal women who attended the orthopedic and menopause clinics of Hospital Tengku Ampuan Afzan, Kuantan. The data were entered into the WHO fracture risk assessment tool (FRAX®) to predict major fracture and risk for hip fracture in 10 years' time. The mean age of the respondents was 61.6 years (SD=7.9). Among the respondents, 50.6% had osteopenia and nearly half (48.3%) had osteoporosis. The mean number of menopausal years of the respondents was 11.9 (SD=8.5), ranging between 1 and 44 years. The FRAX findings indicated 9.7% major osteoporotic fracture probability and 3.5% hip fracture probability, which were denoted as high risk. A Pearson correlation coefficient was computed to assess the relationship between menopausal years and the FRAX major osteoporotic fracture probability. A significant positive correlation was found between the two, but the correlation was weak (r=0.581, n=87, p < 0.001). The present findings indicate that menopausal years have a positive correlation with the risk of obtaining a fracture.

Kekuatan Otot dan Kualiti Hidup dalam Kalangan Dewasa Malaysia Berisiko Keretakan Osteoporotic Rendah dan Sederhana hingga Tinggi

Reduced muscle strength and quality of life (QoL) has an impact on adults at risk of osteoporotic fractures. Muscle strength and QoL among Malaysian adults at risk of osteoporotic fractures is not known. The aim of our study was to examine muscle strength and QoL status and its relationship among adults at low and moderate to high risk of osteoporotic fractures. In this cross-sectional study, we recruited 27 men and 78 women with mean age 69.3 ± 8.5 years from Orthopaedic Clinic, Hospital Canselor Tuanku Muhriz Universiti Kebangsaan Malaysia. A 10-year probability of major osteoporotic fractures were calculated according to WHO fracture risk assessment tool (FRAX) with femoral neck BMD (cut-point 10%). Participants were categorized as low and moderate to high risk of osteoporotic fractures based on FRAX results. Back extensor muscle strength (BES) and dominant hand grip strength (HGS) was measured using a load cell system and a hand dynamometer respectively. European QoL questionnaire (EQ5Dvas) was used to measure QoL. Multiple linear regression was performed with QoL as a dependent variable and back extensor muscle strength and hand grip strength as the independent variables. Approximate 40% of adults were categorized into moderate to high risk of osteoporotic fractures. The mean values among the low and moderate to high risk of osteoporotic fractures for QoL was 80.5 ± 13.2 and 76.9 ± 16.9 (p = 0.77); hand grip strength was 25.7 ± 17.3 and 20.6 ± 5.5 kg (p < 0.001) and back extensor strength was 25.0 ± 7.0 and 18.9 ± 9.5 Newton (p < 0.01) respectively. Hand grip muscle strength appeared to be a determinant of QoL and accounted for 5.8% of the total variance. Improved muscle strength may lead in better QoL among adults at risk of osteoporotic fractures. DOI : http://dx.doi.org./10.17576/JSKM-2018-31

Diagnostic accuracy of FRAX in predicting the 10-year risk of osteoporotic fractures using the USA treatment thresholds: A systematic review and meta-analysis

ObjectivesThe aim of this study was to conduct a systematic review and meta-analysis on the performance of the WHO's Fracture Risk Assessment (FRAX) instrument in predicting 10-year risk of Major Osteoporotic Fractures (MOF) and Hip Fractures (HF), using the USA treatment thresholds, in populations other than their derivation cohorts. DesignEMBASE and MEDLINE database were searched with search engine PubMed and OVID as well as Google Scholar for the English-language literature from July 2008 to July 2016. Limiting our search to articles that analyzed only MOF and/or HF as an outcome, 7 longitudinal cohorts from 5 countries (USA, Poland, France, Canada, New Zealand) were identified and included in the meta-analysis. SAS NLMIXED procedure (SAS v 9.3) was applied to fit the Hierarchical Summary Receiver Operating Characteristics (HSROC) model for meta-analysis. Forest plot and HSROC plot was generated by Review Manager (RevMan v 5.3). ResultsSeven studies (n=57,027) were analyzed to assess diagnostic accuracy of FRAX in predicting MOF, using 20% as the 10-year fracture risk threshold for intervention, the mean sensitivity, specificity, and diagnostic odds ratio (DOR) along with their 95% confidence intervals (CI) were 10.25% (3.76%–25.06%), 97.02% (91.17%–99.03%) and 3.71 (2.73–5.05), respectively. For HF prediction, using 3% as the 10-year fracture risk threshold, six studies (n=50,944) were analyzed. The mean sensitivity, specificity, and DOR along with their 95% confidence intervals (CI) were 45.70% (24.88%–68.13%), 84.70% (76.41%–90.44%) and 4.66 (2.39–9.08), respectively. ConclusionsOverall, using the 10year intervention thresholds of 20% for MOF and 3% for HF, FRAX performed better in identifying patients who will not have a MOF or HF within 10years, than those who will. A substantial number of patients who developed fractures, especially MOF within 10years of follow up, were missed by the baseline FRAX assessment.

Bone management in Japanese patients with prostate cancer: hormonal therapy leads to an increase in the FRAX score.

BackgroundOsteoporosis is a common consequence of androgen deprivation therapy (ADT) for prostate cancer. Up to 20 % of men on ADT have suffered from fractures within 5 years. The WHO Fracture Risk Assessment Tool (FRAX) has been utilized to predict the 10-year probability of major osteoporotic and hip fracture. However, to date, no large studies assessing the utility of the FRAX score in prostate cancer patients with or without ADT have been performed. We herein evaluated the impact of ADT on the FRAX score in prostate cancer patients.MethodsThe assessment of the FRAX score was performed in a total of 1220 prostate cancer patients, including patients who underwent brachytherapy (n = 547), radical prostatectomy (n = 200), external beam radiation therapy (n = 264) and hormonal therapy alone (n = 187) at Yokohama City University Hospital (Yokohama, Japan). We evaluated the effect of ADT on the FRAX score.ResultsUsing the FRAX model, the median and mean 10-year probability of a major osteoporotic fracture according to the clinical risk factors alone was 7.9 % (8.8 ± 4.3 %), while the 10-year probability of hip fracture risk was 2.7 % (3.5 ± 3.1 %). In the ADT group, the duration of ADT was correlated with both major osteoporotic risk and hip fracture risk (R2 = 0.141, p < 0.001 and R2 = 0.166, p < 0.001, respectively). A comparison between the ADT (n = 187) and non-ADT (n = 399) groups demonstrated that the major fracture risk was > 20 % higher and the hip fracture risk was > 3 % higher in the ADT group than in the non-ADT group (ADT: 10 (5.3 %) and 118 (63.1 %), non-ADT 13 (3.3 %) and 189 (47.4 %), p < 0.001 and p < 0.001, respectively).ConclusionsThese results suggested that the longer duration of ADT led to an increased FRAX score, and the FRAX score may be a predictor of bone management treatment, particularly in prostate cancer patients.

The predicted lifetime costs and health consequences of calcium and vitamin D supplementation for fracture prevention-the impact of cardiovascular effects.

Some studies indicate that calcium supplementation increases cardiovascular risk. We assessed whether such effects could counterbalance the fracture benefits from supplementation. Accounting for cardiovascular outcomes, calcium may cause net harm and would not be cost-effective. Clinicians may do well considering cardiovascular effects when prescribing calcium supplementation. Accounting for possible cardiovascular effect of calcium and vitamin D supplementation (CaD), the aims of this study were to assess whether CaD on balance would improve population health and to evaluate the cost-effectiveness of such supplementation. We created a probabilistic Markov simulation model that was analysed at the individual patient level. We analysed 65-year-old Norwegian women with a 2.3% 10-year risk of hip fracture and a 9.3% risk of any major fracture according to the WHO fracture risk assessment tool (FRAX®). Consistent with a recent Cochrane review, we assumed that CaD reduces the risk of hip, vertebral, and wrist fractures by 16, 11, and 5%, respectively. We included the increased risk of acute myocardial infarction (AMI) and stroke under a no-, medium-, and high-risk scenario. Assuming no cardiovascular effects, CaD supplementation produces improved health outcomes resulting in an incremental gain of 0.0223 quality-adjusted life years (QALYs) and increases costs by €322 compared with no treatment (cost-effectiveness ratio €14,453 per QALY gained). Assuming a Norwegian cost-effectiveness threshold of €60,000 per QALY, CaD is likely to be considered a cost-effective treatment alternative. In a scenario with a medium or high increased risk of cardiovascular events, CaD produces net health losses, respectively, -0.0572 and -0.0784 QALY at additional costs of €481 and €1033. We conclude that the magnitude of potential cardiovascular side effects is crucial for the effectiveness and cost-effectiveness of CaD supplementation in elderly women.

Laser-Supported Dual Energy X-Ray Absorptiometry (DXL) Compared to Conventional Absorptiometry (DXA) and to FRAX as Tools for Fracture Risk Assessments

Dual X-ray and Laser (DXL) adds a measure of the external thickness of the heel, measured by laser, to a conventional measurement of bone mineral density (BMD) of the calcaneus, using Dual energy X-ray Absorptiometry (DXA). The addition of heel thickness aims at a better separation of fatty tissue from bone than the standard method of DXA, which may mistake fatty tissue for bone and vice versa. The primary aim of this study was to evaluate whether DXL of the calcaneus can be used to assess the 10-year risk of fractures. Secondary aims were to compare the predictive ability of DXL with the two most established methods, Dual energy X-ray Absorptiometry (DXA) of the hip and spine and the WHO fracture risk assessment tool, FRAX. In 1999 a cohort of 388 elderly Swedish women (mean age 73.2 years) was examined with all three methods. Prospective fracture data was collected in 2010 from health care registers. One SD decrease in BMD of the heel resulted in an age-adjusted Hazard Ratio (HR) of 1.47 for a hip fracture (95% CI 1.09–1.98). Harrell’s C is the Cox regression counterpart of the Area Under Curve (AUC) of the Receiver Operating Characteristic (ROC) as a measure of predictive accuracy. Harrell’s C for BMD of the calcaneus was 0.65 for prediction of hip fractures. These results were not significantly different from those for BMD of the femoral neck or for FRAX. The HR for a hip fracture, for one SD decrease in BMD at the femoral neck, was 1.72 (95% CI 1.21–2.44. Harrell’s C was 0.67 for BMD at the femoral neck and 0.59 for FRAX. We conclude that DXL of the calcaneus could be a useful tool for fracture risk assessments.

Diagnostic criteria for osteoporosis should be expanded

As a relatively newly classified chronic disease, scientific enquiry about pathophysiology, diagnosis, and treatment for osteoporosis has rapidly increased in the past three decades. Under the direction of the National Bone Health Alliance, a working group has proposed expansion of the diagnostic criteria for osteoporosis in men and postmenopausal women aged 50 years and older to include individuals with any of the following: a hip fracture (with or without bone mineral density [BMD] testing); low bone mass as determined by BMD and a vertebral, proximal humeral, pelvic, or, in some cases, distal forearm fracture; or raised fracture risk based on the WHO fracture risk algorithm, FRAX.

FRAX (Aus) and falls risk: Association in men and women

PurposeThe WHO fracture risk prediction tool (FRAX®) utilises clinical risk factors to estimate the probability of fracture over a 10-year period. Although falls increase fracture risk, they have not been incorporated into FRAX. It is currently unclear if FRAX captures falls risk and whether addition of falls would improve fracture prediction. We aimed to investigate the association of falls risk and Australian-specific FRAX. MethodsClinical risk factors were documented for 735 men and 602 women (age 40–90yr) assessed at follow-up (2006–2010 and 2000–2003, respectively) of the Geelong Osteoporosis Study. FRAX scores with and without BMD were calculated. A falls risk score was determined at the time of BMD assessment and self-reported incident falls were documented from questionnaires returned one year later. Multivariable analyses were performed to determine: (i) cross-sectional association between FRAX scores and falls risk score (Elderly Falls Screening Test, EFST) and (ii) prospective relationship between FRAX and time to a fall. ResultsThere was an association between FRAX (hip with BMD) and EFST scores (β=0.07, p<0.001). After adjustment for sex and age, the relationship became non-significant (β=0.00, p=0.79). The risk of incident falls increased with increasing FRAX (hip with BMD) score (unadjusted HR 1.04, 95% CI 1.02, 1.07). After adjustment for age and sex, the relationship became non-significant (1.01, 95% CI 0.97, 1.05). ConclusionsThere is a weak positive correlation between FRAX and falls risk score, that is likely explained by the inclusion of age and sex in the FRAX model. These data suggest that FRAX score may not be a robust surrogate for falls risk and that inclusion of falls in fracture risk assessment should be further explored.

Fracture risk in long term care: a systematic review and meta-analysis of prospective observational studies.

BackgroundThe risk factors associated with fractures have been well-characterized in community dwelling populations, but have not been clearly defined in long-term care (LTC) settings. The objective of this review was to identify risk factors for fractures in LTC settings.MethodsWe searched MEDLINE, the Cochrane Library, EMBASE and CINAHL up to June 2014, scanned reference lists of articles and consulted with experts in the field to identify relevant prospective cohort studies that evaluated risk factors associated with fracture incidence in LTC. We included studies that assessed the association between risk factors included in the WHO-Fracture Risk Assessment Tool (FRAX®) or other predictors relevant to LTC (psychotropic medications, cognitive impairment, mobility, and falls). All articles were screened and extracted by two authors. Available data on the association between a given risk factor and fracture incidence were pooled when possible. We used the GRADE criteria to provide a summary of evidence. The GRADE approach defines the quality of a body of evidence as the extent to which one can be confident that an estimate of effect or association is close to the quantity of specific interest.ResultsWe identified 13 prospective cohort studies which examined fracture incidence among LTC residents. Most predictors showed moderate increases in fracture risk, but the quality of the evidence was often low. Moderate quality evidence showed that prior fractures and falls may moderately increase the risk of fractures. Being a woman and cognitive impairment are probably associated with a small increase. The effect of mobility and psychotropic medication use is still uncertain primarily due to the various definitions used in the studies and difficulty summarising the results.ConclusionsIn addition to criteria used in the FRAX assessment tool, such as a previous fracture and female gender, we found that falls and cognitive impairment are also associated with a small to moderate increases in the risk of fractures in LTC. Developing an assessment tool that includes risk factors that are specific to LTC may improve the identification of individuals who can benefit from fracture prevention programs in these settings.

Can paramedics use FRAX (the WHO Fracture Risk Assessment Tool) to help GPs improve future fracture risk in patients who fall? Protocol for a randomised controlled feasibility study.

IntroductionCurrently identification, and therefore, management of patients at risk of osteoporotic fracture in the UK is suboptimal. As the majority of patients who fracture have fallen, it follows that people who fall can usefully be targeted in any programme that aims to reduce osteoporotic fracture. Targeting vulnerable patients who are likely to benefit from intervention may help shift the management of fracture prevention into primary care, away from emergency departments. Paramedics who attend to patients who have fallen may be well placed to assess future fracture risk, using the Fracture Risk Assessment Tool (FRAX) and communicate that information directly to general practitioners (GPs).Methods and analysisThis feasibility study takes the form of a pragmatic, randomised controlled trial aimed at exploring and refining issues of study design, recruitment, retention, sample size and acceptability preceding a large-scale study with fracture as the end point. Patients (aged >50) who fall, call an ambulance, are attended by a study paramedic and give verbal consent will be asked FRAX and fall questions. Patients who subsequently formally consent to participation will be randomised to control (usual care) or intervention groups. Intervention will constitute transmission of calculated future fracture risk to the patients’ GP with suitable, evidence-based recommendations for investigation or treatment. 3 months after the index fall, data (proportion of patients in each group undergoing investigation or starting new treatment, quality of life and health economic) will be collected and analysed using descriptive statistics. A nested qualitative study will explore issues of acceptability and study design with patients, paramedics and GPs.Ethics and disseminationThis protocol was approved by NRES Committee South Central Oxford C in October 2012. Research Ethics Committee ref.12/SC/0604. The study findings will be disseminated through peer-reviewed journals, conference presentations and local public events. A publication plan and authorship criteria have been preagreed.Trial registration numberISRCTN: 36245726.

Translation, cultural adaptation and validation of the WHO fracture risk assessment tool (FRAX(®) ) into Bengali.

To develop a translated and culturally adapted Bengali version of the WHO Fracture Risk Assessment Tool (FRAX(®) ) and to test its feasibility, content validity and reliability. The English FRAX was translated and culturally adapted for use in Bangladeshi populations following established forward-backward translation methods and being extensively field-tested. The final version was interviewer-administered to 130 consecutive osteoporotic patients between 40 and 90years of age. For test-retest reliability, the questionnaire was re-administered after 14days in 60 odd serial-numbered patients. To better match with the Bengali culture, several adaptations were made to the FRAX items, including replacements and additions for tobacco, prednisolone and alcohol use. The response rate of the pre-final Bengali version of FRAX was 100% and all patients could understand the questions. Test-retest reliability (Pearson's r) in osteoporotic patients was >0.93 for all items. The culturally adapted Bengali version of the FRAX appears to be an acceptable and reliable instrument. Further studies are needed to confirm the ability of the tool to accurately predict the 10-year probability of hip and major osteoporotic fractures in the Bengali population.

Low bone mineral density in Friedreich ataxia.

Friedreich ataxia (FRDA) is the most common inherited neurodegenerative ataxia. Apart from predominant neurological features an involvement of the skeletal system in terms of scoliosis and foot deformities is frequent. Disease-related falls, mobility restrictions, and wheelchair-dependency in later disease stages might additionally compromise bone structure in FRDA. The aim of this pilot study was to systematically evaluate the bone status in a representative FRDA cohort. Twenty-eight FRDA patients became enrolled in this cross-sectional study. Neurological assessment, a questionnaire comprising the history of fractures and osteoporosis as well as osteodensitometric measurements complemented with general and bone-specific laboratory parameters were performed. The WHO Fracture Risk Assessment tool (FRAX®) was applied, calculating the 10-year risk of suffering an osteoporotic fracture. Six patients (21.4%) presented with a bone mineral density below the expected range for age in at least one of the examined sites (femoral neck, lumbar spine, and forearm) irrespective of their gender. Corresponding Z scores were significantly lower compared to normative values for the femoral neck and lumbar spine. Vitamin D status was insufficient in 11 and deficient in 8 FRDA patients. There was a strong negative correlation between ataxia severity, GAA repeat expansion and bone density in the femoral neck of FRDA patients. This is the first report of an increased rate of low bone mineral density in FRDA. Given the increased risk of falls, this data rectifies routine bone mineral density measurements in FRDA which may help to initiate therapeutic interventions to prevent this condition.

Current topics over updating guidelines on the management and treatment of glucocorticoid-induced osteoporosis

Glucocorticoids (GCs) were widely used for the treatment of various disorders. Since GC-induced bone loss is most rapid during the initial 3 - 6 months and primary prevention of bone loss is especially important, guidelines for management of GC-induced osteoporosis have been published overseas and in Japan. In response to changes in the circumstances surrounding GIO regarding fracture assessment tool and drug therapy, ACR revised recommendations incorporated FRAX®, the WHO fracture risk assessment tool and the Japanese Society of Bone and Mineral Research have finished revision work of the guidelines and the updated guideline will be published soon.