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Burnett-Bowie SAM, Wright NC, Yu EW, Langsetmo L, Yearwood GMH, Crandall CJ, Leslie WD, Cauley JA. The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report. J Bone Miner Res 2024; 39:517-530. [PMID: 38590141 DOI: 10.1093/jbmr/zjae048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/23/2024] [Accepted: 03/13/2024] [Indexed: 04/10/2024]
Abstract
Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.
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Affiliation(s)
- Sherri-Ann M Burnett-Bowie
- Endocrine Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Nicole C Wright
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35233, United States
| | - Elaine W Yu
- Endocrine Division, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| | - Lisa Langsetmo
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care Center, Minneapolis, MN 55417, United States
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
| | - Gabby M H Yearwood
- Department of Anthropology and Center for Civil Rights and Racial Justice, University of Pittsburgh, Pittsburgh, PA 15260, United States
| | - Carolyn J Crandall
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, CA 90095, United States
| | - William D Leslie
- Departments of Internal Medicine and Radiology, Max Rady College of Medicine, University of Manitoba, Winnipeg R3E 0T6, Canada
| | - Jane A Cauley
- Department of Epidemiology, School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, United States
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Anagnostis P, Lallas K, Pappa A, Avgeris G, Beta K, Damakis D, Fountoukidou E, Zidrou M, Lambrinoudaki I, Goulis DG. The association of vasomotor symptoms with fracture risk and bone mineral density in postmenopausal women: a systematic review and meta-analysis of observational studies. Osteoporos Int 2024:10.1007/s00198-024-07075-8. [PMID: 38563960 DOI: 10.1007/s00198-024-07075-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/21/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND/AIMS Vasomotor symptoms (VMS) adversely affect postmenopausal quality of life. However, their association with bone health has not been elucidated. This study aimed to systematically review and meta-analyze the evidence regarding the association of VMS with fracture risk and bone mineral density (BMD) in peri- and postmenopausal women. METHODS A literature search was conducted in PubMed, Scopus and Cochrane databases until 31 August 2023. Fracture, low BMD (osteoporosis/osteopenia) and mean change in lumbar spine (LS) and femoral neck (FN) BMD were assessed. The results are presented as odds ratio (OR) and mean difference (MD), respectively, with a 95% confidence interval (95% CI). The I2 index quantified heterogeneity. RESULTS Twenty studies were included in the qualitative and 12 in the quantitative analysis (n=49,659). No difference in fractures between women with and without VMS was found (n=5, OR 1.04, 95% CI 0.93-1.16, I2 16%). However, VMS were associated with low BMD (n=5, OR 1.54, 95% CI 1.42-1.67, I2 0%). This difference was evident for LS (MD -0.019 g/cm2, 95% CI -0.03 to -0.008, I2 85.2%), but not for FN BMD (MD -0.010 g/cm2, 95% CI -0.021 to 0.001, I2 78.2%). These results were independent of VMS severity, age and study design. When the analysis was confined to studies that excluded menopausal hormone therapy use, the association with BMD remained significant. CONCLUSIONS The presence of VMS is associated with low BMD in postmenopausal women, although it does not seem to increase fracture risk.
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Affiliation(s)
- Panagiotis Anagnostis
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Konstantinos Lallas
- Department of Medical Oncology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anna Pappa
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Avgeris
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kristina Beta
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Damakis
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eirini Fountoukidou
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Zidrou
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Irene Lambrinoudaki
- 2nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios G Goulis
- 1st Department of Obstetrics and Gynecology, Medical School, Unit of Reproductive Endocrinology, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Gross AM, Plotkin SR, Watts NB, Fisher MJ, Klesse LJ, Lessing AJ, McManus ML, Larson AN, Oberlander B, Rios JJ, Sarnoff H, Simpson BN, Ullrich NJ, Stevenson DA. Potential endpoints for assessment of bone health in persons with neurofibromatosis type 1. Clin Trials 2024; 21:29-39. [PMID: 37772407 PMCID: PMC10920397 DOI: 10.1177/17407745231201338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Neurofibromatosis type 1 is a genetic syndrome characterized by a wide variety of tumor and non-tumor manifestations. Bone-related issues, such as scoliosis, tibial dysplasia, and low bone mineral density, are a significant source of morbidity for this population with limited treatment options. Some of the challenges to developing such treatments include the lack of consensus regarding the optimal methods to assess bone health in neurofibromatosis type 1 and limited data regarding the natural history of these manifestations. In this review, the Functional Committee of the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration: (1) presents the available techniques for measuring overall bone health and metabolism in persons with neurofibromatosis type 1, (2) reviews data for use of each of these measures in the neurofibromatosis type 1 population, and (3) describes the strengths and limitations for each method as they might be used in clinical trials targeting neurofibromatosis type 1 bone manifestations. The Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration supports the development of a prospective, longitudinal natural history study focusing on the bone-related manifestations and relevant biomarkers of neurofibromatosis type 1. In addition, we suggest that the neurofibromatosis type 1 research community consider adding the less burdensome measurements of bone health as exploratory endpoints in ongoing or planned clinical trials for other neurofibromatosis type 1 manifestations to expand knowledge in the field.
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Affiliation(s)
- Andrea M Gross
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Scott R Plotkin
- Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston, MA, USA
| | - Nelson B Watts
- Mercy Health Osteoporosis and Bone Health Services, Cincinnati, OH, USA
| | - Michael J Fisher
- Division of Oncology, The Children's Hospital of Philadelphia and the University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Laura J Klesse
- Division of Hematology/Oncology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | - A Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Jonathan J Rios
- Center for Pediatric Bone Biology and Translational Research, Scottish Rite for Children, McDermott Center for Human Growth and Development, UT Southwestern Medical Center, Dallas, TX, USA
| | - Herb Sarnoff
- Research and Development, Infixion Bioscience, Inc., San Diego, CA, USA
| | - Brittany N Simpson
- Division of Human Genetics, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Nicole J Ullrich
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - David A Stevenson
- Division of Medical Genetics, Department of Pediatrics, Stanford University, Stanford, CA, USA
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Jain RK, Weiner M, Polley E, Iwamaye A, Huang E, Vokes T. Electronic Health Records (EHRs) Can Identify Patients at High Risk of Fracture but Require Substantial Race Adjustments to Currently Available Fracture Risk Calculators. J Gen Intern Med 2023; 38:3451-3459. [PMID: 37715097 PMCID: PMC10713897 DOI: 10.1007/s11606-023-08347-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/21/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND Osteoporotic fracture prediction calculators are poorly utilized in primary care, leading to underdiagnosis and undertreatment of those at risk for fracture. The use of these calculators could be improved if predictions were automated using the electronic health record (EHR). However, this approach is not well validated in multi-ethnic populations, and it is not clear if the adjustments for race or ethnicity made by calculators are appropriate. OBJECTIVE To investigate EHR-generated fracture predictions in a multi-ethnic population. DESIGN Retrospective cohort study using data from the EHR. SETTING An urban, academic medical center in Philadelphia, PA. PARTICIPANTS 12,758 White, 7,844 Black, and 3,587 Hispanic patients seeking routine care from 2010 to 2018 with mean 3.8 years follow-up. INTERVENTIONS None. MEASUREMENTS FRAX and QFracture, two of the most used fracture prediction tools, were studied. Risk for major osteoporotic fracture (MOF) and hip fracture were calculated using data from the EHR at baseline and compared to the number of fractures that occurred during follow-up. RESULTS MOF rates varied from 3.2 per 1000 patient-years in Black men to 7.6 in White women. FRAX and QFracture had similar discrimination for MOF prediction (area under the curve, AUC, 0.69 vs. 0.70, p=0.08) and for hip fracture prediction (AUC 0.77 vs 0.79, p=0.21) and were similar by race or ethnicity. FRAX had superior calibration than QFracture (calibration-in-the-large for FRAX 0.97 versus QFracture 2.02). The adjustment factors used in MOF prediction were generally accurate in Black women, but underestimated risk in Black men, Hispanic women, and Hispanic men. LIMITATIONS Single center design. CONCLUSIONS Fracture predictions using only EHR inputs can discriminate between high and low risk patients, even in Black and Hispanic patients, and could help primary care physicians identify patients who need screening or treatment. However, further refinements to the calculators may better adjust for race-ethnicity.
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Affiliation(s)
- Rajesh K Jain
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, 5841 South Maryland Ave, MC 1027, Chicago, IL, 60637, USA.
| | - Mark Weiner
- Weill Cornell Medicine, Clinical Population Health Sciences, New York, USA
| | - Eric Polley
- Department of Public Health Sciences, The University of Chicago, Chicago, USA
| | - Amy Iwamaye
- Section of Endocrinology, Diabetes, and Metabolism, Lewis Katz School of Medicine at Temple University, Philadelphia, USA
| | - Elbert Huang
- Department of Medicine and Department of Public Health Sciences, The University of Chicago, Chicago, USA
| | - Tamara Vokes
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, The University of Chicago, 5841 South Maryland Ave, MC 1027, Chicago, IL, 60637, USA
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Fink HA, Butler ME, Claussen AM, Collins ES, Krohn KM, Taylor BC, Tikabo SS, Vang D, Zerzan NL, Ensrud KE. Performance of Fracture Risk Assessment Tools by Race and Ethnicity: A Systematic Review for the ASBMR Task Force on Clinical Algorithms for Fracture Risk. J Bone Miner Res 2023; 38:1731-1741. [PMID: 37597237 DOI: 10.1002/jbmr.4895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 07/18/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023]
Abstract
The American Society of Bone and Mineral Research (ASBMR) Professional Practice Committee charged an ASBMR Task Force on Clinical Algorithms for Fracture Risk to review the evidence on whether current approaches for differentiating fracture risk based on race and ethnicity are necessary and valid. To help address these charges, we performed a systematic literature review investigating performance of calculators for predicting incident fractures within and across race and ethnicity groups in middle-aged and older US adults. We included English-language, controlled or prospective cohort studies that enrolled US adults aged >40 years and reported tool performance predicting incident fractures within individual race and ethnicity groups for up to 10 years. From 4838 identified references, six reports met eligibility criteria, all in women. Just three, all from one study, included results in non-white individuals. In these three reports, non-white women experienced relatively few major osteoporotic fractures (MOFs), especially hip fractures, and risk thresholds for predicting fractures in non-white women were derived from risks in the overall, predominantly white study population. One report suggested the Fracture Risk Assessment Tool (FRAX) without bone mineral density (BMD) overestimated hip fracture similarly across race and ethnicity groups (black, Hispanic, American Indian, Asian, white) but overestimated MOF more in non-white than White women. However, these three reports were inconclusive regarding whether discrimination of FRAX or the Garvan calculator without BMD or of FRAX with BMD for MOF or hip fracture differed between white versus black women. This uncertainty was at least partly due to imprecise hip fracture estimates in black women. No reports examined whether ratios of observed to predicted hip fracture risks within each race or ethnicity group varied across levels of predicted hip fracture risk. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR). This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.
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Affiliation(s)
- Howard A Fink
- Geriatric Research Education and Clinical Center, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Mary E Butler
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy M Claussen
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Erin S Collins
- Masters of Public Health Program, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kristina M Krohn
- Division of Hospital Medicine, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Brent C Taylor
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sina S Tikabo
- Masters of Public Health Program, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Denny Vang
- Masters of Public Health Program, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Nicholas L Zerzan
- Masters of Public Health Program, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Kristine E Ensrud
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
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Theriault G, Reynolds D, Pillay JJ, Limburg H, Grad R, Gates M, Lafortune FD, Breault P. Expanding the measurement of overdiagnosis in the context of disease precursors and risk factors. BMJ Evid Based Med 2023; 28:364-368. [PMID: 36627178 DOI: 10.1136/bmjebm-2022-112117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/12/2023]
Affiliation(s)
- Guylene Theriault
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Donna Reynolds
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer J Pillay
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Heather Limburg
- Global Health and Guidelines Division, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Michelle Gates
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Frantz-Daniel Lafortune
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
- Department of Family Medicine, Universite Laval, Quebec, Quebec, Canada
| | - Pascale Breault
- Department of Family Medicine, Universite Laval, Quebec, Quebec, Canada
- Department of Family Medicine, Universite de Montreal, Montreal, Quebec, Canada
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7
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Gates M, Pillay J, Nuspl M, Wingert A, Vandermeer B, Hartling L. Screening for the primary prevention of fragility fractures among adults aged 40 years and older in primary care: systematic reviews of the effects and acceptability of screening and treatment, and the accuracy of risk prediction tools. Syst Rev 2023; 12:51. [PMID: 36945065 PMCID: PMC10029308 DOI: 10.1186/s13643-023-02181-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/02/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND To inform recommendations by the Canadian Task Force on Preventive Health Care, we reviewed evidence on the benefits, harms, and acceptability of screening and treatment, and on the accuracy of risk prediction tools for the primary prevention of fragility fractures among adults aged 40 years and older in primary care. METHODS For screening effectiveness, accuracy of risk prediction tools, and treatment benefits, our search methods involved integrating studies published up to 2016 from an existing systematic review. Then, to locate more recent studies and any evidence relating to acceptability and treatment harms, we searched online databases (2016 to April 4, 2022 [screening] or to June 1, 2021 [predictive accuracy]; 1995 to June 1, 2021, for acceptability; 2016 to March 2, 2020, for treatment benefits; 2015 to June 24, 2020, for treatment harms), trial registries and gray literature, and hand-searched reviews, guidelines, and the included studies. Two reviewers selected studies, extracted results, and appraised risk of bias, with disagreements resolved by consensus or a third reviewer. The overview of reviews on treatment harms relied on one reviewer, with verification of data by another reviewer to correct errors and omissions. When appropriate, study results were pooled using random effects meta-analysis; otherwise, findings were described narratively. Evidence certainty was rated according to the GRADE approach. RESULTS We included 4 randomized controlled trials (RCTs) and 1 controlled clinical trial (CCT) for the benefits and harms of screening, 1 RCT for comparative benefits and harms of different screening strategies, 32 validation cohort studies for the calibration of risk prediction tools (26 of these reporting on the Fracture Risk Assessment Tool without [i.e., clinical FRAX], or with the inclusion of bone mineral density (BMD) results [i.e., FRAX + BMD]), 27 RCTs for the benefits of treatment, 10 systematic reviews for the harms of treatment, and 12 studies for the acceptability of screening or initiating treatment. In females aged 65 years and older who are willing to independently complete a mailed fracture risk questionnaire (referred to as "selected population"), 2-step screening using a risk assessment tool with or without measurement of BMD probably (moderate certainty) reduces the risk of hip fractures (3 RCTs and 1 CCT, n = 43,736, absolute risk reduction [ARD] = 6.2 fewer in 1000, 95% CI 9.0-2.8 fewer, number needed to screen [NNS] = 161) and clinical fragility fractures (3 RCTs, n = 42,009, ARD = 5.9 fewer in 1000, 95% CI 10.9-0.8 fewer, NNS = 169). It probably does not reduce all-cause mortality (2 RCTs and 1 CCT, n = 26,511, ARD = no difference in 1000, 95% CI 7.1 fewer to 5.3 more) and may (low certainty) not affect health-related quality of life. Benefits for fracture outcomes were not replicated in an offer-to-screen population where the rate of response to mailed screening questionnaires was low. For females aged 68-80 years, population screening may not reduce the risk of hip fractures (1 RCT, n = 34,229, ARD = 0.3 fewer in 1000, 95% CI 4.2 fewer to 3.9 more) or clinical fragility fractures (1 RCT, n = 34,229, ARD = 1.0 fewer in 1000, 95% CI 8.0 fewer to 6.0 more) over 5 years of follow-up. The evidence for serious adverse events among all patients and for all outcomes among males and younger females (<65 years) is very uncertain. We defined overdiagnosis as the identification of high risk in individuals who, if not screened, would never have known that they were at risk and would never have experienced a fragility fracture. This was not directly reported in any of the trials. Estimates using data available in the trials suggest that among "selected" females offered screening, 12% of those meeting age-specific treatment thresholds based on clinical FRAX 10-year hip fracture risk, and 19% of those meeting thresholds based on clinical FRAX 10-year major osteoporotic fracture risk, may be overdiagnosed as being at high risk of fracture. Of those identified as being at high clinical FRAX 10-year hip fracture risk and who were referred for BMD assessment, 24% may be overdiagnosed. One RCT (n = 9268) provided evidence comparing 1-step to 2-step screening among postmenopausal females, but the evidence from this trial was very uncertain. For the calibration of risk prediction tools, evidence from three Canadian studies (n = 67,611) without serious risk of bias concerns indicates that clinical FRAX-Canada may be well calibrated for the 10-year prediction of hip fractures (observed-to-expected fracture ratio [O:E] = 1.13, 95% CI 0.74-1.72, I2 = 89.2%), and is probably well calibrated for the 10-year prediction of clinical fragility fractures (O:E = 1.10, 95% CI 1.01-1.20, I2 = 50.4%), both leading to some underestimation of the observed risk. Data from these same studies (n = 61,156) showed that FRAX-Canada with BMD may perform poorly to estimate 10-year hip fracture risk (O:E = 1.31, 95% CI 0.91-2.13, I2 = 92.7%), but is probably well calibrated for the 10-year prediction of clinical fragility fractures, with some underestimation of the observed risk (O:E 1.16, 95% CI 1.12-1.20, I2 = 0%). The Canadian Association of Radiologists and Osteoporosis Canada Risk Assessment (CAROC) tool may be well calibrated to predict a category of risk for 10-year clinical fractures (low, moderate, or high risk; 1 study, n = 34,060). The evidence for most other tools was limited, or in the case of FRAX tools calibrated for countries other than Canada, very uncertain due to serious risk of bias concerns and large inconsistency in findings across studies. Postmenopausal females in a primary prevention population defined as <50% prevalence of prior fragility fracture (median 16.9%, range 0 to 48% when reported in the trials) and at risk of fragility fracture, treatment with bisphosphonates as a class (median 2 years, range 1-6 years) probably reduces the risk of clinical fragility fractures (19 RCTs, n = 22,482, ARD = 11.1 fewer in 1000, 95% CI 15.0-6.6 fewer, [number needed to treat for an additional beneficial outcome] NNT = 90), and may reduce the risk of hip fractures (14 RCTs, n = 21,038, ARD = 2.9 fewer in 1000, 95% CI 4.6-0.9 fewer, NNT = 345) and clinical vertebral fractures (11 RCTs, n = 8921, ARD = 10.0 fewer in 1000, 95% CI 14.0-3.9 fewer, NNT = 100); it may not reduce all-cause mortality. There is low certainty evidence of little-to-no reduction in hip fractures with any individual bisphosphonate, but all provided evidence of decreased risk of clinical fragility fractures (moderate certainty for alendronate [NNT=68] and zoledronic acid [NNT=50], low certainty for risedronate [NNT=128]) among postmenopausal females. Evidence for an impact on risk of clinical vertebral fractures is very uncertain for alendronate and risedronate; zoledronic acid may reduce the risk of this outcome (4 RCTs, n = 2367, ARD = 18.7 fewer in 1000, 95% CI 25.6-6.6 fewer, NNT = 54) for postmenopausal females. Denosumab probably reduces the risk of clinical fragility fractures (6 RCTs, n = 9473, ARD = 9.1 fewer in 1000, 95% CI 12.1-5.6 fewer, NNT = 110) and clinical vertebral fractures (4 RCTs, n = 8639, ARD = 16.0 fewer in 1000, 95% CI 18.6-12.1 fewer, NNT=62), but may make little-to-no difference in the risk of hip fractures among postmenopausal females. Denosumab probably makes little-to-no difference in the risk of all-cause mortality or health-related quality of life among postmenopausal females. Evidence in males is limited to two trials (1 zoledronic acid, 1 denosumab); in this population, zoledronic acid may make little-to-no difference in the risk of hip or clinical fragility fractures, and evidence for all-cause mortality is very uncertain. The evidence for treatment with denosumab in males is very uncertain for all fracture outcomes (hip, clinical fragility, clinical vertebral) and all-cause mortality. There is moderate certainty evidence that treatment causes a small number of patients to experience a non-serious adverse event, notably non-serious gastrointestinal events (e.g., abdominal pain, reflux) with alendronate (50 RCTs, n = 22,549, ARD = 16.3 more in 1000, 95% CI 2.4-31.3 more, [number needed to treat for an additional harmful outcome] NNH = 61) but not with risedronate; influenza-like symptoms with zoledronic acid (5 RCTs, n = 10,695, ARD = 142.5 more in 1000, 95% CI 105.5-188.5 more, NNH = 7); and non-serious gastrointestinal adverse events (3 RCTs, n = 8454, ARD = 64.5 more in 1000, 95% CI 26.4-13.3 more, NNH = 16), dermatologic adverse events (3 RCTs, n = 8454, ARD = 15.6 more in 1000, 95% CI 7.6-27.0 more, NNH = 64), and infections (any severity; 4 RCTs, n = 8691, ARD = 1.8 more in 1000, 95% CI 0.1-4.0 more, NNH = 556) with denosumab. For serious adverse events overall and specific to stroke and myocardial infarction, treatment with bisphosphonates probably makes little-to-no difference; evidence for other specific serious harms was less certain or not available. There was low certainty evidence for an increased risk for the rare occurrence of atypical femoral fractures (0.06 to 0.08 more in 1000) and osteonecrosis of the jaw (0.22 more in 1000) with bisphosphonates (most evidence for alendronate). The evidence for these rare outcomes and for rebound fractures with denosumab was very uncertain. Younger (lower risk) females have high willingness to be screened. A minority of postmenopausal females at increased risk for fracture may accept treatment. Further, there is large heterogeneity in the level of risk at which patients may be accepting of initiating treatment, and treatment effects appear to be overestimated. CONCLUSION An offer of 2-step screening with risk assessment and BMD measurement to selected postmenopausal females with low prevalence of prior fracture probably results in a small reduction in the risk of clinical fragility fracture and hip fracture compared to no screening. These findings were most applicable to the use of clinical FRAX for risk assessment and were not replicated in the offer-to-screen population where the rate of response to mailed screening questionnaires was low. Limited direct evidence on harms of screening were available; using study data to provide estimates, there may be a moderate degree of overdiagnosis of high risk for fracture to consider. The evidence for younger females and males is very limited. The benefits of screening and treatment need to be weighed against the potential for harm; patient views on the acceptability of treatment are highly variable. SYSTEMATIC REVIEW REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO): CRD42019123767.
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Affiliation(s)
- Michelle Gates
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Jennifer Pillay
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada.
| | - Megan Nuspl
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Aireen Wingert
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Ben Vandermeer
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
| | - Lisa Hartling
- Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton Clinic Health Academy, 11405-87 Avenue NW, Edmonton, Alberta, T6G 1C9, Canada
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8
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Yang L, Dempsey M, Brennan A, Whelan B, Erjiang E, Wang T, Egan R, Gorham K, Heaney F, Armstrong C, Ibarrola GM, Gsel A, Yu M, Carey JJ. Ireland DXA-FRAX may differ significantly and substantially to Web-FRAX. Arch Osteoporos 2023; 18:43. [PMID: 36939937 PMCID: PMC10027809 DOI: 10.1007/s11657-023-01232-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Abstract
Appropriate use of FRAX reduces the number of people requiring DXA scans, while contemporaneously determining those most at risk. We compared the results of FRAX with and without inclusion of BMD. It suggests clinicians to carefully consider the importance of BMD inclusion in fracture risk estimation or interpretation in individual patients. PURPOSE FRAX is a widely accepted tool to estimate the 10-year risk of hip and major osteoporotic fracture in adults. Prior calibration studies suggest this works similarly with or without the inclusion of bone mineral density (BMD). The purpose of the study is to compare within-subject differences between FRAX estimations derived using DXA and Web software with and without the inclusion of BMD. METHOD A convenience cohort was used for this cross-sectional study, consisting of 1254 men and women aged between 40 and 90 years who had a DXA scan and complete validated data available for analysis. FRAX 10-year estimations for hip and major osteoporotic fracture were calculated using DXA software (DXA-FRAX) and the Web tool (Web-FRAX), with and without BMD. Agreements between estimates within each individual subject were examined using Bland-Altman plots. We performed exploratory analyses of the characteristics of those with very discordant results. RESULTS Overall median DXA-FRAX and Web-FRAX 10-year hip and major osteoporotic fracture risk estimations which include BMD are very similar: 2.9% vs. 2.8% and 11.0% vs. 11% respectively. However, both are significantly lower than those obtained without BMD: 4.9% and 14% respectively, P < 0.001. Within-subject differences between hip fracture estimates with and without BMD were < 3% in 57% of cases, between 3 and 6% in 19% of cases, and > 6% in 24% of cases, while for major osteoporotic fractures such differences are < 10% in 82% of cases, between 10 and 20% in 15% of cases, and > 20% in 3% of cases. CONCLUSIONS Although there is excellent agreement between the Web-FRAX and DXA-FRAX tools when BMD is incorporated, sometimes there are very large differences for individuals between results obtained with and without BMD. Clinicians should carefully consider the importance of BMD inclusion in FRAX estimations when assessing individual patients.
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Affiliation(s)
- Lan Yang
- Insight SFI Research Centre for Data Analytics, Data Science Institute, University of Galway, IDA Business Park, Lower Dangan, Galway, H91 AEX4, Ireland.
| | - Mary Dempsey
- School of Engineering, College of Science and Engineering, University of Galway, Galway, Ireland
| | - Attracta Brennan
- School of Computer Science, College of Science and Engineering, University of Galway, Galway, Ireland
| | - Bryan Whelan
- School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
| | - E Erjiang
- School of Management, Guangxi Minzu University, Nanning, China
| | - Tingyan Wang
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rebecca Egan
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Kelly Gorham
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Fiona Heaney
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | | | | | - Amina Gsel
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
| | - Ming Yu
- Department of Industrial Engineering, Tsinghua University, Beijing, China
| | - John J Carey
- School of Medicine, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
- Department of Rheumatology, Galway University Hospitals, Galway, Ireland
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9
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Abstract
PURPOSE OF REVIEW Type 1 (T1D) and 2 diabetes (T2D) are associated with increased risk of fracture independent of bone mineral density (BMD). Fracture risk prediction tools can identify individuals at highest risk, and therefore, most likely to benefit from antifracture therapy. This review summarizes recent advances in fracture prediction tools as applied to individuals with diabetes. RECENT FINDINGS The Fracture Risk Assessment (FRAX) tool, Garvan Fracture Risk Calculator (FRC), and QFracture tool are validated tools for fracture risk prediction. FRAX is most widely used internationally, and considers T1D (but not T2D) under secondary osteoporosis disorders. FRAX underestimates fracture risk in both T1D and T2D. Trabecular bone score and other adjustments for T2D-associated risk improve FRAX-based estimations. Similar adjustments for T1D are not identified. Garvan FRC does not incorporate diabetes as an input but does includes falls. Garvan FRC slightly underestimates osteoporotic fracture risk in women with diabetes. QFracture incorporates both T1D and T2D and falls as input variables, but has not been directly validated in individuals with diabetes. SUMMARY Further research is needed to validate and compare available fracture prediction tools and their performance in individuals with diabetes.
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Affiliation(s)
- Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario
| | - William D Leslie
- Department of Medicine (C5121), University of Manitoba, Winnipeg, Manitoba, Canada
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10
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Allbritton-King JD, Elrod JK, Rosenberg PS, Bhattacharyya T. Reverse engineering the FRAX algorithm: Clinical insights and systematic analysis of fracture risk. Bone 2022; 159:116376. [PMID: 35240349 PMCID: PMC9035136 DOI: 10.1016/j.bone.2022.116376] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 01/28/2022] [Accepted: 02/24/2022] [Indexed: 11/28/2022]
Abstract
The Fracture Risk Assessment Tool (FRAX) is a computational tool developed to predict the 10-year probability of hip fracture and major osteoporotic fracture based on inputs of patient characteristics, bone mineral density (BMD), and a set of seven clinical risk factors. While the FRAX tool is widely available and clinically validated, its underlying algorithm is not public. The relative contribution and necessity of each input parameter to the final FRAX score is unknown. We systematically collected hip fracture risk scores from the online FRAX calculator for osteopenic Caucasian women across 473,088 unique inputs. This dataset was used to dissect the FRAX algorithm and construct a reverse-engineered fracture risk model to assess the relative contribution of each input variable. Within the reverse-engineered model, age and T-Score were the strongest contributors to hip fracture risk, while BMI had marginal contribution. Of the clinical risk factors, parent history of fracture and ongoing glucocorticoid treatment had the largest additive effect on risk score. A generalized linear model largely recapitulated the FRAX tool with an R2 of 0.91. Observed effect sizes were then compared to a true patient population by creating a logistic regression model of the Study of Osteoporotic Fractures (SOF) cohort, which closely paralleled the effect sizes seen in the reverse-engineered fracture risk model. Analysis identified several clinically relevant observations of interest to FRAX users. The role of major osteoporotic fracture risk prediction in contributing to an indication of treatment need is very narrow, as the hip fracture risk prediction accounted for 98% of treatment indications for the SOF cohort. Removing any risk factor from the model substantially decreased its accuracy and confirmed that more parsimonious models are not ideal for fracture prediction. For women 65 years and older with a previous fracture, 98% of FRAX combinations exceeded the treatment threshold, regardless of T-score or other factors. For women age 70+ with a parent history of fracture, 99% of FRAX combinations exceed the treatment threshold. Based on these analyses, we re-affirm the efficacy of the FRAX as the best tool for fracture risk assessment and provide deep insight into the interplay between risk factors.
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Affiliation(s)
- Jules D Allbritton-King
- Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, United States of America
| | - Julia K Elrod
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, United States of America
| | - Philip S Rosenberg
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, United States of America
| | - Timothy Bhattacharyya
- Clinical and Investigative Orthopedics Surgery Unit, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, United States of America.
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11
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Comparison between real-world practice and application of the FRAX algorithm in the treatment of osteoporosis. Aging Clin Exp Res 2022; 34:2807-2814. [PMID: 35972688 PMCID: PMC9675657 DOI: 10.1007/s40520-022-02212-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 07/26/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS The most recent guidelines suggest treating patients whose FRAX 10-year fracture risk scores are ≥ 20%. However, this method of evaluation does not take into account parameters that are nonetheless relevant to the therapeutic choice. Our aim was to compare the therapeutic choices for treatment based on a wider assessment (real-world practice) with those based on FRAX scores, taking 20% as the cut-off score. METHODS We obtained the medical history, bone mineral density (BMD) values, and the presence of major fragility fractures in a sample of 856 postmenopausal women. The 10-year FRAX risk of major osteoporotic fracture was calculated, and patients were grouped into risk classes ("FRAX < 20%" = low, "FRAX ≥ 20%" = high); we then compared the treated and untreated patients in each class. After an average interval of 2.5 years, changes in lumbar and femoral BMD and appearances of new fragility fractures were recorded. RESULTS 83% of high-risk patients and 57% of low-risk patients were treated. The therapeutic decision was based mainly on densitometric values and the presence of vertebral fractures. At the 2.5 year follow-up, lumbar spine and femur BMD had decreased in the untreated group; 9.9% of the treated patients developed new vertebral fragility fractures, compared with 5.3% of the untreated patients. DISCUSSION AND CONCLUSIONS Our wider assessment designated as at high fracture risk a group of patients who had not been identified by the FRAX assessment. FRAX could underestimate the risk of fracture in older people, for which the therapeutic choice should consider a broader approach, also based on individual patient's needs.
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12
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Copês RM, Comim FV, Barrios NS, Premaor MO. Incidence of fractures in women in the post-menopause: a cohort study in primary care in southern Brazil. Arch Osteoporos 2021; 16:126. [PMID: 34490540 DOI: 10.1007/s11657-021-00972-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/14/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED The incidences of total fracture, major fracture, and hip fractures in primary care in Southern Brazil were 22.3, 15.0, and 3.3 per 1000 person/year. The FRAX algorithm showed an adequate discriminatory capacity for the identification of these fractures. OBEJECTIVE Few studies are evaluating the incidence of fractures in Latin America and Brazil. This study aimed to estimate the incidence of bone fractures in postmenopausal women seen in primary care and evaluate the FRAX algorithm's performance in these women. METHODS A cohort study was carried out in the municipality of Santa Maria, Southern Brazil. Postmenopausal women aged 55 years and over who attended primary health care were included. The recruitment period was from March 1 to August 31, 2013, and the participants were followed for 5 years. The fracture risk was calculated using the FRAX algorithm. The reported incident fractures were confirmed by imaging studies or surgical reports. RESULTS Of the 1057 women recruited for the study, 854 were followed. They contributed to 2732 person/year. The mean follow-up time was 3.2 years (SD 1.05). The incidences of total fractures, major fractures, and hip fractures were 22.3, 15.0, and 3.3 per 1000 person/year. The most frequent fracture sites were the wrist, shoulder, and ribs. The fracture predictors were rheumatoid arthritis, previous fracture, and the use of glucocorticoids. The discriminatory capacity of incident fractures calculated by FRAX without the inclusion of BMD was AUC 0.730 (95% CI 0.570, 0.890) for hip fracture and AUC 0.691 (95% CI 0.598, 0.784) for major fractures. CONCLUSION The FRAX algorithm showed an adequate discriminatory capacity to identify incident fractures in primary care in our study. The incidence of fractures found in our study appears to be lower than that reported in North America and Europe.
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Affiliation(s)
| | - Fabio Vasconcellos Comim
- Department of Clinical Medicine, Medical School, Federal University of Minas Gerais (UFMG), Avenida Professor Alfredo Balena, 190 - sala 246, Belo Horizonte, MG, Brazil
| | | | - Melissa Orlandin Premaor
- Department of Clinical Medicine, Medical School, Federal University of Minas Gerais (UFMG), Avenida Professor Alfredo Balena, 190 - sala 246, Belo Horizonte, MG, Brazil.
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13
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Abstract
Screening for osteoporosis in women can be based on age and weight, using the Osteoporosis Screening Tool for Asians and assessment for other risk factors such as early menopause, Chinese ethnicity and other secondary factors. Based on the resulting risk profile, women can be triaged to dual-energy X-ray absorptiometry (DEXA) scanning for definite diagnosis of osteoporosis. Treatment should be considered in women with previous fragility fractures, DEXA-diagnosed osteoporosis and high risk of fracture. Exercise improves muscle function, can help prevent falls and has moderate effects on improvements in bone mass. Women should ensure adequate calcium intake and vitamin D. Menopausal hormone therapy (MHT) effectively prevents osteoporosis and fractures, and should be encouraged in those aged < 50 years. For women aged < 60 years, MHT or tibolone can be considered, especially if they have vasomotor or genitourinary symptoms. Risedronate or bisphosphonates may then be reserved for those aged over 60 years.
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Affiliation(s)
- Eu-Leong Yong
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Susan Logan
- Department of Obstetrics and Gynaecology, National University Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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14
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Teeratakulpisarn N, Charoensri S, Theerakulpisut D, Pongchaiyakul C. FRAX score with and without bone mineral density: a comparison and factors affecting the discordance in osteoporosis treatment in Thais. Arch Osteoporos 2021; 16:44. [PMID: 33635451 DOI: 10.1007/s11657-021-00911-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/12/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED We investigate the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD. We found that predictions were concordant in 83.8% of patients. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD. INTRODUCTION The Fracture Risk Assessment Tool (FRAX) is used to calculate the 10-year probability of fracture using important clinical factors, with bone mineral density (BMD) as an optional input variable. We aimed to determine the rate of concordance between treatment recommendations of osteoporosis with 10-year probability of hip fracture calculated using FRAX scores with and without BMD and to identify relevant clinical risk factors associated with discordance. METHODS This was a cross-sectional study conducted in patients between 40 and 90 years of age who were screened for osteoporosis by BMD measurement using dual energy X-ray absorptiometry (DXA) from 2010 to 2018 at a university hospital in Thailand. A FRAX questionnaire was administered to determine demographic data and osteoporotic risk factors. FRAX scores with and without BMD were calculated for each participant using the Thai reference, and patients were categorized into either the treatment or non-treatment group based on a cut-off of 3% 10-year probability of hip fracture. When FRAX scores with and without BMD results were consistent, they were considered concordant. Otherwise, they were deemed discordant. Clinical risk factors were compared between the concordant and discordant groups. RESULTS A total of 3545 participants were included in the study. The majority (83.8%) were in the concordant group. However, older age, lower BMD, and FRAX without BMD around the intervention threshold were significantly associated with discordant results. In the discordant group, FRAX with BMD suggested treatment in more participants with lower age, higher BMI, and lower BMD when compared with FRAX without BMD. CONCLUSION FRAX scores with and without BMD yielded concordant predictions regarding the 10-year probability of hip fracture suggesting pharmacological treatment. However, this concordance declined in elderly and osteoporotic participants and in those with FRAX without BMD around intervention threshold. BMD data may be required in these populations in order to facilitate accurate risk assessment.
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Affiliation(s)
| | - Suranut Charoensri
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand.
| | - Daris Theerakulpisut
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Chatlert Pongchaiyakul
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand
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15
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Jazinizadeh F, Adachi JD, Quenneville CE. Advanced 2D image processing technique to predict hip fracture risk in an older population based on single DXA scans. Osteoporos Int 2020; 31:1925-1933. [PMID: 32415372 DOI: 10.1007/s00198-020-05444-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/29/2020] [Indexed: 01/04/2023]
Abstract
UNLABELLED A new technique to enhance hip fracture risk prediction in older adults was presented and assessed. The new method dramatically improved prediction at high specificity levels using only a standard clinical diagnostic scan. This has the potential to be implemented in clinical practice to enhance patient fragility diagnosis. INTRODUCTION Diagnosis of osteoporosis is based on the measurement of bone mineral density (BMD) using dual-energy X-ray absorptiometry (DXA) scans. However, studies have shown this to be insufficient to accurately predict hip fractures. Therefore, complementary methods are needed to enhance hip fracture risk prediction to identify vulnerable patients. METHODS Hip DXA scans were obtained for 192 subjects from the Canadian Multicenter Osteoporosis Study (CaMos), 50 of whom had experienced a hip fracture within 5 years of the scan. 2D statistical shape and appearance modeling was performed to account for the effect of the femur's geometry and BMD distribution on hip fracture risk. Statistical shape modeling (SSM), and statistical appearance modeling (SAM) were also used separately to predict the fracture risk based solely on the femur's geometry and BMD distribution, respectively. Combined with BMD, age, and body mass index (BMI), logistic regression was performed to estimate the fracture risk over the 5-year period. RESULTS Using the new technique, hip fractures were correctly predicted in 78% of cases compared with 36% when using the T-score. The accuracy of the prediction was not greatly reduced when using SSM and SAM (78% and 74% correct, respectively). Various geometric and BMD distribution traits were identified in the fractured and non-fractured groups. CONCLUSION 2D SSAM can dramatically improve hip fracture prediction at high specificity levels and estimate the year of the impending fracture using standard clinical images. This has the potential to be implemented in clinical practice to estimate hip fracture risk.
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Affiliation(s)
- F Jazinizadeh
- Department of Mechanical Engineering, McMaster University, ABB-C308, 1280 Main St. West, Hamilton, Ontario, L8S 4L8, Canada
| | - J D Adachi
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - C E Quenneville
- Department of Mechanical Engineering, McMaster University, ABB-C308, 1280 Main St. West, Hamilton, Ontario, L8S 4L8, Canada.
- School of Biomedical Engineering, McMaster University, Hamilton, Ontario, Canada.
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16
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Abstract
Approximately 50% of women experience at least one bone fracture postmenopause. Current screening approaches target anti-fracture interventions to women aged >60 years who satisfy clinical risk and bone mineral density criteria for osteoporosis. Intervention is only recommended in 7-25% of those women screened currently, well short of the 50% who experience fractures. Large screening trials have not shown clinically significant decreases in the total fracture numbers. By contrast, six large clinical trials of anti-resorptive therapies (for example, bisphosphonates) have demonstrated substantial decreases in the number of fractures in women not identified as being at high risk of fracture. This finding suggests that broader use of generic bisphosphonates in women selected by age or fracture risk would result in a reduction in total fracture numbers, a strategy likely to be cost-effective. The utility of the current bone density definition of osteoporosis, which neither corresponds with who suffers fractures nor defines who should be treated, requires reappraisal.
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Affiliation(s)
- Ian R Reid
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
- Auckland District Health Board, Auckland, New Zealand.
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17
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Narla RR, Ott SM. Structural and Metabolic Assessment of Bone. Handb Exp Pharmacol 2020; 262:369-396. [PMID: 32885312 DOI: 10.1007/164_2020_376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The assessment of bone structure and metabolism should focus on the bone strength. Many factors are involved, and although bone density is an important component, it is not the same as bone strength. Other aspects of bone quality include bone volume, micro-architecture, material composition, and ability to repair damage. This chapter briefly reviews some of the methods that can be used to assess both density and quality of bone. Non-invasive measurements of density or structure include dual X-ray absorptiometry (DXA), quantitative computed tomography, ultrasound, and magnetic resonance imaging. DXA is most widely used and has advantages of safety and accessibility, but there are limitations in the interpretation of the results, and in clinical practice positioning errors are frequently seen. Invasive methods are used primarily for research. Samples of bone can be used to measure structure by histology as well as micro-computed tomography and infra-red spectroscopy or backscattered electron microscopy. Force can be directly applied to bone samples to measure the bones strength. Impact microindentation is a new minimally invasive technique that measures bone hardness. Metabolic assessment includes blood and urine tests that reflect diseases that cause bone loss, particularly problems with mineral metabolism. Tetracycline-labelled bone biopsies are the standard for measuring bone formation. Non-invasive biochemical tests of bone formation and resorption can evaluate a patient's skeletal physiology.
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Affiliation(s)
- Radhika R Narla
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Susan M Ott
- Department of Medicine, University of Washington, Seattle, WA, USA.
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