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Unlabelled: Bone loss, a fracture risk factor, may play a role in post-fracture mortality. We found accelerated bone loss (≥1.31 % bone loss/year for women and ≥1.35 % bone loss/year for men) associated with 44-77 % increased mortality. It remains unclear whether bone loss is a marker or plays a role in mortality., Introduction: Osteoporotic fractures are associated with increased mortality although the cause is unknown. Bone loss, a risk factor for osteoporotic fracture is also associated with increased mortality, but its role in mortality risk post-fracture is unclear. This study aimed to examine post-fracture mortality risk according to levels of bone loss., Methods: Community-dwelling participants aged 60+ from Dubbo Osteoporosis Epidemiology Study with incident fractures were followed from 1989 to 2011. Kaplan-Meier survival curves were constructed according to bone loss quartiles. Cox proportional hazard models were used to determine the effect of bone loss on mortality., Results: There were 341 women and 106 men with ≥2 BMD measurements. The rate of bone loss was similar for women and men (women mean -0.79 %/year, highest bone loss quartile -1.31 %/year; men mean -0.74 %/year, highest quartile -1.35 %/year). Survival was lowest for the highest quartile of bone loss for women (p < 0.005) and men (p = 0.05). When analysed by fracture type, the association of bone loss with mortality was observed for vertebral (highest vs lower 3 quartiles of bone loss, women p = 0.03 and men p = 0.02) and non-hip non-vertebral fractures in women (p < 0.0001). Bone loss did not play an additional role in mortality risk following hip fractures. Importantly, overall, rapid bone loss was associated with 44-77 % increased mortality risk after multiple variable adjustment., Conclusion: Rapid bone loss was an independent predictor of post-fracture mortality risk in both women and men. The association of bone loss and post-fracture mortality was predominantly observed following vertebral fracture in both women and men and non-hip non-vertebral fracture in women. It remains to be determined whether bone loss is a marker or plays a role in the mortality associated with fractures.

Unlabelled: Hypertension is an independent risk factor for osteoporosis and osteoporotic fracture in postmenopausal women., Introduction: Although hypertension has been suggested to be associated with increased fracture risk, it is not clear whether the association is independent of bone mineral density (BMD). The present study sought to examine the interrelationships between hypertension, BMD, and fracture risk., Methods: The study included 1,032 men and 1,701 women aged 50 years and older who were participants in the Dubbo Osteoporosis Epidemiology Study. BMD at the femoral neck and lumbar spine was measured by dual energy X-ray absorptiometry (GE-LUNAR Corp., Madison, WI, USA). The presence of hypertension was ascertained by direct interview and verification through clinical history. The incidence of fragility fractures was ascertained by X-ray report during the follow-up period (1989-2008). The Cox proportional hazards model was used to assess the association between hypertension and fracture risk., Results: Women with hypertension had lower BMD at the femoral neck (0.79 versus 0.82 g/cm(2), P = 0.02) than those without the disease. After adjusting for BMD and covariates, hypertension was an independent risk factor for fragility fracture [hazard ratio (HR), 1.49; 95% CI, 1.13-1.96]. In men, hypertension was associated with higher femoral neck BMD (0.94 versus 0.92 g/cm(2), P = 0.02), but the association between hypertension and fracture risk did not reach statistical significance., Conclusion: Hypertension is associated with increased fracture risk in women, and the association is independent of BMD.

Unlabelled: This study sought to determine the association between calcaneal quantitative ultrasound (QUS) and fracture risk in individuals without osteoporosis according to the World Health Organization criteria (i.e., BMD T-score > -2.5). We found that calcaneal QUS is an independent predictor of fracture risk in women with non-osteoporotic bone mineral density (BMD)., Introduction: More than 50 % of women and 70 % of men who sustain a fragility fracture have BMD above the osteoporotic threshold (T-score > -2.5). Calcaneal QUS is associated with fracture risk. This study aimed to test the hypothesis that low calcaneal QUS is associated with increased fracture risk in individuals with non-osteoporotic BMD., Methods: We included 312 women and 390 men aged 62-90 years with BMD T-score > -2.5 at femoral neck. QUS was measured in broadband ultrasound attenuation (BUA) at the calcaneus using a CUBA sonometer. BMD was measured at the femoral neck (FNBMD) by dual energy X-ray absorptiometry using GE Lunar DPX-L densitometer. The incidences of any fragility fracture were ascertained by X-ray reports during the follow-up period from 1994 to 2011., Results: Of the 702 participants, 26 % of women (n = 80/312) and 14 % of men (n = 53/390) experienced at least one fragility fracture during the follow-up period. In women, after adjusting for covariates, increased risk of any fracture was significantly associated with decreased BUA (HR = 1.50; 95 % CI, 1.13-1.99). Compared with that of FNBMD, the models with BUA, in women, had greater AUC (0.71, 0.85, 0.71 for any, hip and vertebral fracture, respectively), and yielded a net reclassification improvement of 16.4 % (P = 0.009) when combined with FNBMD. In men, BUA was not significantly associated with fracture risk before and after adjustment., Conclusion: These results suggest that calcaneal BUA is an independent predictor of fracture risk in women with non-osteoporotic BMD.

Unlabelled: In this cross-sectional study in Vietnam, the prevalence of vitamin D insufficiency was 46% in adult women and 20% in adult men. There was a linear inverse relationship between serum 25(OH)D and PTH concentrations, but there was no threshold of 25(OH)D at which PTH levels plateaued., Introduction: Vitamin D insufficiency is adversely associated with health outcomes. Vitamin D status in Asian populations is not well documented. This study sought to assess vitamin D status and its relationship to parathyroid hormone in a Vietnamese population., Methods: This cross-sectional study involved 205 men and 432 women aged 18-87 years, who were randomly sampled from various districts in Ho Chi Minh City (Vietnam) according to a proportional sampling scheme. Serum concentration of 25(OH)D and PTH were measured by the Electrochemiluminescence immunoassay on the Roche Elecsys 10100/201 system (Roche Diagnosis Elecsys). Vitamin D insufficiency was quantified as serum 25(OH)D levels below 30 ng/ml (75 nmol/L)., Results: The average age for men and women was 43.8 ± 18.4 years (mean ± SD) and 47.7 ± 17.1 years, respectively. The mean 25(OH)D concentration in men (36.8 ± 10.2 ng/mL) was significantly higher than in women (30.1 ± 5.9; P < 0.0001). The prevalence of vitamin D insufficiency in men was 20% (41/205) which was significantly lower than in women (46%, 199/432). Age, height and weight were independent predictors of 25(OH)D concentrations, and the three factors explained 15% and 5% of variance in 25(OH)D in men and women, respectively. There was a linear inverse relationship between serum 25(OH)D and PTH concentrations, but there was no threshold of 25(OH)D at which PTH levels plateaued., Conclusions: These data show that vitamin D insufficiency is common even in tropical region, and that women had a greater risk of vitamin D insufficiency than men. These data suggest that an elevation in PTH cannot be used as a marker for vitamin D deficiency.

Unlabelled: We evaluated the prognostic accuracy of fracture risk assessment tool (FRAX) and Garvan algorithms in an independent Australian cohort. The results suggest comparable performance in women but relatively poor fracture risk discrimination in men by FRAX. These data emphasize the importance of external validation before widespread clinical implementation of prognostic tools in different cohorts., Introduction: Absolute risk assessment is now recognized as a preferred approach to guide treatment decision. The present study sought to evaluate accuracy of the FRAX and Garvan algorithms for predicting absolute risk of osteoporotic fracture (hip, spine, humerus, or wrist), defined as major in FRAX, in a clinical setting in Australia., Methods: A retrospective validation study was conducted in 144 women (69 fractures and 75 controls) and 56 men (31 fractures and 25 controls) aged between 60 and 90 years. Relevant clinical data prior to fracture event were ascertained. Based on these variables, predicted 10-year probabilities of major fracture were calculated from the Garvan and FRAX algorithms, using US (FRAX-US) and UK databases (FRAX-UK). Area under the receiver operating characteristic curves (AUC) was computed for each model., Results: In women, the average 10-year probability of major fracture was consistently higher in the fracture than in the nonfracture group: Garvan (0.33 vs. 0.15), FRAX-US (0.30 vs. 0.19), and FRAX-UK (0.17 vs. 0.10). In men, although the Garvan model yielded higher average probability of major fracture in the fracture group (0.32 vs. 0.14), the FRAX algorithm did not: FRAX-US (0.17 vs. 0.19) and FRAX-UK (0.09 vs. 0.12). In women, AUC for the Garvan, FRAX-US, and FRAX-UK algorithms were 0.84, 0.77, and 0.78, respectively, vs. 0.76, 0.54, and 0.57, respectively, in men., Conclusion: In this analysis, although both approaches were reasonably accurate in women, FRAX discriminated fracture risk poorly in men. These data support the concept that all algorithms need external validation before clinical implementation.

Unlabelled: We have developed clinical nomograms for predicting 5-year and 10-year fracture risks for any elderly man or woman. The nomograms used age and information concerning fracture history, fall history, and BMD T-score or body weight., Introduction: Although many fracture risk factors have been identified, the translation of these risk factors into a prognostic model that can be used in primary care setting has not been well realized. The present study sought to develop a nomogram that incorporates non-invasive risk factors to predict 5-year and 10-year absolute fracture risks for an individual man and woman., Methods: The Dubbo Osteoporosis Epidemiology Study was designed as a community-based prospective study, with 1358 women and 858 men aged 60+ years as at 1989. Baseline measurements included femoral neck bone mineral density (FNBMD), prior fracture, a history of falls and body weight. Between 1989 and 2004, 426 women and 149 men had sustained a low-trauma fracture (not including morphometric vertebral fractures). Two prognostic models based on the Cox's proportional hazards analysis were considered: model I included age, BMD, prior fracture and falls; and model II included age, weight, prior fracture and fall., Results: Analysis of the area under the receiver operating characteristic curve (AUC) suggested that model I (AUC = 0.75 for both sexes) performed better than model II (AUC = 0.72 for women and 0.74 for men). Using the models' estimates, we constructed various nomograms for individualizing the risk of fracture for men and women. If the 5-year risk of 10% or greater is considered "high risk", then virtually all 80-year-old men with BMD T-scores < -1.0 or 80-year-old women with T-scores < -2.0 were predicted to be in the high risk group. A 60-year-old woman's risk was considered high risk only if her BMD T-scores < or = -2.5 and with a prior fracture; however, no 60-year-old men would be in the high risk regardless of their BMD and risk profile., Conclusion: These data suggest that the assessment of fracture risk for an individual cannot be based on BMD alone, since there are clearly various combinations of factors that could substantially elevate an individual's risk of fracture. The nomograms presented here can be useful for individualizing the short- and intermediate-term risk of fracture and identifying high-risk individuals for intervention to reduce the burden of fracture in the general population.

Unlabelled: Until now there has been no published prognostic tool available for predicting of hip fracture to primary care settings. We have developed a nomogram for predicting the absolute risk of hip fracture for any individual by using clinical factors, including age, prior fracture and fall, in addition to BMD that was based on a 15-year follow-up cohort study., Introduction: Bone mineral density or clinical risk factors alone are useful but limited tools for the identification of individuals with high-risk of hip fracture. It is hypothesized that the combination of clinical risk factors and BMD can improve the accuracy of fracture prediction. This study was aimed at developing a nomogram which combines these factors for predicting 5-year and 10-year risk of hip fracture for an individual., Methods: The study, designed as a epidemiologic, community-based prospective study, included 1,208 women and 740 men aged 60+ years with median duration of follow-up of 13 years (inter-quartile range, IQR: 6-14) for both women and men, yielding 10,523 and 7,586 person-years of observation, respectively. Main outcome measures were incidence of hip fractures and risk factors were femoral neck bone mineral density (FNBMD), prior fracture, history of fall, postural sway and quadriceps strength. Femoral neck BMD was measured by DXA (GE-LUNAR Corp, Madison, Wisconsin, USA). Cox's proportional hazards model was used to estimate the risk of fracture for individuals, and a nomogram was constructed for predicting hip fracture risk., Results: Between 1989 and 2004, 127 individuals (96 women) sustained a hip fracture. Advancing age, low femoral neck BMD, prior fracture and history of falls were independent predictors of hip fracture. The area under the receiver operating characteristic curve for the model was 0.85 for both sexes. A nomogram was constructed for predicting hip fracture risk for an individual. Among those aged 75 or older with BMD T-scores < or = -2.5, the risk of hip fracture in men was comparable to or higher than in women; however, in younger age groups, the risk was higher in women than in men., Conclusion: The combination of BMD and non-invasive clinical risk factors in a nomogram could be useful for identifying high-risk individuals for intervention to reduce the risk of hip fracture.

The primary aim of this study was to validate the Osteoporosis Self-Assessment Tools for Asians (OSTA) instrument in Thai women, and to evaluate its utility in terms of economic costs and fracture prediction. Femoral neck and lumbar spine BMD was measured by dual energy X-ray absorptiometry in 322 Thai women, aged 60+/-10 years (mean+/-SD; range: 45-84 years). The women were classified as having osteoporosis if their BMD T-scores were < or =-2.5. The OSTA score was calculated for each woman using her age and weight according to the formula: 0.2(weight-age). Women with OSTA scores < or =-1 and >-1 were classified as "high risk" and "low risk," respectively. The prevalence of osteoporosis was 33% by femoral neck or lumbar spine BMD. Using the OSTA score, 165 (51.2%) women were classified as high risk. The sensitivity, specificity and positive predictive value of OSTA was 82% 64% and 53%, respectively. If the OSTA score is used to identify women with high risk of fracture, and assuming that the incidence of fracture among osteoporotic and non-osteoporotic women are 2% and 1% per year, respectively, the OSTA score can identify 59% of fracture cases correctly, and 41% are expected to be missed. Furthermore, if the high-risk subjects identified by OSTA are to be treated, and if the treatment reduces fracture incidence by 50%, and assuming that the treatment cost is $1 per day, then the cost to prevent one fracture is estimated to be $48,530. Results of this study suggest that, in the Thai population, the OSTA score had high sensitivity but low specificity and low positive predictive value in the identification of osteoporotic women. Its use in the general population can result in a high false-positive rate and incur significant cost to the community.