FRAX-based assessment and intervention threshold curves for osteoporosis evaluation in Ecuador

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Due to its prevalence around the world, osteoporosis is considered a serious public health problem. At least 30% of postmenopausal women in the United States and Europe have osteoporosis.<a class="elsevierStyleCrossRef" href="#bib0130">1</a> About 40% of these women and 15–30% of men will have one or more fragility fractures.<a class="elsevierStyleCrossRef" href="#bib0135">2</a>The World Health Organization (WHO) defines the disease according to the measurement of bone mineral density (BMD) by dual x-ray absorptiometry (DXA). BMD values of the femoral neck ≤−2.5 SD are considered osteoporosis.<a class="elsevierStyleCrossRefs" href="#bib0140">3,4</a> The main difficulty in assessing fracture risk is that the T score threshold ≤−2.5 SD has a high specificity but low sensitivity and many of the fragility fractures occur in individuals with BMD values above the osteoporosis threshold.<a class="elsevierStyleCrossRef" href="#bib0150">5</a>FRAX is the most widely used fracture risk assessment tool, demonstrating a high predictive capacity.<a class="elsevierStyleCrossRef" href="#bib0155">6</a> FRAX uses mortality and fracture rates and by combining multiple risk factors (age, sex, body mass index, family history of fracture, alcohol and tobacco consumption, rheumatoid arthritis, use of glucocorticoids and fragility fractures) and the presence or absence of femoral neck DXA, predicts a percentage of fracture risk.<a class="elsevierStyleCrossRef" href="#bib0160">7</a> The FRAX has been validated and adapted to different countries, covering almost 80% of the world's population,<a class="elsevierStyleCrossRef" href="#bib0165">8</a> including Ecuador for where it was adapted in 2009.<a class="elsevierStyleCrossRef" href="#bib0170">9</a>Due to the great variability in fracture and mortality rates in the different regions, the FRAX model is calibrated based on local epidemiology, which makes it difficult to use universal intervention thresholds based on FRAX. For example in the study of Maldonado et al. it was found that the risk of major osteoporotic fracture according to FRAX Ecuador was 1.4%, and when the FRAX calculators for Colombia, Brazil and the United States (Hispanic) were applied to the same population, the fracture risk percentages were higher (4.8%, 3.20%, and 2.08% respectively).<a class="elsevierStyleCrossRef" href="#bib0175">10</a> Due to this difference in values and the new trend of implementing intervention and evaluation curves in the osteoporosis management guidelines,<a class="elsevierStyleCrossRefs" href="#bib0180">11,12</a> the authors launched in July 2017 a proposal of these curves for the Ecuadorian population.<a class="elsevierStyleCrossRef" href="#bib0190">13</a> In this paper we present the elaboration and application of these curves.MethodsUsing the FRAX Ecuador model available on the web, we calculated the probability of major osteoporotic fracture and female hip fracture without any risk factor and without the inclusion of BMD. The probabilities were calculated in 5-year intervals from 40 years to 90 years. The BMI was set at 25kg/m2 for all calculations.Likewise, the probabilities of a major fracture and a hip fracture were calculated in 3 different scenarios:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.History of prior fracture without the inclusion of BMD.</li><li class="elsevierStyleListItem" id="lsti0010">2.T score −2.5 SD without other clinical risk factors.</li><li class="elsevierStyleListItem" id="lsti0015">3.T score −1.5 SD without other clinical risk factors.</li></ul>These scenarios were established based on recommendations from the osteoporosis treatment guidelines. The National Osteoporosis Foundation recommends initiating treatment in patients with a T score ≤−2.5 SD (BMD based intervention threshold).<a class="elsevierStyleCrossRef" href="#bib0195">14</a> On the other hand, the National Osteoporosis Guideline Group (NOGG) recommends intervention in women with a history of fragility fracture without the need for BMD and in women without prior fracture but with an age-specific FRAX probability equivalent to that of a woman with prior fracture (intervention threshold based on FRAX).<a class="elsevierStyleCrossRef" href="#bib0200">15</a> The T score −1.5 SD was chosen to represent osteopenia. The probabilities of fracture by age of the intervention thresholds were compared with the specific probabilities by age without clinical risk factors (without the inclusion of BMD).In addition, the evaluation thresholds for BMD were calculated according to the NOGG. Several studies have shown that the inclusion of BMD in the calculation of the FRAX probability is most useful when the fracture probabilities are close to the intervention threshold,<a class="elsevierStyleCrossRefs" href="#bib0205">16,17</a> that is, in people in whom there is a reasonable probability of that by including BMD in the FRAX calculation their risk of fracture goes from high to low or vice versa. Based on that, the evaluation thresholds were defined as follows:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">•The lower evaluation threshold corresponds to the FRAX probabilities for which neither the treatment nor the BMD test should be considered. This was based on the 10-year probability, without BMD, of a major osteoporotic fracture, in women without clinical risk factors, since the guidelines state that people without clinical risk factors should not be considered eligible for evaluation.<a class="elsevierStyleCrossRef" href="#bib0215">18</a></li><li class="elsevierStyleListItem" id="lsti0025">•The upper evaluation threshold corresponds to the FRAX probabilities for which treatment can be recommended without the need for BMD. The intervention threshold was set at 1.2 times since Kanis et al.<a class="elsevierStyleCrossRef" href="#bib0200">15</a> found that when patients have a fracture probability equal to or greater than 20% of the intervention threshold, the addition of BMD in the calculation of FRAX probability has no greater effect.</li></ul>ResultsIn women without risk factors, the probability of a major osteoporotic fracture increased with age from 0.4% at 40 years to 7.3% at 90 years. Likewise, the probability of hip fracture increased with age from 0% at 40 years to 3.6% at 90 years. The probability of a major osteoporotic fracture increased in women with a T score of −2.5 SD from 0.9% at 40 years to 5.5% at 90 years; with a T-score of −1.5 SD, from 0.6% at 40 years to 3.9% at 90 years; and in women with a history of fracture from 0.9% at 40 years to 12% at 90 years (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Intervention thresholdIn 50-year-old women with a T score −2.5 (intervention threshold based on BMD), the probability of osteoporotic fracture was 1.8 times higher than in women of the same age without any risk. As the age progressed, the difference in probabilities between these two groups was decreasing. From the age of 80, the probability of fracture was lower in women with T score −2.5 than in women without risk factors. The same happened with the T-score group −1.5, from the age of 65, the probability of fracture was lower in this group than in women without risk factors. On the other hand, the probability of fracture was consistently higher in the group of women with a history of fracture (intervention threshold based on FRAX), than in women without risk factors (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the comparison of intervention curves. As evidenced, the curve corresponding to T-score −2.5 crosses the curve of women without risk factors, thus demonstrating that the intervention threshold using a fixed T score becomes less appropriate as age advances. On the other hand, the FRAX intervention curve with a history of prior fracture is always above the curve of women without risk factors. This suggests that the probabilities equivalent to a previous fracture constitute a better reference value above which patients could receive treatment in the absence of a previous fracture.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>We found similarities when analyzing the probabilities of hip fracture. From the age of 80, the probability of fracture with a T score −2.5 SD was lower than in women of the same age but without risk factors. With a T score −1.5 this trend was seen from the age of 65 (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Evaluation thresholdAccording to the NOGG guidelines, the intervention threshold corresponds to the FRAX probability equivalent to a woman with a previous fragility fracture. The lower evaluation threshold was established in the age-specific probabilities of women without clinical risk factors. The superior evaluation was set at 1.2 times the intervention threshold. The three thresholds are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a> shows the established thresholds based on the FRAX of major osteoporotic fracture. The orange area is where the treatment could be recommended, the gray area is where the treatment would not be recommended and the yellow area is where BMD could be measured to improve the estimation of the risk of fracture.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>DiscussionBMD has proven to be a predictor of fracture risk.<a class="elsevierStyleCrossRef" href="#bib0220">19</a> For this reason, criteria based on BMD have been adopted as intervention thresholds, however, it is evident that there is a weakness in the use of fixed BMD values. At first, a T score of −2.5 was a strong risk factor for fracture at an early age, but as the age advanced the association with fracture risk decreased. An 80-year-old woman from Ecuador with a T score of −2.5 has a lower probability of fracture than a woman of the same age without any risk factor, which makes the T score −2.5 seem like a fracture protective factor at that age.Similar results were presented in the study by Johansson et al.<a class="elsevierStyleCrossRef" href="#bib0225">20</a> since the FRAX probability in 85-year-old women with T score −2.5 was lower than in women without risk factors, while for women with a T score −1-5 the effect was seen from the age of 70. In another study,<a class="elsevierStyleCrossRef" href="#bib0230">21</a> starting at age 80, a T score of −2.5 SD appeared to be a protective factor for fracture. The reason for this event is the decrease in BMD that occurs with age. In one study it was shown that the average T-score for women of 80 years was less than −2.5,<a class="elsevierStyleCrossRef" href="#bib0235">22</a> demonstrating that in women>80 years old, clinical risk factors alone are enough to make therapeutic decisions. Applying DXA in these age group may have no influence on the fracture risk.Another problem in recommending treatment only when the BMD T score is ≤−2.5 SD is that the high probability of fracture associated with other risk factors is ignored. For example, treatment should be offered to a 65-year-old woman who smokes and consumes alcohol if she has a T score of −2.5 SD but not with a T score of −2.0, ignoring the fact that in both cases the probability of fracture (3.2% with T score −2.5 and 2.3% with T score −1.5) is higher than the threshold based on BMD (2%). Likewise, a 65-year-old woman with a family history of hip fracture would only be treated if she has a T score of −2.5 SD (Frax 3.5%) but not a T score of −2.0 (FRAX 2.9%).Finally, the intervention threshold based on BMD makes it necessary to perform densitometries to all patients, which within the country's macroeconomic condition is not routinely accessible. On the other hand, the intervention threshold based on the FRAX has the advantage of making it easy to estimate the probability of fracture within any establishment or situation, without necessarily requiring a bone densitometry test. In the present study, we apply the intervention threshold recommended by the NOGG to the Ecuadorian population based on the probability of age-specific fracture equivalent to that of a woman with a previous fragility fracture. This ranged from 0.9% at 40 years to 12% at 90 years, so women with a FRAX probability equal to or greater than these values should be eligible for treatment without densitometry. For example, a 60-year-old woman with RA who uses corticosteroids even in the absence of BMD should be considered for treatment since her FRAX probability (2%) exceeds that of a woman with a previous fracture (1.8%).The use of evaluation thresholds proposed by the NOGG improves the risk assessment in patients near the threshold and decreases the number of densitometries required. People with a FRAX probability below the lower evaluation threshold do not require further intervention, while those above the upper evaluation threshold can be considered for treatment without densitometry. People with a FRAX probability within the limits of the evaluation thresholds should undergo densitometry and their FRAX should be recalculated using BMD.In 2017, Clark et al.<a class="elsevierStyleCrossRef" href="#bib0240">23</a> published the FRAX intervention thresholds of seven Latin American countries, including Ecuador. Our results are similar to those presented in that study, which suggests that there has been no modification of the FRAX Ecuador calculator, although it is evident that the model used underestimates the probability of fracture of the Ecuadorian population. This is because the epidemiology of fractures in Ecuador has changed dramatically. The study that served as a reference for the elaboration of the FRAX Ecuador model reported a crude annual incidence of hip fracture of 49.5 per 100,000 inhabitants, 38.8 per 100,000 men and 63.2 per 100,000 women.<a class="elsevierStyleCrossRef" href="#bib0170">9</a> In 2018, López et al.<a class="elsevierStyleCrossRef" href="#bib0245">24</a> reported a Crude annual incidence of 123 cases per 100,000 inhabitants, 74.6 per 100,000 men and 165.8 per 100,000 women, figures that are significantly higher than in the previous study. Likewise, the hospital mortality rate due to hip fracture has increased from 4.4% in men and 2.9% in women<a class="elsevierStyleCrossRef" href="#bib0170">9</a> to 5.1% in men and 3.8% in women.<a class="elsevierStyleCrossRef" href="#bib0245">24</a> Another study by López et al.<a class="elsevierStyleCrossRef" href="#bib0250">25</a> demonstrated an increase in the rate of mortality from hip fracture from 1.3 per 100,000 women and 2.19 per 100,000 men in 1997 to 6.5 per 100,000 women and 3.5 per 100,000 men in 2016. Due to these changes the revalidation of the FRAX Ecuador calculator is fundamental in order to be applicable to the current reality of the Ecuadorian population.ConclusionData shows the importance of applying tools such as FRAX, specific for each country and also the creation of evaluation and intervention curves that allow discerning according to each patient the need for the use of resources such as DXA and specific treatments. Due to a possible underestimation of the FRAX calculator in the probability of fracture for the Ecuadorian population, a modification is essential.Conflict of interestThe authors declare no conflict of interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1382524" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1269083" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1382525" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1269082" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Intervention threshold" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Evaluation threshold" ] ] ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0035" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-12-21" "fechaAceptado" => "2020-04-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1269083" "palabras" => array:5 [ 0 => "Assessment thresholds" 1 => "FRAX" 2 => "Intervention threshold" 3 => "Ecuador" 4 => "Osteoporosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1269082" "palabras" => array:5 [ 0 => "Curva de evaluación" 1 => "FRAX" 2 => "Curva de intervención" 3 => "Ecuador" 4 => "Osteoporosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionFRAX has been validated and adapted to different countries, covering almost 80% of the world's population, including Ecuador where it was adapted in 2009. The purpose of this study is to elaborate evaluation and intervention curves based on FRAX Ecuador. MethodsUsing the FRAX Ecuador model, we calculated the probability of a major osteoporotic fracture and a female hip fracture without any risk factor and without the inclusion of BMD. The probabilities were calculated in 5-year intervals from 40 to 90 years. The probabilities of major fractures and hip fractures were calculated in 3 different scenarios: 1. History of previous fracture without the inclusion of BMD, 2. T score −2.5 SD without other clinical risk factors, 3. T score −1.5 SD without other clinical risk factors. ResultsIn women without risk factors, the probability of a major osteoporotic fracture increased with age from 0.4% at 40 years to 7.3% at 90 years. The probability of hip fracture increased with age from 0% at 40 years to 3.6% at 90 years. The probability of a major osteoporotic fracture increased in women with a T score of −2.5 SD from 0.9% at 40 years to 5.5% at 90 years; with a T-score of −1.5 SD, from 0.6% at 40 years to 3.9% at 90 years. ConclusionData shows the importance of applying tools such as FRAX, specific for each country and also the creation of evaluation and intervention curves that allow discerning according to each patient the need for the use of resources such as DXA and specific treatments." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa herramienta FRAX ha sido validada y adaptada a diferentes países, cubriendo a casi el 80% de la población mundial, incluido Ecuador, donde fue adaptada en 2009. El objetivo de este estudio fue elaborar curvas de evaluación e intervención basadas en FRAX Ecuador. MétodosUtilizando el modelo FRAX Ecuador, calculamos la probabilidad de fractura osteoporótica mayor y fractura de cadera femenina sin ningún factor de riesgo y sin la inclusión de DMO. Las probabilidades se calcularon en intervalos de 5 años de 40 a 90 años. Las probabilidades de fractura mayor y de cadera se calcularon en 3 escenarios diferentes: 1. Historia de fractura previa sin la inclusión de DMO, 2. T-Score de -2,5 SD sin otros factores de riesgo clínico, 3. T-Score -1,5 SD sin otros factores de riesgo clínico. ResultadosEn mujeres sin factores de riesgo, la probabilidad de fractura osteoporótica mayor aumentó con la edad del 0,4% a los 40 años al 7,3% a los 90 años. La probabilidad de fractura de cadera aumentó con la edad de 0% a los 40 años a 3,6% a los 90 años. La probabilidad de fractura osteoporótica mayor aumentó en mujeres con un puntaje T de -2,5 SD de 0,9% a los 40 años a 5,5% a los 90 años; con puntaje T de -1,5 DE, de 0,6% a los 40 años a 3,9% a los 90 años. ConclusiónLos datos muestran la importancia de aplicar herramientas como FRAX, específicas para cada país y también la creación de curvas de evaluación e intervención que permitan discernir según cada paciente la necesidad de utilizar recursos como DXA y tratamientos específicos." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 930 "Ancho" => 1584 "Tamanyo" => 70905 ] ] "descripcion" => array:1 [ "en" => "10-year probability (%) of major osteoporotic fracture in Ecuadorian women without risk factors, with a T score of −2.5 SD, −1.5 SD and previous fracture." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 963 "Ancho" => 1595 "Tamanyo" => 75317 ] ] "descripcion" => array:1 [ "en" => "10-year probability (%) of hip fracture in women of Ecuador without risk factors, with a T score of −2.5 SD, −1.5 SD and with a previous fracture." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1453 "Ancho" => 2584 "Tamanyo" => 73335 ] ] "descripcion" => array:1 [ "en" => "Assessment threshold curve for Ecuadorian population, 10-year probability risk of major osteoporotic fracture." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="11" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Osteoporotic</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="11" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hip</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">40 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">45 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">50 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">55 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">60 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">65 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">70 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">80 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">85 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">90 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">40 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">45 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">50 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">55 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">60 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">65 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">70 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">75 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">80 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">85 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">90 \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No clinical risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T score −2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">T score −1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Previous fragility fracture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2373438.png" ] ] ] ] "descripcion" => array:1 [ "en" => "10-Year probability of fracture (%) for women with a BMI of 25kg/m according to age." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "fx1.jpeg" "imagenAlto" => 569 "imagenAncho" => 2508 "imagenTamanyo" => 140608 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Ratios between FRAX probabilities of major fractures when compared with the group of women without risk factors. The points from which the FRAX probabilities with T score −1.5 and −2.5 are lower than in women without FR are shown in red." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Osteoporotic</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " colspan="3" align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Hip</th></tr><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Years \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intervention threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower evaluation threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Superior evaluation threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Intervention threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Lower evaluation threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Superior evaluation threshold \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.7 \t\t\t\t\t\t\n 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Original Investigation

Curvas de intervención y evaluación basadas en FRAX Ecuador

Genessis Maldonadoa,

Corresponding author

genesismaldonadovelez92@gmail.com

Corresponding author.

, María Intriagoa, Roberto Guerreroa, Osvaldo Daniel Messinab, Carlos Riosc

a Universidad Espiritu Santo, Guayaquil, Ecuador

b Hospital Cosme Argerich, Buenos Aires, Argentina

c Universidad Espiritu Santo, Guayaquil, Ecuador

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        "titulo" => "Curvas de intervenci&#243;n y evaluaci&#243;n basadas en FRAX Ecuador"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">10-year probability &#40;&#37;&#41; of hip fracture in women of Ecuador without risk factors&#44; with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD&#44; &#8722;1&#46;5 SD and with a previous fracture&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoporosis is a systemic disease characterized by loss of mineral bone mass&#46; Due to its prevalence around the world&#44; osteoporosis is considered a serious public health problem&#46; At least 30&#37; of postmenopausal women in the United States and Europe have osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">1</span></a> About 40&#37; of these women and 15&#8211;30&#37; of men will have one or more fragility fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The World Health Organization &#40;WHO&#41; defines the disease according to the measurement of bone mineral density &#40;BMD&#41; by dual x-ray absorptiometry &#40;DXA&#41;&#46; BMD values of the femoral neck &#8804;&#8722;2&#46;5 SD are considered osteoporosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">3&#44;4</span></a> The main difficulty in assessing fracture risk is that the <span class="elsevierStyleItalic">T</span> score threshold &#8804;&#8722;2&#46;5 SD has a high specificity but low sensitivity and many of the fragility fractures occur in individuals with BMD values above the osteoporosis threshold&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">FRAX is the most widely used fracture risk assessment tool&#44; demonstrating a high predictive capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">6</span></a> FRAX uses mortality and fracture rates and by combining multiple risk factors &#40;age&#44; sex&#44; body mass index&#44; family history of fracture&#44; alcohol and tobacco consumption&#44; rheumatoid arthritis&#44; use of glucocorticoids and fragility fractures&#41; and the presence or absence of femoral neck DXA&#44; predicts a percentage of fracture risk&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">7</span></a> The FRAX has been validated and adapted to different countries&#44; covering almost 80&#37; of the world&#39;s population&#44;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">8</span></a> including Ecuador for where it was adapted in 2009&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to the great variability in fracture and mortality rates in the different regions&#44; the FRAX model is calibrated based on local epidemiology&#44; which makes it difficult to use universal intervention thresholds based on FRAX&#46; For example in the study of Maldonado et al&#46; it was found that the risk of major osteoporotic fracture according to FRAX Ecuador was 1&#46;4&#37;&#44; and when the FRAX calculators for Colombia&#44; Brazil and the United States &#40;Hispanic&#41; were applied to the same population&#44; the fracture risk percentages were higher &#40;4&#46;8&#37;&#44; 3&#46;20&#37;&#44; and 2&#46;08&#37; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">10</span></a> Due to this difference in values and the new trend of implementing intervention and evaluation curves in the osteoporosis management guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">11&#44;12</span></a> the authors launched in July 2017 a proposal of these curves for the Ecuadorian population&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">13</span></a> In this paper we present the elaboration and application of these curves&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Using the FRAX Ecuador model available on the web&#44; we calculated the probability of major osteoporotic fracture and female hip fracture without any risk factor and without the inclusion of BMD&#46; The probabilities were calculated in 5-year intervals from 40 years to 90 years&#46; The BMI was set at 25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span> for all calculations&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Likewise&#44; the probabilities of a major fracture and a hip fracture were calculated in 3 different scenarios&#58;</span><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0035" class="elsevierStylePara elsevierViewall">History of prior fracture without the inclusion of BMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 SD without other clinical risk factors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5 SD without other clinical risk factors&#46;</p></li></ul></p><p id="par0050" class="elsevierStylePara elsevierViewall">These scenarios were established based on recommendations from the osteoporosis treatment guidelines&#46; The National Osteoporosis Foundation recommends initiating treatment in patients with a <span class="elsevierStyleItalic">T</span> score &#8804;&#8722;2&#46;5 SD &#40;BMD based intervention threshold&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">14</span></a> On the other hand&#44; the National Osteoporosis Guideline Group &#40;NOGG&#41; recommends intervention in women with a history of fragility fracture without the need for BMD and in women without prior fracture but with an age-specific FRAX probability equivalent to that of a woman with prior fracture &#40;intervention threshold based on FRAX&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> The <span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5 SD was chosen to represent osteopenia&#46; The probabilities of fracture by age of the intervention thresholds were compared with the specific probabilities by age without clinical risk factors &#40;without the inclusion of BMD&#41;&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In addition&#44; the evaluation thresholds for BMD were calculated according to the NOGG&#46; Several studies have shown that the inclusion of BMD in the calculation of the FRAX probability is most useful when the fracture probabilities are close to the intervention threshold&#44;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">16&#44;17</span></a> that is&#44; in people in whom there is a reasonable probability of that by including BMD in the FRAX calculation their risk of fracture goes from high to low or vice versa&#46; Based on that&#44; the evaluation thresholds were defined as follows&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0060" class="elsevierStylePara elsevierViewall">The lower evaluation threshold corresponds to the FRAX probabilities for which neither the treatment nor the BMD test should be considered&#46; This was based on the 10-year probability&#44; without BMD&#44; of a major osteoporotic fracture&#44; in women without clinical risk factors&#44; since the guidelines state that people without clinical risk factors should not be considered eligible for evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">&#8226;</span><p id="par0065" class="elsevierStylePara elsevierViewall">The upper evaluation threshold corresponds to the FRAX probabilities for which treatment can be recommended without the need for BMD&#46; The intervention threshold was set at 1&#46;2 times since Kanis et al&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">15</span></a> found that when patients have a fracture probability equal to or greater than 20&#37; of the intervention threshold&#44; the addition of BMD in the calculation of FRAX probability has no greater effect&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">In women without risk factors&#44; the probability of a major osteoporotic fracture increased with age from 0&#46;4&#37; at 40 years to 7&#46;3&#37; at 90 years&#46; Likewise&#44; the probability of hip fracture increased with age from 0&#37; at 40 years to 3&#46;6&#37; at 90 years&#46; The probability of a major osteoporotic fracture increased in women with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD from 0&#46;9&#37; at 40 years to 5&#46;5&#37; at 90 years&#59; with a <span class="elsevierStyleItalic">T</span>-score of &#8722;1&#46;5 SD&#44; from 0&#46;6&#37; at 40 years to 3&#46;9&#37; at 90 years&#59; and in women with a history of fracture from 0&#46;9&#37; at 40 years to 12&#37; at 90 years &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Intervention threshold</span><p id="par0075" class="elsevierStylePara elsevierViewall">In 50-year-old women with a <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 &#40;intervention threshold based on BMD&#41;&#44; the probability of osteoporotic fracture was 1&#46;8 times higher than in women of the same age without any risk&#46; As the age progressed&#44; the difference in probabilities between these two groups was decreasing&#46; From the age of 80&#44; the probability of fracture was lower in women with <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 than in women without risk factors&#46; The same happened with the <span class="elsevierStyleItalic">T</span>-score group &#8722;1&#46;5&#44; from the age of 65&#44; the probability of fracture was lower in this group than in women without risk factors&#46; On the other hand&#44; the probability of fracture was consistently higher in the group of women with a history of fracture &#40;intervention threshold based on FRAX&#41;&#44; than in women without risk factors &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the comparison of intervention curves&#46; As evidenced&#44; the curve corresponding to <span class="elsevierStyleItalic">T</span>-score &#8722;2&#46;5 crosses the curve of women without risk factors&#44; thus demonstrating that the intervention threshold using a fixed <span class="elsevierStyleItalic">T</span> score becomes less appropriate as age advances&#46; On the other hand&#44; the FRAX intervention curve with a history of prior fracture is always above the curve of women without risk factors&#46; This suggests that the probabilities equivalent to a previous fracture constitute a better reference value above which patients could receive treatment in the absence of a previous fracture&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">We found similarities when analyzing the probabilities of hip fracture&#46; From the age of 80&#44; the probability of fracture with a <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 SD was lower than in women of the same age but without risk factors&#46; With a <span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5 this trend was seen from the age of 65 &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Evaluation threshold</span><p id="par0090" class="elsevierStylePara elsevierViewall">According to the NOGG guidelines&#44; the intervention threshold corresponds to the FRAX probability equivalent to a woman with a previous fragility fracture&#46; The lower evaluation threshold was established in the age-specific probabilities of women without clinical risk factors&#46; The superior evaluation was set at 1&#46;2 times the intervention threshold&#46; The three thresholds are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> shows the established thresholds based on the FRAX of major osteoporotic fracture&#46; The orange area is where the treatment could be recommended&#44; the gray area is where the treatment would not be recommended and the yellow area is where BMD could be measured to improve the estimation of the risk of fracture&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">BMD has proven to be a predictor of fracture risk&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">19</span></a> For this reason&#44; criteria based on BMD have been adopted as intervention thresholds&#44; however&#44; it is evident that there is a weakness in the use of fixed BMD values&#46; At first&#44; a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 was a strong risk factor for fracture at an early age&#44; but as the age advanced the association with fracture risk decreased&#46; An 80-year-old woman from Ecuador with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 has a lower probability of fracture than a woman of the same age without any risk factor&#44; which makes the <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 seem like a fracture protective factor at that age&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Similar results were presented in the study by Johansson et al&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">20</span></a> since the FRAX probability in 85-year-old women with <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 was lower than in women without risk factors&#44; while for women with a <span class="elsevierStyleItalic">T</span> score &#8722;1-5 the effect was seen from the age of 70&#46; In another study&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">21</span></a> starting at age 80&#44; a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD appeared to be a protective factor for fracture&#46; The reason for this event is the decrease in BMD that occurs with age&#46; In one study it was shown that the average <span class="elsevierStyleItalic">T</span>-score for women of 80 years was less than &#8722;2&#46;5&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">22</span></a> demonstrating that in women<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>80 years old&#44; clinical risk factors alone are enough to make therapeutic decisions&#46; Applying DXA in these age group may have no influence on the fracture risk&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another problem in recommending treatment only when the BMD <span class="elsevierStyleItalic">T</span> score is &#8804;&#8722;2&#46;5 SD is that the high probability of fracture associated with other risk factors is ignored&#46; For example&#44; treatment should be offered to a 65-year-old woman who smokes and consumes alcohol if she has a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD but not with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;0&#44; ignoring the fact that in both cases the probability of fracture &#40;3&#46;2&#37; with <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 and 2&#46;3&#37; with <span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5&#41; is higher than the threshold based on BMD &#40;2&#37;&#41;&#46; Likewise&#44; a 65-year-old woman with a family history of hip fracture would only be treated if she has a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD &#40;Frax 3&#46;5&#37;&#41; but not a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;0 &#40;FRAX 2&#46;9&#37;&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Finally&#44; the intervention threshold based on BMD makes it necessary to perform densitometries to all patients&#44; which within the country&#39;s macroeconomic condition is not routinely accessible&#46; On the other hand&#44; the intervention threshold based on the FRAX has the advantage of making it easy to estimate the probability of fracture within any establishment or situation&#44; without necessarily requiring a bone densitometry test&#46; In the present study&#44; we apply the intervention threshold recommended by the NOGG to the Ecuadorian population based on the probability of age-specific fracture equivalent to that of a woman with a previous fragility fracture&#46; This ranged from 0&#46;9&#37; at 40 years to 12&#37; at 90 years&#44; so women with a FRAX probability equal to or greater than these values should be eligible for treatment without densitometry&#46; For example&#44; a 60-year-old woman with RA who uses corticosteroids even in the absence of BMD should be considered for treatment since her FRAX probability &#40;2&#37;&#41; exceeds that of a woman with a previous fracture &#40;1&#46;8&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The use of evaluation thresholds proposed by the NOGG improves the risk assessment in patients near the threshold and decreases the number of densitometries required&#46; People with a FRAX probability below the lower evaluation threshold do not require further intervention&#44; while those above the upper evaluation threshold can be considered for treatment without densitometry&#46; People with a FRAX probability within the limits of the evaluation thresholds should undergo densitometry and their FRAX should be recalculated using BMD&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In 2017&#44; Clark et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">23</span></a> published the FRAX intervention thresholds of seven Latin American countries&#44; including Ecuador&#46; Our results are similar to those presented in that study&#44; which suggests that there has been no modification of the FRAX Ecuador calculator&#44; although it is evident that the model used underestimates the probability of fracture of the Ecuadorian population&#46; This is because the epidemiology of fractures in Ecuador has changed dramatically&#46; The study that served as a reference for the elaboration of the FRAX Ecuador model reported a crude annual incidence of hip fracture of 49&#46;5 per 100&#44;000 inhabitants&#44; 38&#46;8 per 100&#44;000 men and 63&#46;2 per 100&#44;000 women&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> In 2018&#44; L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> reported a Crude annual incidence of 123 cases per 100&#44;000 inhabitants&#44; 74&#46;6 per 100&#44;000 men and 165&#46;8 per 100&#44;000 women&#44; figures that are significantly higher than in the previous study&#46; Likewise&#44; the hospital mortality rate due to hip fracture has increased from 4&#46;4&#37; in men and 2&#46;9&#37; in women<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">9</span></a> to 5&#46;1&#37; in men and 3&#46;8&#37; in women&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">24</span></a> Another study by L&#243;pez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">25</span></a> demonstrated an increase in the rate of mortality from hip fracture from 1&#46;3 per 100&#44;000 women and 2&#46;19 per 100&#44;000 men in 1997 to 6&#46;5 per 100&#44;000 women and 3&#46;5 per 100&#44;000 men in 2016&#46; Due to these changes the revalidation of the FRAX Ecuador calculator is fundamental in order to be applicable to the current reality of the Ecuadorian population&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Data shows the importance of applying tools such as FRAX&#44; specific for each country and also the creation of evaluation and intervention curves that allow discerning according to each patient the need for the use of resources such as DXA and specific treatments&#46; Due to a possible underestimation of the FRAX calculator in the probability of fracture for the Ecuadorian population&#44; a modification is essential&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">FRAX has been validated and adapted to different countries&#44; covering almost 80&#37; of the world&#39;s population&#44; including Ecuador where it was adapted in 2009&#46; The purpose of this study is to elaborate evaluation and intervention curves based on FRAX Ecuador&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Using the FRAX Ecuador model&#44; we calculated the probability of a major osteoporotic fracture and a female hip fracture without any risk factor and without the inclusion of BMD&#46; The probabilities were calculated in 5-year intervals from 40 to 90 years&#46; The probabilities of major fractures and hip fractures were calculated in 3 different scenarios&#58; 1&#46; History of previous fracture without the inclusion of BMD&#44; 2&#46; <span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5 SD without other clinical risk factors&#44; 3&#46; <span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5 SD without other clinical risk factors&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In women without risk factors&#44; the probability of a major osteoporotic fracture increased with age from 0&#46;4&#37; at 40 years to 7&#46;3&#37; at 90 years&#46; The probability of hip fracture increased with age from 0&#37; at 40 years to 3&#46;6&#37; at 90 years&#46; The probability of a major osteoporotic fracture increased in women with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD from 0&#46;9&#37; at 40 years to 5&#46;5&#37; at 90 years&#59; with a <span class="elsevierStyleItalic">T</span>-score of &#8722;1&#46;5 SD&#44; from 0&#46;6&#37; at 40 years to 3&#46;9&#37; at 90 years&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Data shows the importance of applying tools such as FRAX&#44; specific for each country and also the creation of evaluation and intervention curves that allow discerning according to each patient the need for the use of resources such as DXA and specific treatments&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusion"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La herramienta FRAX ha sido validada y adaptada a diferentes pa&#237;ses&#44; cubriendo a casi el 80&#37; de la poblaci&#243;n mundial&#44; incluido Ecuador&#44; donde fue adaptada en 2009&#46; El objetivo de este estudio fue elaborar curvas de evaluaci&#243;n e intervenci&#243;n basadas en FRAX Ecuador&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Utilizando el modelo FRAX Ecuador&#44; calculamos la probabilidad de fractura osteopor&#243;tica mayor y fractura de cadera femenina sin ning&#250;n factor de riesgo y sin la inclusi&#243;n de DMO&#46; Las probabilidades se calcularon en intervalos de 5 a&#241;os de 40 a 90 a&#241;os&#46; Las probabilidades de fractura mayor y de cadera se calcularon en 3 escenarios diferentes&#58; 1&#46; Historia de fractura previa sin la inclusi&#243;n de DMO&#44; 2&#46; T-Score de -2&#44;5 SD sin otros factores de riesgo cl&#237;nico&#44; 3&#46; T-Score -1&#44;5 SD sin otros factores de riesgo cl&#237;nico&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En mujeres sin factores de riesgo&#44; la probabilidad de fractura osteopor&#243;tica mayor aument&#243; con la edad del 0&#44;4&#37; a los 40 a&#241;os al 7&#44;3&#37; a los 90 a&#241;os&#46; La probabilidad de fractura de cadera aument&#243; con la edad de 0&#37; a los 40 a&#241;os a 3&#44;6&#37; a los 90 a&#241;os&#46; La probabilidad de fractura osteopor&#243;tica mayor aument&#243; en mujeres con un puntaje T de -2&#44;5 SD de 0&#44;9&#37; a los 40 a&#241;os a 5&#44;5&#37; a los 90 a&#241;os&#59; con puntaje T de -1&#44;5 DE&#44; de 0&#44;6&#37; a los 40 a&#241;os a 3&#44;9&#37; a los 90 a&#241;os&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los datos muestran la importancia de aplicar herramientas como FRAX&#44; espec&#237;ficas para cada pa&#237;s y tambi&#233;n la creaci&#243;n de curvas de evaluaci&#243;n e intervenci&#243;n que permitan discernir seg&#250;n cada paciente la necesidad de utilizar recursos como DXA y tratamientos espec&#237;ficos&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
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          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusi&#243;n"
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        "etiqueta" => "Fig&#46; 1"
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        "figura" => array:1 [
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">10-year probability &#40;&#37;&#41; of major osteoporotic fracture in Ecuadorian women without risk factors&#44; with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD&#44; &#8722;1&#46;5 SD and previous fracture&#46;</p>"
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      1 => array:7 [
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        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">10-year probability &#40;&#37;&#41; of hip fracture in women of Ecuador without risk factors&#44; with a <span class="elsevierStyleItalic">T</span> score of &#8722;2&#46;5 SD&#44; &#8722;1&#46;5 SD and with a previous fracture&#46;</p>"
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        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Assessment threshold curve for Ecuadorian population&#44; 10-year probability risk of major osteoporotic fracture&#46;</p>"
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        "etiqueta" => "Table 1"
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            "identificador" => "at1"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">60&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">65&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">90&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">No clinical risk factors&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">3&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">7&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">T</span> score &#8722;2&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">T</span> score &#8722;1&#46;5&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 01218123
Original language: English

DOI:10.1016/j.rcreu.2020.04.004

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Year/Month	Html	Pdf	Total

2024 November	8	0	8
2024 October	59	4	63
2024 September	101	8	109
2024 August	78	6	84
2024 July	66	3	69
2024 June	49	5	54
2024 May	66	6	72
2024 April	73	5	78
2024 March	60	10	70
2024 February	72	6	78
2024 January	62	5	67
2023 December	64	9	73
2023 November	69	8	77
2023 October	104	15	119
2023 September	51	4	55
2023 August	65	1	66
2023 July	73	9	82
2023 June	64	9	73
2023 May	102	9	111
2023 April	70	2	72
2023 March	100	5	105
2023 February	62	4	66
2023 January	66	9	75
2022 December	55	4	59
2022 November	68	7	75
2022 October	56	8	64
2022 September	67	8	75
2022 August	71	19	90
2022 July	48	5	53
2022 June	35	10	45
2022 May	48	8	56
2022 April	35	11	46
2022 March	40	17	57
2022 February	52	7	59
2022 January	77	8	85
2021 December	33	13	46
2021 November	44	14	58
2021 October	52	13	65
2021 September	47	21	68
2021 August	59	11	70
2021 July	20	10	30
2021 June	34	17	51
2021 May	44	13	57
2021 April	72	16	88
2021 March	0	2	2
2021 February	0	1	1
2021 January	0	1	1
2020 December	0	3	3
2020 November	0	3	3
2020 October	1	1	2
2020 September	1	5	6
2020 August	14	5	19
2020 July	4	3	7

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