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Original Investigation
The application of FRAX in Ecuador
La aplicación del modelo FRAX en Ecuador
Enrique López Gaviláneza,b,
Corresponding author
enrique_lopezg57@hotmail.com

Corresponding author.
, Helena Johanssonc,d, Nicholas Harveye, Mattias Lorentzonf,g, Eugene McCloskeyh,i, Judith Valdivieso Jaraa, John A. Kanisc,i
a AECE Research Group, Association of Clinical Endocrinologists of Ecuador, Guayaquil, Ecuador
b Endocrinology Service, Guayaquil National Police Teaching Hospital No. 2, Guayaquil, Ecuador
c Department of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
d Mary McKillop Institute for Health Research, Australian Catholic University, Melbourne, Australia
e MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
f Geriatric Medicine, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
g Geriatric Medicine, Sahlgrenska University Hospital, Molndal, Sweden
h Centre for Integrated Research in Musculoskeletal Ageing (CIMA), Mellan by Centre for Bone Research, University of Sheffield, Sheffield, UK
i Centre for Metabolic Bone Diseases, University of Sheffield Medical School, Sheffield, UK
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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">A wide range of treatments is available that improve bone mass and decrease the risk of fractures associated with osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">1</span></a> The use of such interventions by health care practitioners is assisted by instruments that assess patients&#8217; fracture risk to optimize clinical decisions about prevention and treatment&#46; The most widely used web-based tool FRAX&#174; &#40;<a href="https://www.sheffield.ac.uk/FRAX/">https&#58;&#47;&#47;www&#46;sheffield&#46;ac&#46;uk&#47;FRAX&#47;</a>&#41; meets these requirements and computes the 10-year probability of fragility fractures based on several common clinical risk factors and&#44; optionally&#44; a bone densitometry result obtained from dual X-ray absorptiometry &#40;DXA&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">2&#44;3</span></a> FRAX models are available for 73 countries covering more than 80&#37; of the world population at risk<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">4</span></a> and have been incorporated into more than 100 guidelines worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The adoption of FRAX demands the development of intervention thresholds&#44; namely the fracture probability above which treatment should be recommended&#46; Many different approaches to intervention thresholds have been adopted but in those countries where FRAX rather than BMD is used as a gateway to patient assessment&#44; age-specific thresholds are widely used<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;5&#8211;7</span></a> based on criteria originally developed by the National Osteoporosis Guideline Group &#40;NOGG&#41; in the UK&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">8&#44;9</span></a> More recently NOGG modified their age-dependent intervention thresholds and now use a &#8216;hybrid&#8217; threshold where the intervention threshold is constant from the age of 70 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A country specific FRAX model was developed for Ecuador in 2012&#44; subsequently updated with the availability of more recent epidemiology of hip fracture and death&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">12&#44;13</span></a> The aim of the present study was to explore potential assessment pathways for treatment and characteristics of women selected for treatment in Ecuador based on FRAX using either an age-specific intervention threshold or a hybrid threshold&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Population sample</span><p id="par0020" class="elsevierStylePara elsevierViewall">This study used data from 2370 women age 60 years or more in the SABE survey &#40;National Survey of Health&#44; Wellbeing&#44; and Aging&#41;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a> residing in the Andes and the coast of Ecuador&#46; The SABE survey was conducted in the continental regions of Ecuador &#40;only the island territory and Amazon was excluded because of its lower population density&#44; 4&#46;4&#37;&#41;&#44; therefore it is a representative sample of the Ecuadorian population&#46; This survey is a probability sample of households with a least one person aged 60 years or older residing in the Andes Mountains and coastal regions of Ecuador&#46; In the primary sampling stage&#44; a total of 317 sectors from rural areas &#40;&#60;2000 inhabitants&#41; and 547 sectors from urban areas of the country were selected from the 2001 population Census cartography&#46; In the secondary sampling stage&#44; 18 households within each sector were randomly selected based on the assumption that at least one person aged 60 years or older live in 24&#37; and 23&#37; of the households along the coast and Andes Mountains region&#44; respectively&#46; Between April and August 2010&#44; participants underwent biochemical evaluation to determine their metabolic risk factors&#46; Survey data and methodology&#44; including operation manuals are publicly available&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A structured questionnaire was used to collect information from all participants and used to provide risk variables for the calculation of FRAX probabilities in the absence of bone mineral density &#40;BMD&#41;&#46; Age and sex were self-reported by survey participants&#46; Body height in centimeters and weight in kilograms were measured and the body mass index was calculated &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Smoking was classified as current&#44; former&#44; and never&#46; Average alcohol consumption per week during the previous three months was classified as none&#44; one day&#44; or two or more days per week&#46; Participants self-reported forearm and hip fractures in the past year&#46; The SABE survey questioned participants&#59; Has he&#47;she fallen in the last year&#63;&#44; Did he suffer a fracture when he&#47;she fell&#63;&#44; In the last year he fractured his hip&#63;&#44; In the last year&#44; he&#47;she fracture his wrist&#63;&#44; so we assumed it was frailty fractures&#46; The SABE survey did not collect data on the long-term use of glucocorticoids&#44; family history of hip fractures&#44; or secondary osteoporosis&#46; These missing data were simulated&#46; In a sensitivity analysis&#44; missing data were coded as a &#8216;no&#8217; response to determine the impact of missing variables on fracture probability&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Simulation of variables</span><p id="par0035" class="elsevierStylePara elsevierViewall">Data from the derivation cohorts used to synthesize FRAX were used to simulate missing values&#46; Logistic regression equations were identified to generate data for the dichotomous FRAX variables as described previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">15&#8211;17</span></a> The equations were applied to the data in the cohort to predict the probability of having a positive value for the missing key risk factor for each individual&#46; Next&#44; a random number was generated using a computer program&#44; which was then compared with the predicted probability for that variable for that individual&#46; If the random number was less than or equal to the predicted probability&#44; the individual was assigned a positive response for the risk factor&#46; If the random number was larger than the predicted probability&#44; the person was assigned a negative response for the risk factor&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Fracture probabilities</span><p id="par0040" class="elsevierStylePara elsevierViewall">The 10-year probabilities of hip fracture and a major osteoporotic fracture &#40;clinical spine&#44; hip&#44; humerus or distal forearm fracture&#41; were calculated using the FRAX model for Ecuador &#40;version 4&#46;1&#41;&#46; Calculations were undertaken without the inclusion of femoral neck BMD&#46; The upper age limit for the calculation of FRAX probabilities is 90 years&#46; FRAX estimates for women age greater than 90 years was set at 90 &#40;28 women&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Intervention thresholds based on FRAX</span><p id="par0045" class="elsevierStylePara elsevierViewall">Two intervention thresholds were explored&#58; an age-specific threshold and a hybrid threshold&#44; shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0050" class="elsevierStylePara elsevierViewall">Age-specific thresholds</p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Many guidelines recommend that postmenopausal women with a prior fragility fracture may be considered for intervention without the necessity for a BMD test &#40;other than to monitor treatment&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;7&#44;9&#44;19</span></a> Given that a prior fracture was considered to carry a sufficient risk to recommend treatment&#44; the intervention threshold in women without a prior fracture can be set at the age-specific 10-year probability of a major fracture &#40;hip&#44; spine&#44; forearm or humerus&#41; equivalent to women with a prior fragility fracture&#46; The approach&#44; originally developed for NOGG&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">8</span></a> has been widely adopted&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;5&#44;7&#44;9</span></a> The same approach was used in the present study using the Ecuadorian FRAX model&#46; Body mass index was set at 25<span class="elsevierStyleHsp" style=""></span>kg&#47;m<span class="elsevierStyleSup">2</span>&#46;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hybrid threshold</p></li></ul></p><p id="par0065" class="elsevierStylePara elsevierViewall">With age-specific thresholds&#44; inequalities in access to therapy arose in the original NOGG guidelines especially at older ages &#40;&#8805;70 years&#41; depending on the presence or absence of a prior fracture&#46; An alternative threshold &#40;a fixed threshold from the age of 70 years&#41; reduced this disparity&#44; increased treatment access and decrease the need for bone densitometry&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">11</span></a> This &#8216;hybrid&#8217; threshold that combined age-dependent thresholds up to age 70 years and thereafter a fixed threshold with a single probability of fracture was subsequently adopted by NOGG&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">10</span></a> In the present study&#44; the same approach was used using the Ecuadorian FRAX model but with a fixed threshold from the age of 75 years&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Assessment thresholds for BMD testing</span><p id="par0070" class="elsevierStylePara elsevierViewall">Assessment thresholds for making recommendations for the measurement of BMD followed the approach of the UK and European guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">5&#44;7&#44;8</span></a> The two thresholds comprised&#58;</p><p id="par0075" class="elsevierStylePara elsevierViewall">A threshold probability below which neither treatment nor a BMD test should be considered &#40;lower assessment threshold&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">A threshold probability above which treatment may be recommended irrespective of BMD &#40;upper assessment threshold&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The lower assessment threshold was set to exclude a requirement for BMD testing in women without clinical risk factors&#44; as given in current European guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;7</span></a> It was therefore set to the age-specific 10-year probability of a major fracture equivalent to women with no clinical risk factors&#46; An upper threshold was chosen to minimize the probability that an individual&#44; characterized to be at high risk using clinical risk factors alone&#44; would be reclassified to be at low risk with additional information on BMD and vice versa&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a> The upper assessment threshold was set at 1&#46;2 times the intervention threshold&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Assessment strategy</span><p id="par0090" class="elsevierStylePara elsevierViewall">As noted above&#44; women with a prior fragility fracture were considered to be eligible for treatment without the need for further assessment&#46; In women without a previous fragility fracture&#44; the management strategy was based on the assessment of the 10-year probability of a major osteoporotic fracture &#40;MOF&#59; clinical spine&#44; hip&#44; forearm or humerus&#41;&#46; Women with probabilities below the lower assessment threshold were not considered eligible for treatment&#46; Women with probabilities above the upper assessment threshold were eligible for treatment&#46; Women with probabilities between the upper and lower assessment thresholds were to be referred for BMD measurements and their fracture probability reassessed&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Where BMD is not available&#44; FRAX can be used for the assessment of fracture probability&#46; The performance characteristics of FRAX without BMD are approximately equal to BMD without FRAX&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> Assessment strategies were additionally examined in the absence of BMD&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0100" class="elsevierStylePara elsevierViewall">The baseline characteristics are given in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The ten-year probability of MOF and hip fracture &#40;calculated without BMD&#41; is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46; The distribution of fracture probabilities was skewed to the left both for MOF and hip fracture &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The effect of simulation uplifted probabilities by more than 20&#37;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Thresholds</span><p id="par0105" class="elsevierStylePara elsevierViewall">The intervention threshold in women &#40;set at the age specific fracture probability equivalent to women with a prior fragility fracture&#41; rose with age from a 10-year probability of 1&#46;8&#37; at the age of 60 years to 12&#46;5&#37; at the age of 85 years &#40;<a class="elsevierStyleCrossRef" href="#sec0085">Supp Table 1 and Fig&#46; 1</a>&#41;&#46; At older ages&#44; the intervention threshold decreased due to the competing effect of mortality&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#sec0085">Supp Table 1 and Fig&#46; 1</a> also give the age-specific upper and lower assessment thresholds for recommending the measurement of BMD in the assessment of fracture probability&#46; At the age of 65 years&#44; for example&#44; a BMD test would not be recommended in an individual with a fracture probability below 1&#46;3&#37;&#46; At the same age&#44; a BMD test would be recommended with a fracture probability that lay between 1&#46;3 and 3&#46;1&#37;&#46; Treatment would be recommended without the requirement of a BMD test &#40;for fracture risk assessment&#44; though possibly for monitoring of treatment&#41; in individuals with a fracture probability that exceeded 3&#46;1&#37;&#46; In women in whom a BMD test was undertaken&#44; treatment would be recommended in those with a fracture probability that was 2&#46;6&#37; or greater&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Management pathway</span><p id="par0115" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#sec0085">Suppl Fig&#46; 1</a> shows the distribution of 10-year probabilities of a major osteoporotic fracture set against age-specific thresholds&#46; 87 women &#40;3&#46;7&#37;&#41; had a prior fracture and would thus be eligible for treatment&#46; 1131 women &#40;47&#46;8&#37;&#41; had probabilities above the lower assessment threshold but below the upper assessment threshold&#44; so that a BMD test would be recommended&#46; Treatment without the necessity for a BMD test could be recommended in 49 women &#40;2&#46;1&#37;&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the case of using a hybrid threshold&#44; 87 women &#40;3&#46;7&#37;&#41; had a prior fracture and would thus be eligible for treatment&#46; 1218 women &#40;51&#46;4&#37;&#41; had probabilities above the lower assessment threshold but below the upper assessment threshold&#44; so that a BMD test would be recommended&#46; Treatment without the necessity for a BMD test could be recommended in 170 women &#40;7&#46;2&#37;&#41;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">If treatment was allocated solely of FRAX without BMD &#40;excluding those with a prior fracture&#41;&#44; the number of women eligible for treatment was 111 with an age-specific intervention threshold and 354 with the hybrid threshold&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The disposition of the various scenarios is shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; The hybrid threshold allocated substantially more women to treatment than the age-specific threshold&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> gives the fracture probabilities in women eligible for treatment according to the categorisation&#46; Fracture probabilities were highest in those eligible for treatment on the basis of age-specific thresholds&#44; intermediate with the hybrid threshold and lowest in those with a prior fracture&#46; The table also provides the number of fractures expected in each category&#46; Including those with a prior fracture&#44; the age-specific threshold would identify 12 women who would sustain a MOF in the next 10 years including 7 hip fractures&#46; The hybrid threshold would identify 23 women who would sustain a MOF in the next 10 years including 15 hip fractures&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">In this report&#44; we present a method of categorizing women on the basis of fracture probabilities derived from FRAX&#46; The categories identified comprised those women at low risk&#44; those at intermediate risk in whom a BMD test might be recommended&#44; and those eligible for treatment&#46; The triage used was similar to that originally adopted by the National Osteoporosis Guideline Group &#40;NOGG&#41; in the UK and more recently in European guidelines&#44;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">1&#44;7&#8211;9</span></a> but applied to the FRAX model for Ecuador&#46; As noted above&#44; the intervention threshold was set at a fracture probability equivalent to a woman of the same age with a prior fragility fracture&#46; The rationale is that if women with a prior fragility fracture are considered eligible for treatment&#44; as commonly considered&#44; then women without fracture but with equivalent probabilities are also eligible for treatment&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The starting point in the assessment of women is the presence of a clinical risk factor that alerts the physician to consider osteoporosis&#46; The opportunistic case finding strategy arises because screening the general population is not widely recommended in Europe&#44; though advocated in North America&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">18&#44;19</span></a> In those eligible for assessment and in common with the NOGG guidelines&#44; we limited the use of BMD testing&#46; Those individuals with fracture probabilities equivalent or lower than women with no clinical risk factors &#40;as used in FRAX&#41; would not be assessed with BMD&#46; At the other extreme&#44; BMD testing was not universally recommended in individuals at high risk&#46; The rationale is that reclassification of risk with the addition of a BMD test &#40;from high risk to low risk and vice versa&#41; is high when fracture probabilities estimated without BMD are close to the intervention threshold but the likelihood of reclassification decreases the further away the probability estimate is from the intervention threshold&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">20</span></a> The approach used has been well validated in the UK and Canada&#46;<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">20&#44;22&#44;23</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">The attraction of this approach is that this makes efficient use of BMD resources&#46; The strategy implies&#44; however&#44; that patients at high risk&#44; but identified without BMD&#44; would respond to pharmacological intervention&#46; The evidence that such patients respond to treatment is strong&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">24&#8211;27</span></a> The principal reason is that BMD values are low in patients identified with FRAX but without a BMD test&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">From the present survey&#44; the proportion of the female population potentially eligible for treatment was 5&#46;8 or 10&#46;9&#37; depending on the intervention threshold that was applied &#40;age-specific or hybrid&#41;&#46; As would be expected&#44; the proportion of women eligible for treatment was higher with the application of the hybrid thresholds&#46; The proportion of women who would ultimately be treated would be higher&#46; Approximately 50&#37; of women would be recommended for a BMD test and an uncertain proportion of these would have fracture probabilities above the intervention threshold and be eligible&#44; therefore&#44; for treatment&#46; The uncertainty arises because BMD was not measured in this population sample&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">It should be noted that&#44; where facilities for BMD testing are limited&#44; FRAX can be used without BMD&#46; The performance characteristics of FRAX without BMD are approximately equivalent to BMD without FRAX&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">21</span></a> When applied to women in the present study&#44; those eligible for treatment increased by 46 or 71&#37; depending whether the age-specific or hybrid threshold was used&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The implementation of these thresholds is expected to avoid unnecessary treatment of individuals at low fracture risk and direct treatments to those at high risk but there are a number of limitations of the present study to consider&#46; First&#44; the cohort itself had missing variables for the calculation of FRAX which were simulated&#46; Simulation creates some uncertainty with regard to individual probabilities but improves the population estimate&#46; Indeed&#44; the quantum of effect of simulation on fracture probabilities was sufficiently marked that without it the treatment pathway could not have been assessed&#46; Several of the other FRAX variables provided limited information particularly the history of prior fracture&#46; This was limited to hip and forearm fractures in the previous year and would thus underestimate the prevalence of prior fragility fracture and hence&#44; the proportion of women eligible for treatment on this basis&#46; The approach to intervention thresholds is based on the principles of case finding and does not consider a health economic perspective&#46; Although the approach has been shown to be cost-effective in a UK setting&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">28</span></a> cost-effectiveness will necessarily differ in Ecuador because of different fracture risks and cost&#46; It will be important&#44; therefore&#44; to underpin these approaches to fracture risk assessment with an economic assessment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0170" class="elsevierStylePara elsevierViewall">The present study has shown that it is possible to apply FRAX-based assessment guidelines using the same principles that have been applied to guidelines elsewhere but tailored to the epidemiology of Ecuador&#46; The hybrid threshold identifies more women eligible for treatment than age-specific thresholds&#46; Although age-specific thresholds identify women at higher risk of fracture&#44; the lower number of women identified results in fewer identified fracture cases&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0175" class="elsevierStylePara elsevierViewall">None&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflict of interest</span><p id="par0180" 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">Intervention thresholds for the treatment of osteoporosis have been based historically on the measurement of bone mineral density&#46; The development of FRAX&#174; has permitted more accurate assessment of fracture risk&#46;</p></span> <span id="abst1015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1020">Objective</span><p id="spar1015" class="elsevierStyleSimplePara elsevierViewall">The aim of the present study was to explore treatment paths and characteristics of women eligible for treatment in Ecuador based on FRAX&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A total of 2367 women aged 60&#8211;94 years were selected from the National Health&#44; Welfare and Aging Survey &#40;SABE&#41; conducted in Ecuador&#46; Probabilities of major osteoporotic and hip fracture were computed using the Ecuadorian FRAX model&#46; The proportion of women eligible for treatment and bone mineral density assessment was determined based on age-specific intervention thresholds and a hybrid threshold was fixed from age 75 years&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 87 women &#40;3&#46;7&#37;&#41; had a prior fragility fracture and would be eligible for treatment for this reason&#46; An additional 49 women were eligible for treatment in that MOF probabilities lay above the upper assessment threshold using age-specific thresholds&#46; An BMD test would be recommended in 1131 women &#40;48&#37;&#41; so that FRAX could be recalculated with the inclusion of femoral neck BMD&#46; With the hybrid threshold&#44; an additional 170 women were eligible for treatment and an BMD test recommended in 1218 women&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The hybrid threshold identifies more women eligible for treatment than age-specific thresholds&#46; Although age-specific thresholds identify women at higher risk of fracture&#44; the lower number of women identified results in fewer identified fracture cases&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los umbrales de intervenci&#243;n para el tratamiento de osteoporosis se han basado hist&#243;ricamente en la medici&#243;n de la densidad &#243;sea&#46; El desarrollo del FRAX&#174; ha permitido una evaluaci&#243;n m&#225;s precisa del riesgo de fractura&#46;</p></span> <span id="abst1030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1040">Objetivo</span><p id="spar1030" class="elsevierStyleSimplePara elsevierViewall">El objetivo del estudio fue explorar las rutas de tratamiento y las caracter&#237;sticas de las mujeres elegibles para tratamiento en Ecuador con base en FRAX&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Materiales y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se seleccion&#243; a 2&#46;367 mujeres de 60 a 94 a&#241;os de la encuesta SABE&#46; Se calcularon las probabilidades de fracturas osteopor&#243;ticas principales y de cadera utilizando el modelo FRAX ecuatoriano&#46; Se calcul&#243; la proporci&#243;n de mujeres elegibles para tratamiento y evaluaci&#243;n de la densidad &#243;sea&#44; con base en umbrales de intervenci&#243;n espec&#237;ficos de la edad y de un umbral fijo a partir de los 75 a&#241;os&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Ochenta y siete mujeres &#40;3&#44;7&#37;&#41; ten&#237;an una fractura previa y eran elegibles para tratamiento&#46; Utilizando umbrales espec&#237;ficos de edad&#44; otras 49 mujeres eran elegibles para recibir tratamiento debido a que las probabilidades de fractura osteopor&#243;tica principal estaban por encima del umbral de evaluaci&#243;n superior&#46; Se recomienda medir la densidad &#243;sea en 1&#46;131 mujeres para que el FRAX pueda ser recalculado con la inclusi&#243;n de la densidad &#243;sea del cuello femoral&#46; Con el umbral h&#237;brido&#44; otras 170 mujeres fueron elegibles para tratamiento y la medici&#243;n de la densidad &#243;sea se recomend&#243; a 1&#46;218 mujeres&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El umbral h&#237;brido identifica a m&#225;s mujeres elegibles para tratamiento que los umbrales espec&#237;ficos de la edad&#46; Aunque estos &#250;ltimos identifican a las mujeres con mayor riesgo de fractura&#44; el menor n&#250;mero de mujeres identificadas resulta en menos casos de fractura identificados&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst1030"
            "titulo" => "Objetivo"
          ]
          2 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Materiales y m&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0195" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0085"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1249
            "Ancho" => 2500
            "Tamanyo" => 250037
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Graphs of intervention and assessment thresholds showing the original &#40;left&#41; and current &#40;right&#41; NOGG thresholds applied to the FRAX model for Ecuador&#46; The dotted line represents the intervention threshold while the assessment thresholds enclose the amber area &#40;see text for details&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1132
            "Ancho" => 2167
            "Tamanyo" => 123593
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Distribution of probabilities for major osteoporotic fracture &#40;MOF&#41; and hip fracture including simulated variables&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1951
            "Ancho" => 2925
            "Tamanyo" => 238435
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Disposition of women assessed for fracture risk using age-specific or hybrid intervention and assessment thresholds&#46; The bars on the left predicate the subsequent use of BMD in those at intermediate risk&#46; Those on the right direct treatment only using FRAX without BMD&#46;</p>"
        ]
      ]
      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:2 [
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
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                  <table border="0" frame="\n
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                  \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">&nbsp;\t\t\t\t\t\t\n
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                  \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">Mean&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&nbsp;\t\t\t\t\t\t\n
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                  \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"><span class="elsevierStyleItalic">n</span>&nbsp;\t\t\t\t\t\t\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" scope="col" style="border-bottom: 2px solid black">&#37;&nbsp;\t\t\t\t\t\t\n
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                  \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">Age &#40;years&#41;&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">70&#46;9&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;8&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41;&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\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 fracture&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;7&nbsp;\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">Current smoking&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">65&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;7&nbsp;\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">Secondary osteoporosis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">289&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;2&nbsp;\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">Alcohol 3 or more units per day&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;7&nbsp;\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">Parental history of hip fracture<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">147&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;2&nbsp;\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">Glucocorticoid exposure<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">117&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;9&nbsp;\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">Rheumatoid arthritis<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">101&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">4&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Summary description of the baseline variables in women age 60 years or more &#40;<span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2367&#41;&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ten-year probability &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&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
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hip fracture&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;6&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#8211;44&#46;8&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&#8211;1&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
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                  \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&#46;4&#8211;49&#46;2&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;1&#8211;4&#46;1&nbsp;\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  " colspan="6" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Without simulation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hip fracture&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;5&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\ttop\n
                  \t\t\t\t">0&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0&#8211;9&#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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;3&#8211;2&#46;0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>MOF&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">2&#46;9&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&#46;3&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">0&#46;0&#8211;13&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;3&#8211;4&#46;8&nbsp;\t\t\t\t\t\t\n
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                  <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-with-role" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col">Criterion for treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
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                  \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">SD&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fractures&nbsp;\t\t\t\t\t\t\n
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                  \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">Mean&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SD&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Fractures&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Prior fracture&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">87&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;86&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7&#46;12&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#46;60&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6&#46;27&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\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">Age-specific&nbsp;\t\t\t\t\t\t\n
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                  \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">49&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;06&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;82&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">8&#46;91&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
                  \t\t\t\t\ttop\n
                  \t\t\t\t">5&#46;56&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">4&nbsp;\t\t\t\t\t\t\n
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                  \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">Hybrid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">170&nbsp;\t\t\t\t\t\t\n
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ISSN: 01218123
Original language: English
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