***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Osteoporosis-related fractures are associated with reductions in health-related quality of life ( HRQL ) . We examined the benefits of zoledronic acid ( ZOL ) on HRQL in patients sustaining vertebral and clinical fractures from HORIZON-Pivotal Fracture Trial using mini-Osteoporosis quality of life Question naire ( OQLQ ) . In this multicenter , double-blind , placebo-controlled trial , 1434 patients from a cohort of postmenopausal women with osteoporosis ( mean age 73years ) were r and omized to receive annual infusions of ZOL 5 mg or placebo for 3years . Baseline HRQL scores were comparable between ZOL and placebo groups based on the presence or absence of fractures , with exception of prevalent vertebral fractures where patients ( irrespective of the treatment group ) had lower baseline HRQL scores than those without prevalent vertebral fractures . Greater number of prevalent vertebral fractures was associated with lower baseline HRQL ( p<0.001 ) . No significant difference between ZOL and placebo in the overall summary score was observed but a significant benefit was noted in certain domains with ZOL , especially in patients sustaining incident clinical fractures . Improvements in HRQL were marked at first assessment after a morphometric vertebral fracture with significant differences favouring ZOL in pain ( p=0.0115 ) , st and ing pain ( p=0.0125 ) ) , physical ( lifting , p=0.0333 ) and emotional function ( fear of fractures , p=0.0243 ; fear of falls , p=0.0075 ) but not for activities of daily living or leisure domains . HRQL is reduced in patients with vertebral fractures . Treatment with ZOL over 3years was associated with improvements in specific domains of quality of life vs. placebo , particularly in patients sustaining incident fractures The construction of reference ranges that accurately represent the population at large is essential for the correct identification of osteoporosis from bone mineral density ( BMD ) measurements . In this study , reference data supplied by the manufacturer of the Lunar DPX+ bone densitometer were compared with data obtained locally . Lumbar spine , proximal femur and total body BMD measurements were made in an age-stratified r and om sample of 702 Southampton women aged 20 to 89 years . Relevant demographic and medical data were recorded for each subject using a question naire . Reference curves of BMD ( mean + /- SD ) were plotted against age for each measurement site and were found to be higher than the manufacturer 's reference values at all ages and sites . Exclusion of women with factors known to affect bone mass only served to increase this discrepancy . According to World Health Organisation definitions , osteoporosis may be identified from BMD values alone . Based upon neck of femur BMD values , 100 ( 14.8 % ) of the women in this study group were categorized as osteoporotic using local young normal reference data , compared with only 39 ( 5.8 % ) using the manufacturer 's data . By normalizing for age distribution , these findings were extrapolated to the local population where it was predicted that 26.0 % and 10.1 % of females over 50 years of age would be classified as osteoporotic using the respective reference ranges . This study clearly illustrates how the numbers of women diagnosed as osteoporotic vary with the use of different reference population Background The aim of this study is to vali date the question naire ECOS-16 ( Assessment of health related quality of life in osteoporosis ) for the evaluation of health related quality of life ( HRQoL ) in post-menopausal women with osteoporosis . Methods An observational , prospect i ve and multi-centre study was carried out among post-menopausal women with osteoporosis in primary care centres and hospital outpatient clinics . All patients attended 2 visits : at baseline and at 6 months . In addition , the subgroup of out patients attended another visit a month after the baseline to assess the test-retest reliability . The psychometric properties of the question naire were evaluated in terms of feasibility , validity ( content validity and construct validity ) and internal consistency in baseline , and in terms of test-retest reliability and responsiveness to change in visit at month and visit at 6 months , respectively . In all visits , ECOS-16 , EUROQoL-5D ( EQ-5D ) and four 7-point items about health status ( general health status , back pain , limitation in daily activities and emotional status ) were administered , whereas only out patients were given MINI-OQLQ ( Mini Osteoporosis Quality of Life Question naire ) , besides all clinical variables ; and sociodemographic variables at baseline . Results 316 women were consecutively included , 212 from primary care centres and 104 from hospital outpatient clinics . Feasibility : 94.3 % of patients answered all items of the question naire . The mean administration time was 12.3 minutes . Validity : factor analysis suggested that the question naire was unidimensional . In the multivariate analysis , patients with vertebral fractures , co-morbidity and a lower education level showed to have worse HRQoL. Moderate to high correlations were found between the ECOS-16 score and the other health status question naires ( 0.47–0.82 ) . Reliability : internal consistency ( Cronbach 's α ) was 0.92 and test-retest reliability ( ICC ) was 0.80 . Responsiveness to change : ECOS-16 scores increased according to change perceived by the patient , as well as the effect size ( ranges between 1.35 to 0.43 ) , the greater the perception of change in patients ' general health status , the greater the changes in patients ' scores . The Minimal Clinical ly Important Difference ( MCID ) suggested a change of 0.5 points in the ECOS-16 score , representing the least improvement in general health status due to their osteoporosis : " slightly better " . Conclusion ECOS-16 has been proven preliminarily to have good psychometric properties , so that it can be potentially a useful tool to evaluate HRQoL of post-menopausal women with osteoporosis in research and routine clinical practice Objectives : There have been no studies of generic health-related quality of life ( HR-QOL ) measured prospect ively , in patients referred for bone mass measurement . The aim of this study was to examine the relationship between HR-QOL , measured before DXA scanning was undertaken , and bone mineral density ( BMD ) . Comparison of HR-QOL with the age- and sex-matched general population was also made . Design : HR-QOL question naires were completed by patients who were being entered into a r and omized , prospect i ve , parallel group trial to assess the impact of direct access DXA scanning ( DADS ) versus referral to a hospital consultant , upon clinical decision making by general practitioners ( GPs ) ( Dhillon et al. , Osteoporos Int 14:326–333 , 2003 ) . HR-QOL question naires were completed prior to both r and omization and DXA scanning . Participants : 325 patients from18 representative general practice s of a total of 77 in the city of Edinburgh . Patients had been referred by their GPs who had access to national guidelines on the identification of patients at high risk of osteoporosis . Outcome measures : Generic HR-QOL was measured using Euroqol ( EQ5D ) . This provides a profile of self-reported problems in five dimensions ( EQ5Dprofile ) , health utility ( EQ5Dutility ) , and a visual analogue global self-rated health assessment ( EQ5Dvas ) . Results : Odds ratios ( ORs ) for any self-reported problems on EQ5Dprofile were higher in patients with osteoporosis than those without , and compared with the general population . Age-adjusted mean ( SD ) EQ5Dutility was significantly lower in patients with osteoporosis than in those without ( 0.65 [ 0.28 ] vs 0.76 [ 0.27 ] ; p<0.01 ) , but the difference lessened with advancing age . Age-adjusted mean ( SD ) EQ5Dvas was significantly reduced in patients with compared with no osteoporosis ( 68 [ 20 ] vs 76 [ 16 ] ; p<0.01 ) . There were no such differences in patients with a history of prior fracture compared with those without a history of prior fracture . Conclusions : Female patients with osteoporosis have reduced generic HR-QOL compared with the age-matched female general population , irrespective of a history of prior fracture . The causal relationship between osteoporosis and HR-QOL , if any , is unclear . Further studies are needed to define this relationship and to determine whether treatment of osteoporosis has a beneficial effect on HR-QOL independent of fracture risk Data are scarce on the impact of vertebral fractures ( VFX ) on utility . The objective of this study was to assess the impact of prevalent and incident VFX on utility in both a patient-based and population -based sample . Data from the Multiple Outcomes of Raloxifene Evaluation ( MORE ) study ( n = 550 for prevalent VFX and n = 174 for incident VFX ) and the European Prospect i ve Osteoporosis Study ( EPOS ) ( n = 236 ) were used .  Utility was assessed by the index score of the EQ-5D . In the MORE study , highly statistically significant associations were found between utility and the presence of prevalent VFX ( p < 0.001 ) , number of prevalent VFX ( p < 0.001 ) , severity of prevalent VFX ( p < 0.001 ) , the combination of number and severity of prevalent VFX ( p = 0.001 ) and location of prevalent VFX ( p = 0.019 ) . The mean utility was significantly lower among women who suffered an incident VFX ( utility = 0.67 ) than among women who did not ( utility = 0.77 ) ( p = 0.005 ) , although utility loss was not significantly different between the two groups ( p = 0.142 ) . In EPOS , the combination of number and severity of incident VFX was significantly related to utility ( p = 0.030 ) . In conclusion , utility is lower among persons with prevalent and incident VFX , especially in a patient-based sample . Utility loss was not significantly different between women without and with incident VFX Although the long-term outcomes of osteoporosis ( Op ) such as fracture , kyphosis , and pain are well known , the physical , psychological , and social consequences , beyond fracture and pain , are less clear . The Osteoporosis-targeted Quality -of-life ( OPTQoL ) question naire aim ed at assessing the physical difficulty , fears , and adaptations to one 's daily life was developed as a cross-sectional instrument to characterize the burden of Op within a community . The purpose of this study was to assess the impact of Op and related factors on community women participating in the OFELY study in France .  Femoral neck bone mineral density ( BMD ) and  OPTQoL question  naire data were collected from women r and omly selected from a large insurance company . Data were obtained for 756 women ( mean age 59 years , range 36 - 92 ) , most of whom were white . Women were classified into five groups based on the extent of physical manifestations and family history of Op . Women who had prior fractures , height loss , and /or kyphosis or both reported greater physical difficulty , more adaptations to their lives , and greater fears than women reporting no such changes . Scores on the Physical Difficulty domain , however , did not differ significantly based on BMD alone ( BMD T score < or=2.5 ) , after controlling for age and self-reported arthritis . The negative impact of Op on quality -of-life ( QoL ) seems to be more related to the physical manifestations of Op than to bone density levels . Recognition of the impact of Op-related factors on QoL may help health-care providers more fully appreciate the importance of prevention and treatment Fractures and subsequent morbidity determine the impact of established postmenopausal osteoporosis .  Health-related quality of life ( HRQOL ) has become an important outcome criterion in the assessment and follow-up of osteoporotic patients . As part of the baseline measurements of the Multiple Outcomes of Raloxifene Evaluation ( MORE ) study , HRQOL was assessed in 751 osteoporotic ( bone mineral density [ BMD ] T score > or = -2.5 ) women from Europe with or without vertebral fractures ( VFX ) . This was done using the  quality of life question naire of the European Foundation for Osteoporosis ( QUALEFFO ) , Nottingham Health Profile ( NHP ) and the EQ-5D ( former EuroQol ) . QUALEFFO contains questions in five domains : pain , physical function , social function , general health perception , and mental function . Each domain score and QUALEFFO total scores are expressed on a 100-point scale , with 0 corresponding to the best HRQOL . In comparison with patients without VFX , those with VFX were older ( 66.2 + /- 5.9 years vs. 68.8 + /- 6.3 years ; p < 0.001 ) , had higher prevalence of nonvertebral fractures ( 25 % vs. 36 % ; p = 0.002 ) , and higher QUALEFFO scores ( worse HRQOL ; total score , 26 + /- 14 vs. 36 + /- 17 ; p < 0.001 ) . QUALEFFO scores increased progressively with increasing number of VFX , especially lumbar fractures ( p < 0.001 ) . Patients with a single VFX already had a significant increase in QUALEFFO scores 
    Output:
    
Using Qualeffo-41 , pain and physical function were worse in these patients .
Also , HRQoL was related to upper femur , but not lumbar spine BMD .
HRQoL data in patients with osteoporosis without VFX are limited and variable but suggest that HRQoL is adversely affected by osteoporosis in the absence of VFX .
The association of lower BMD and worse HRQoL suggests that more attention should be paid to HRQoL in those without VFX .