***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: Summary We have developed clinical nomograms for predicting 5-year and 10-year fracture risks for any elderly man or woman . The nomograms used age and information concerning fracture history , fall history , and BMD T-score or body weight . Introduction Although many fracture risk factors have been identified , the translation of these risk factors into a prognostic model that can be used in primary care setting has not been well realized . The present study sought to develop a nomogram that incorporates non-invasive risk factors to predict 5-year and 10-year absolute fracture risks for an individual man and woman . Methods The Dubbo Osteoporosis Epidemiology Study was design ed as a community-based prospect i ve study , with 1358 women and 858 men aged 60 + years as at 1989 . Baseline measurements included femoral neck bone mineral density ( FNBMD ) , prior fracture , a history of falls and body weight .  Between 1989 and 2004 , 426 women and 149 men had sustained a low-trauma fracture ( not including morphometric vertebral fractures ) . Two prognostic models based on the Cox ’s proportional hazards analysis were considered : model I included  age , BMD , prior fracture and falls ;  and model II included  age , weight , prior fracture and fall  . Results Analysis of the area under the receiver operating characteristic curve ( AUC ) suggested that model I ( AUC = 0.75 for both sexes ) performed better than model II ( AUC = 0.72 for women and 0.74 for men ) . Using the models ’ estimates , we constructred various nomograms for individualizing the risk of fracture for men and women . If the 5-year risk of 10 % or greater is considered “ high risk ” , then virtually all 80-year-old men with BMD T-scores < -1.0 or 80-year-old women with T-scores < -2.0 were predicted to be in the high risk group . A 60-year-old woman ’s risk was considered high risk only if her BMD T-scores ≤-2.5 and with a prior fracture ; however , no 60-year-old men would be in the high risk regardless of their BMD and risk profile . Conclusion These data suggest that the assessment of fracture risk for an individual can not be based on BMD alone , since there are clearly various combinations of factors that could substantially elevate an individual ’s risk of fracture . The nomograms presented here can be useful for individualizing the short- and intermediate-term risk of fracture and identifying high-risk individuals for intervention to reduce the burden of fracture in the general population PURPOSE To assess the ability of the Spanish version of the WHO fracture risk assessment tool ( FRAX ® ) to predict the observed incident fractures in the ECOSAP Study cohort . METHODS 5201 women , aged 65 or older , were enrolled in a three-year , prospect i ve study by a non-r and omized sampling of consecutive cases in 58 primary care centers in Spain . Participants completed an osteoporosis and fracture risk question naire and attended follow-up visits every 6 months . All radiologically or surgically confirmed low-trauma , non-spinal fractures were collected . The individual 10-year absolute risks of hip and major osteoporotic fractures were calculated with the FRAX ® algorithms for Spain without the inclusion of the bone mineral density ( BMD ) measurements . Calibration was evaluated by comparing the three-year estimated ( E ) fractures predicted with FRAX ® with the number of observed ( O ) fractures , and their discriminative ability for the probability of new fractures with the area under the receiving operating characteristic ( ROC ) curves . RESULTS Fifty ( 0.96 % ) women sustained an incident hip fracture , and 201 ( 3.81 % ) women presented with major osteoporotic fractures ( hip , forearm or humerus ) . The E/O ratios for hip and major osteoporotic fractures were 1.10 and 0.66 respectively . Clinical vertebral fractures were not collected ; therefore , the E/O ratio for major fractures should be expected to be lower . The difference between E and O cases reached statistical significance ( χ(2 ) , p<0.001 ) . Areas under the ROC curves were 0.640 and 0.615 for hip and major osteoporotic fractures respectively . CONCLUSIONS The Spanish FRAX ® underestimates the risk for major osteoporotic fractures . The estimated risk for hip fractures was similar to the observed fractures ; however the algorithm had only modest discriminative ability . These results should be interpreted in the context of the relatively low number of observed fractures , especially at the hip Objective To evaluate the performance of the QFractureScores for predicting the 10 year risk of osteoporotic and hip fractures in an independent UK cohort of patients from general practice records . Design Prospect i ve cohort study . Setting 364 UK general practice s contributing to The Health Improvement Network ( THIN ) data base . Participants 2.2 million adults registered with a general practice between 27 June 1994 and 30 June 2008 , aged 30 - 85 ( 13 million person years ) , with 25 208 osteoporotic fractures and 12 188 hip fractures . Main outcome measures First ( incident ) diagnosis of osteoporotic fracture ( vertebra , distal radius , or hip ) and incident hip fracture recorded in general practice records . Results Results from this independent and external validation of QFractureScores indicated good performance data for both osteoporotic and hip fracture end points . Discrimination and calibration statistics were comparable to those reported in the internal validation of QFractureScores . The hip fracture score had better performance data for both women and men . It explained 63 % of the variation in women and 60 % of the variation in men , with areas under the receiver operating characteristic curve of 0.89 and 0.86 , respectively . The risk score for osteoporotic fracture explained 49 % of the variation in women and 38 % of the variation in men , with corresponding areas under the receiver operating characteristic curve of 0.82 and 0.74 . QFractureScores were well calibrated , with predicted risks closely matching those across all 10ths of risk and for all age groups . Conclusion QFractureScores are useful tools for predicting the 10 year risk of osteoporotic and hip fractures in patients in the United Kingdom The World Health Organization ( WHO ) Fracture Risk Assessment Tool ( FRAX ) computes 10-year probability of major osteoporotic fracture from multiple risk factors , including femoral neck ( FN ) T-scores . Lumbar spine ( LS ) measurements are not currently part of the FRAX formulation but are used widely in clinical practice , and this creates confusion when there is spine-hip discordance . Our objective was to develop a hybrid 10-year absolute fracture risk assessment system in which nonvertebral ( NV ) fracture risk was assessed from the FN and clinical vertebral ( V ) fracture risk was assessed from the LS . We identified 37,032 women age 45 years and older undergoing baseline FN and LS dual-energy X-ray absorptiometry ( DXA ; 1990 - 2005 ) from a population data base that contains all clinical DXA results for the Province of Manitoba , Canada . Results were linked to longitudinal health service records for physician billings and hospitalizations to identify nontrauma vertebral and nonvertebral fracture codes after bone mineral density ( BMD ) testing . The population was r and omly divided into equal-sized derivation and validation cohorts . Using the derivation cohort , three fracture risk prediction systems were created from Cox proportional hazards models ( adjusted for age and multiple FRAX risk factors ) : FN to predict combined all fractures , FN to predict nonvertebral fractures , and LS to predict vertebral ( without nonvertebral ) fractures . The hybrid system was the sum of nonvertebral risk from the FN model and vertebral risk from the LS model . The FN and hybrid systems were both strongly predictive of overall fracture risk ( p < .001 ) . In the validation cohort , ROC analysis showed marginally better performance of the hybrid system versus the FN system for overall fracture prediction ( p = .24 ) and significantly better performance for vertebral fracture prediction ( p < .001 ) . In a discordance subgroup with  FN and LS T-score differences greater than 1 SD , there was a significant improvement in overall fracture prediction with the hybrid method ( p = .025 ) . Risk reclassification under the hybrid system showed better alignment with observed fracture risk , with 6.4 % of the women reclassified to a different risk category . In conclusion , a hybrid 10-year absolute fracture risk assessment system based on combining FN and LS information is feasible . The improvement in fracture risk prediction is small but supports clinical interest in a system that integrates LS in fracture risk assessment Background One in four Swedish women suffers a hip fracture yielding high morbidity and mortality . We wanted to revali date a 4-item clinical risk score and evaluate a portable heel bone mineral density ( BMD ) technique regarding hip and fragility fracture risk among elderly women . Methods In a population -based prospect i ve cohort study we used clinical risk factors from a baseline question naire and heel BMD to predict a two-year hip and fragility fracture outcome for women , in a fracture preventive program . Calcaneal heel BMD was measured by portable dual X-ray laser absorptiometry ( DXL ) and compared to hip BMD , measured with stationary dual X-ray absorptiometry ( DXA ) technique . Results Seven women suffered hip fracture and 14 women fragility fracture/s ( at hip , radius , humerus and pelvis ) among 285 women ; 60 % having heel BMD ≤ -2.5 SD . The 4-item FRAMO ( Fracture and Mortality ) Index combined the clinical risk factors age ≥80 years , weight < 60 kg , prior fragility fracture , and impaired rise-up ability . Women having 2 - 4 risk factors showed odds ratio ( OR ) for hip fracture of 5.9 and fragility fracture of 4.4 . High risk group hip fracture risk was 2.8 % annually compared to 0.5 % for the low risk majority ( 69 % ) . Heel BMD showed hip fracture OR of 3.1 and fragility fracture OR of 2.6 per SD decrease . For 30 DXA assessed participants mean hip BMD at -2.5 SD level corresponded to a lower BMD at the heel . Five of seven hip fractures occurred within a small risk group of 32 women , identified by high FRAMO Index + prior fragility fracture + heel T-score ≤-3.5 SD . Conclusions In a follow-up study we identified high risk groups for hip and fragility fracture with our plain 4-item risk model . Increased fracture risk was also related to decreasing heel BMD in calcaneal bone , measured with a mobile DXL technique . A combination of high FRAMO Index , prior fragility fracture , and very low BMD restricted the high risk group to 11 % , among whom most hip fractures occurred ( 71 % ) . These practical screening methods could eventually reduce hip fracture incidence by concentrating preventive re sources to high fracture risk women Summary A new Canadian WHO fracture risk assessment ( FRAX ® ) tool to predict 10-year fracture probability was compared with observed 10-year fracture outcomes in a large Canadian population -based study ( CaMos ) . The Canadian FRAX tool showed good calibration and discrimination for both hip and major osteoporotic fractures . Introduction The purpose of this study was to vali date a new Canadian WHO fracture risk assessment ( FRAX ® ) tool in a prospect i ve , population -based cohort , the Canadian Multicentre Osteoporosis Study ( CaMos ) . Methods A FRAX tool calibrated to the Canadian population was developed by the WHO Collaborating Centre for Metabolic Bone Diseases using national hip fracture and mortality data . Ten-year FRAX probabilities with and without bone mineral density ( BMD ) were derived for CaMos women ( N = 4,778 ) and men ( N = 1,919 ) and compared with observed fracture outcomes to 10 years ( Kaplan – Meier method ) . Cox proportional hazard models were used to investigate the contribution of individual FRAX variables . Results Mean overall 10-year FRAX probability with BMD for major osteoporotic fractures was not significantly different from the observed value in men [ predicted 5.4 % vs. observed 6.4 % ( 95%CI 5.2–7.5 % ) ] and only slightly lower in women [ predicted 10.8 % vs. observed 12.0 % ( 95%CI 11.0–12.9 % ) ] . FRAX was well calibrated for hip fracture assessment in women [ predicted 2.7 % vs. observed 2.7 % ( 95%CI 2.2–3.2 % ) ] but underestimated risk in men [ predicted 1.3 % vs. observed 2.4 % ( 95%CI 1.7–3.1 % ) ] . FRAX  with BMD showed better fracture discrimination  than FRAX  without BMD or BMD alone . Age , body mass index , prior fragility fracture and femoral neck BMD were significant independent predictors of major osteoporotic fractures ; sex , age , prior fragility fracture and femoral neck BMD were significant independent predictors of hip fractures . Conclusion The Canadian FRAX tool provides predictions consistent with observed 
    Output:
    
Most of the 13 tools are feasible in clinical practice .
FRAX has the largest number of externally vali date d and independent studies .
Significant method ological limitations were observed in many studies , suggesting caution when comparing tools based solely on the AUC