Helena T. Johansson

FRAX®, a risk calculator that provides individualized 10-year probabilities of hip and major osteoporotic fracture, has been widely used for fracture risk assessment since its launch in 2008. It is now incorporated into very many guidelines worldwide to inform osteoporosis management. In this review, we explore the development of FRAX and how it enhances fracture risk prediction as compared to use of bone mineral density alone, as well as approaches to utilizing FRAX in determining intervention and assessment thresholds. We also discuss the limitations of FRAX and the arithmetic adjustments that have been proposed to address these. The introduction of FRAXplus® includes these adjustments on a web-based platform for ease of application to enhance treatment decisions in osteoporosis.

: Using data from a meta-analysis including 606,715 women, we found that the predictive value of a fall the past year for future hip fractures in women significantly decreases with age, resulting in a diminishing population attributable risk with increasing age. Objective: In a recent meta-analysis of 40 cohorts, we demonstrated that a fall history in the past year was associated with an increased risk of hip fracture. An interaction between fall history and age was observed in women, with lower hazard ratios (HR) for older women. This study aimed to determine the population-attributable risk (PAR) for hip fracture due to increased fall risk in women of different ages. Methods: Fall history associated attributable risk (AR, %) for hip fracture was calculated [100·(1-1/relative risk (HR))] for women per age stratum, using previously calculated HRs. PAR (%) of hip fractures in the female population (≥ 50 years) that could be prevented if the fall history-mediated risk increase could be eliminated was calculated as 100·Pexp·(HR-1)/[1 + Pexp·(HR-1)] where Pexp was the exposed proportion of the population (i.e. the proportion with past falls). Results: A total of 606,715 women included from 40 cohorts, with fall risk documented in the past year (fall history yes/no or 2 or more falls) and prospective information about hip fracture and death, were analysed. The proportion of fallers increased progressively with age from 24.6% at age 50-54 years to 45.5% at age 90-94 years. In contrast, the AR due to falls decreased, from 54.8% at age 50-54 years to 8.3% at age 90-94 years, and the PAR diminished with age, from 23.9% in women 50-54 years old to 3.9% in women 90-94 years old. Conclusions: As falls become more common with age, their predictive value for future hip fractures in women significantly decreases. This suggests that the effectiveness of fall prevention strategies in reducing hip fractures is lower in older women, who are at higher risk for serious falls and hip fractures.

FRAXplus® facilitates adjustment of FRAX® fracture probabilities for additional clinical risk factors. This study examined how FRAXplus adjustments affect the proportion of older Swedish women eligible for treatment at a major osteoporotic fracture (MOF) probability intervention threshold (IT) ≥ 26%. Background: FRAXplus enables adjustments based on additional clinical information, such as recency of osteoporotic fractures, high-dose oral glucocorticoids, T2DM duration, lumbar spine (LS) bone mineral density (BMD), trabecular bone score (TBS), falls in the previous year, and hip axis length. We aimed to determine how these adjustments alter treatment eligibility in older Swedish women. Methods: Ten-year fracture probabilities with femoral neck BMD were calculated using FRAX and adjusted by FRAXplus in the SUPERB cohort of 3028 Swedish women aged 75 to 80 years. Clinical risk factors (CRFs) and outcomes were collected via questionnaires and national registers over 8 years, with incident X-ray-verified MOFs. FRAXplus adjustments were applied one factor at a time; if multiple were available, the most influential factor was used. Net reclassification improvement (NRI) was calculated. Results: Overall, 90% (n = 2723) had their 10-year MOF probability adjusted upwards, with a mean (± SD) change of 4.25% (5.12%). Common adjustments included HAL (31%), TBS (23%), falls (20%), LS BMD (8%), and recent fracture (5%). Similar patterns were observed for hip fracture probabilities. Among those below the IT using FRAX alone, 1785 remained below, with 365 (20.4%) experiencing incident MOFs. Of 339 women uplifted above the IT using FRAXplus, 119 (35.1%) sustained incident MOFs. Among 904 above the IT with both FRAX and FRAXplus, 324 (35.8%) experienced incident MOFs. The NRI was 4.82% (95% CI: 1.87-7.77%; p < 0.01). Conclusions: FRAXplus improved risk stratification, with a significant proportion of older Swedish women having their fracture probabilities uplifted above the IT, more accurately reflecting their elevated fracture risk, thereby enhancing the utility of risk assessment tools and improving patient management.

Chronic Obstructive Pulmonary Disease (COPD) is an irreversible lung disease. People with COPD and their next of kin are affected in daily life and need support from each other, health care, and the surrounding society. This systematic integrative review aims to identify which support is given to persons affected by COPD and/or their next of kin from the health care and surrounding society. A second aim was to evaluate the support. A systematic integrative review was conducted to aggregate the knowledge by searching PubMed, CINAHL, PsycINFO, Scopus, and Web of Science databases. Search terms were chronic obstructive pulmonary disease (COPD) and support. The time limit was 2014-2023. The review protocol was registered on PROSPERO (CRD42023462784). The inclusion was selected from the aim, and quality review instruments checked quality. The result was analyzed with a constant comparison method. Persons with COPD receive support from their next of kin, practically and emotionally. Health care also supplies support through information, knowledge, and different training programs. Health care can be in all types of health care, from hospital and primary care to care in the home, all with varying types of support. The next of kin supplies support to their sick relative, becomes support from health care on a small scale, and wishes for more information, knowledge, and understanding about the disease, symptoms, and treatment. The sick person and their carer want to be acknowledged and supported more on their terms. Support for next of kin is virtually non-existent. Next of kin needs more support from health care and the surrounding society. Healthcare interventions in the future need to involve the person with COPD and the next of kin in a person-centered approach out of every person´s needs and support more on their terms.

Spasticity is characterized by increased muscle tone, which can result in pain, contractures, impaired hygiene, and deformities. Stroke is a leading cause of paresis, and nearly 40% of stroke patients will develop spasticity. Objective: To assess trends in upper and lower extremity spasticity-reducing surgery and botulinum toxin A (BoNT-A) treatment. Methods: A national cohort register study. Methods: Upper and lower extremity spasticity-reducing surgery and BoNT-A treatment in Swedish stroke patients over a 12-year period was assessed using the National Patient Register. Results: A total of 6,258 patients were treated during this period; their mean age was 58, and the majority were male. In both upper and lower extremities, tenotomy was the most common surgical procedure, followed by tendon lengthening. The need for BoNT-A injections was significantly reduced after surgery compared with before surgery. The total number of BoNT-A treatments increased during the study period, and ultrasound guidance of injections became more common. Conclusions: The frequency of BoNT-A treatments was significantly reduced in patients who underwent surgery. Even though no causative association can be established due to the nature of these registry data, this may indicate that surgery reduces the need for further BoNT-A treatments.