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Figure 13. Meta-analysis of fracture prediction using different bne density measurement sites. (Adapted from Marshall D: BMJ 1996; 312:1254-1259)

Patient-related factors also need to be considered in the timing of repeat testing, including the average rate of expected bone loss and the maximum rate of loss that is likely to be encountered. The latter is critical since follow-up bone mass measurements should ideally identify patients who are failing treatment before substantial bone loss develops or fractures occur. Average rates of bone loss are greater in untreated early postmenopausal women (approximately 2% per year) than in older women (less than one percent per year). The site of most rapid bone loss also changes with age. Loss of trabecular bone from the spine exceeds that of the hip in early postmenopausal women. Similarly, increase in skeletal mass from antiresorptive treatment is usually most evident in the spine due to the relatively faster turnover of trabecular bone. For untreated older subjects the decline in the hip generally exceeds that of the spine due to the development of age-related degenerative artifacts in the spine. It should be emphasized that measurement imprecision makes it difficult to accurately assess loss rates in individuals. These have been stated to exceed 5% per year in some cases but the frequency of such rapid loss in the absence of major medical factors (such as high-dose steroid therapy) is unclear. It is likely that active

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Figure 14. A 70-year-old woman has bone density measurements of the hip with T-score -4.2 and Z-score -3. Relative risk of hip fracture (compared with an average 70-year-old woman) increases with relative risk (RR) of 2.6 for each standard deviation (SD) below average. Therefore, relative risk of hip fracture is increased 18-fold (2.63), placing the woman at markedly increased risk.

Figure 14. A 70-year-old woman has bone density measurements of the hip with T-score -4.2 and Z-score -3. Relative risk of hip fracture (compared with an average 70-year-old woman) increases with relative risk (RR) of 2.6 for each standard deviation (SD) below average. Therefore, relative risk of hip fracture is increased 18-fold (2.63), placing the woman at markedly increased risk.

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