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Summary: We describe the collection of cohorts together with the analysis plan for an update of the fracture risk prediction tool FRAX with respect to current and novel risk factors. The resource comprises 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. Introduction: The availability of the fracture risk assessment tool FRAX® has substantially enhanced the targeting of treatment to those at high risk of fracture with FRAX now incorporated into more than 100 clinical osteoporosis guidelines worldwide. The aim of this study is to determine whether the current algorithms can be further optimised with respect to current and novel risk factors. Methods: A computerised literature search was performed in PubMed from inception until May 17, 2019, to identify eligible cohorts for updating the FRAX coefficients. Additionally, we searched the abstracts of conference proceedings of the American Society for Bone and Mineral Research, European Calcified Tissue Society and World Congress of Osteoporosis. Prospective cohort studies with data on baseline clinical risk factors and incident fractures were eligible. Results: Of the 836 records retrieved, 53 were selected for full-text assessment after screening on title and abstract. Twelve cohorts were deemed eligible and of these, 4 novel cohorts were identified. These cohorts, together with 60 previously identified cohorts, will provide the resource for constructing an updated version of FRAX comprising 2,138,428 participants with a follow-up of approximately 20 million person-years and 116,117 documented incident major osteoporotic fractures. For each known and candidate risk factor, multivariate hazard functions for hip fracture, major osteoporotic fracture and death will be tested using extended Poisson regression. Sex- and/or ethnicity-specific differences in the weights of the risk factors will be investigated. After meta-analyses of the cohort-specific beta coefficients for each risk factor, models comprising 10-year probability of hip and major osteoporotic fracture, with or without femoral neck bone mineral density, will be computed. Conclusions: These assembled cohorts and described models will provide the framework for an updated FRAX tool enabling enhanced assessment of fracture risk (PROSPERO (CRD42021227266)).

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ObjectiveTo assess the feasibility and acceptability of a telephone-based Cognitive Behaviour Therapy (tCBT) intervention for individuals with axial spondyloarthritis (axSpA), with and without co-morbid fibromyalgia and measure change in patient reported health outcomes.MethodsA convenience sample of individuals recruited from British Society for Rheumatology Biologics Registry for Ankylosing Spondylitis (BSRBR-AS) sites were offered a course of tCBT (framed as ‘coaching’). Patient reported outcomes were measured at baseline and on course completion. Semi-structured qualitative interviews assessed intervention acceptability. Thematic analysis was informed by the Theoretical Framework of Acceptability (TFA).Results42 participants attended for initial assessment. Those completing at least one tCBT session (n = 28) were younger, more likely to meet classification criteria for fibromyalgia (57% vs 29%) and reported higher disease activity. Modest improvements were reported across a range of disease activity and wider health measures, with 62% patients self-rating their health as improved (median 13 weeks post intervention). 26 participants were interviewed (including six who discontinued after initial assessment). tCBT was widely acceptable, offering a personalised approach. Despite low or unclear expectations, participants described improved sleep and psychological well-being, and gained new skills to support self-management. Reasons for non-uptake of tCBT centered on lack of perceived need and fit with individual value systems. Many felt tCBT would be most useful closer to diagnosis.ConclusionHigher uptake among axSpA patients with co-morbid fibromyalgia suggests these individuals have additional needs. Findings are helpful in identifying patients most likely to engage with and benefit from tCBT, and maximise participation.

Background:\ud Individuals on renal replacement therapy (RRT) have increased fracture risk, but risk in less advanced chronic kidney disease (CKD) is unclear.\ud \ud Objective:\ud To investigate CKD associations with hip fracture incidence and mortality.\ud \ud Design: \ud Record linkage cohort study (GLOMMS-II).Setting Single health region in Scotland.\ud \ud Participants:\ud All individuals (>5 years) with sustained CKD stage 3-5 and those on RRT, and a 20% random sample of those with normal renal function, in the resident population in 2003.\ud \ud Outcome measures:\ud Outcomes were (i) incident hip fracture measured with (a) admissions or (b) deaths, with at least 5.5 years follow-up; and (ii) post-hip fracture mortality. Unadjusted and adjusted, incident (IRR) and mortality (MRR) rate ratios, were calculated using Poisson regression.\ud \ud Results:\ud Of 39 630 individuals identified in 2003 (41% males, mean age 63.3 years), 19 537 had CKD stage 3-5, 345 were on RRT, and 19 748 had normal eGFR. Hip fracture incidence, measured by admissions, was increased in CKD stage 3-5 (compared to normal eGFR), both overall (adjusted IRR 1.49 [95% CI, 1.24-1.79]) and for individual CKD stages 3a, 3b and 4. Hip fracture incidence, measured using deaths, was increased in those with CKD stage 3b and 4. Post-hip fracture mortality, was only increased in CKD stage 4. There was only a small number of individuals and events for CKD stage 5, resulting in insufficient statistical power.\ud \ud Conclusion:\ud Hip fracture incidence was higher in CKD stage 3-5 compared to normal eGFR. Post-hip fracture mortality was only increased in CKD Stage 4. Reducing hip fracture incidence in CKD through regular fall and fracture risk review, should reduce overall deaths after hip fracture in the population.