The evidence that exercise during growth or adulthood reduces the risk of fragility fractures is weak

There has never been, and will never be, a randomized double-blind placebo-controlled trial demonstrating that exercise in youth, adulthood or old age reduces fragility or osteoporosis-related fractures in old age. The next level of evidence, a randomized, controlled but unblinded study with fractures as an end-point is feasible but has never been done. The basis for the belief that exercise reduces fractures is derived from lower levels of ‘evidence’, namely, retrospective and prospective observation cohort studies and case–control studies. These studies are at best hypothesis generating, never hypothesis testing. They are all subject to many systematic biases and should be interpreted with extreme scepticism. Surrogate measures of anti-fracture efficacy are the next level of evidence, such as the demonstration of a reduction in risk factors for falls, a reduction in falls, a reduction in fractures due to falls, an increase in peak bone size and mass, prevention of bone loss in midlife and restoration of bone mass and structure in old age.

The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community : the Geelong Osteoporosis Study

Fractures associated with severe trauma are generally excluded from estimates of the prevalence of osteoporotic fractures in the community. Because the degree of trauma is difficult to quantitate, low bone mass may contribute to fractures following severe trauma. We ascertained all fractures in a defined population and compared the bone mineral density (BMD) of women who sustained fractures in either 'low' or 'high' trauma events with the BMD of a random sample of women from the same population. BMD was measured by dual-energy X-ray absorptiometry and expressed as a standardized deviation (Z score) adjusted for age. The BMD Z scores (mean ± SEM) were reduced in both the low and high trauma groups, respectively: spine-posterior-anterior (- 0.50 ± 0.05 and -0.21 ± 0.08), spine-lateral (-0.28 ± 0.06 and -0.19 ± 0.10), femoral neck (-0.42 ± 0.04 and -0.26 ± 0.09), Ward's triangle (- 0.44 ± 0.04 and -0.28 ± 0.08), trochanter (-0.44 ± 0.05 and -0.32 ± 0.08), total body (-0.46 ± 0.06 and -0.32 ± 0.08), ultradistal radius (- 0.47 ± 0.05 and -0.42 ± 0.07), and midradius (-0.52 ± 0.06 and -0.33 ± 0.09). Except at the PA spine, the deficits were no smaller in the high trauma group. Compared with the population, the age-adjusted odds ratio for osteoporosis (t-score < -2.5) at one or more scanning sites was 3.1 (95% confidence interval 1.9, 5.0) in the high trauma group and 2.7 (1.9, 3.8) in the low trauma group. The data suggest that the exclusion of high trauma fractures in women over 50 years of age may result in underestimation of the contribution of osteoporosis to fractures in the community. Bone density measurement of women over 50 years of age who sustain fractures may be warranted irrespective of the classification of trauma.

Half the burden of fragility fractures in the community occur in women without osteoporosis. When is fracture prevention cost-effective?

To determine the age- and BMD-specific burden of fractures in the community and the cost-effectiveness of targeted drug therapy, we studied a demographically well-categorized population with a single main health provider. Of 1224 women over 50 years of age sustaining fractures during 2 years, the distribution of all fractures was 11%, 20%, 33%, and 36% in those aged 50–59, 60–69, 70–79, and 80+ years, respectively. Osteoporosis (T score < −2.5) was present in 20%, 46%, 59%, and 69% in the respective age groups. Based on this sample and census data for the whole country, treating all women over 50 years of age in Australia with a drug that halves fracture risk in osteoporotic women and reduces fractures in those without osteoporosis by 20%, was estimated to prevent 18,000 or 36% of the 50,000 fractures per year at a total cost of $573 million (AUD). Screening using a bone mineral density of T score of −2.5 as a cutoff, misses 80%, 54%, 41%, and 31% of fractures in women in the respective age groups. An analysis of cost per averted fracture by age group suggests that treating women in the 50- to 59-year age group with osteoporosis alone costs $156,400 per averted fracture. However, in women aged over 80 years, the cost per averted fracture is $28,500. We infer that treating all women over 50 years of age is not feasible. Using osteoporosis and age (>60 years) as criteria for intervention reduces the population burden of fractures by 28% and is cost-effective but solutions to the prevention of the remaining 72% of fragility fractures remain unavailable.

Beyond the usual suspects: complexity of fragility and analytical framework

Development in so-called ‘fragile states’ has become a key priority for the international community over the past few years, but international actors have not yet adequately incorporated sufficiently nuanced understandings of fragility into policies or practices. The increasing proportion of the world’s poor living in fragile contexts, the depth of human need in these contexts, and the potential regional spillover implications of this fragility, all make this an urgent concern. This chapter examines this growing need and discusses the origins and methodological approach in this volume, before setting up the rest of the book with definitions and an analysis framework. The chapter concludes with a summary of the book chapters and contributions.

Critiques and alternatives: development in contexts of fragility

The question of effective development in fragile contexts is increasingly significant, but as the literature and case studies throughout this volume have shown, the existing literature and principles for development effectiveness are built on a narrow conceptualisation of fragility. By exploring case studies that go well-beyond the ‘usual’ examples of ‘fragile states’, this volume has demonstrated that a much broader range of fragile contexts (set of causes and characteristics) exist, requiring a much more nuanced range of principles and approaches. This concluding chapter therefore summarises the key critiques of development theory and practice in fragile contexts found woven throughout the literature review and case studies, then offers tentative first steps towards more nuanced, context-specific recommendations for the roles of development actors, development approaches and modalities of interaction with structures and use of power in development, arranged according to thoughts around potential key drivers and characteristics of fragility, as illustrated by the case studies.

Changes in quality of life associated with fragility fractures: Australian arm of the International Cost and Utility Related to Osteoporotic Fractures Study (AusICUROS).

We investigated change in health-related quality of life due to fracture in Australian adults aged over 50 years. Fractures reduce quality of life with the loss sustained at least over 12 months. At a population level, the loss was equivalent to 65 days in full health per fracture.

Aid, growth, policies and fragility

The impact of aid on per capita income growth has been a particularly controversial topic among researchers and policy-makers alike. Most studies agree that growth would be lower in the absence of aid. This is evident from comprehensive literature surveys of aid and growth studies, including Hansen and Tarp (2000), Morrissey (2001), McGillivray et al. (2006), Mekasha and Tarp (2011) and Clemens et al. (2012). There is no such agreement in this literature regarding what might be described as the contingencies on which the impact of aid on growth is partially dependent. Debate over this topic is intensive and a failure to reach agreement over it is arguably the principal failing of the aid–growth literature owing to the potential guidance such agreement could provide for the selection of interventions aimed at improving aid effectiveness. Debate on aid–growth contingencies commenced after publication of the pioneering econometric investigation of Burnside and Dollar (1997, 2000). Burnside and Dollar multiplicatively interacted aid with a measure of policy, and found that aid only had a positive impact on growth in developing countries with good fiscal, monetary, and trade policies. Subsequent studies have sought to test the robustness of the Burnside and Dollar result, test for the relevance of different contingencies, or both. No study has been able to replicate the Burnside and Dollar result, and as such there is widespread concern in the research community over its robustness.

Ontology of building in war and reconstruction

Post-war cities epitomise both a disjuncture and resonance between the end of the nation-state, on the one hand, and a preoccupation with reinventing the city through building, on the other. Programs of 'reconstruction' and 'remaking a city' are preceded by destruction: a destructive force has altered the face of the city, buildings have been destroyed and damaged, their ordered and ordering materiality is eroded, and the city is no longer an image of an idealized symbol of unity and identity. Belying the mythical power of architecture as a material and symbolic force, is also its fragility. Architecture can be monumentally erected and can have a presence and persistence that inspires awe and wonder, but it can also, just as easily be de-erected, demolished, destroyed. It can be de-constructed in a way that the literal sense of the term signals its symbolic frailty. Perceiving the symbolic as intrinsically tied to the physical articulation and presence of the architectural edifice, both reveals and conceals that the symbolic is also tied to fantasy, memory and fiction. Drawings that precede construction are projections of an idealized image of something that does not yet exist, and photographs that remain after a building is demolished are representations of a past realist that is now fictional.

Promoting the health and well being of older carers : a proactive strategy

Research has indicated that carers are concerned about their ageing status, their deteriorating health and their ability to continue to care for their dependants. Given that the health care system will become increasingly reliant on carers the health care needs of carers should be a concern for all health care professionals. This paper describes the first stage of a project designed to enhance older carers health promotion knowledge and skills and improve their health promoting behaviours. This stage investigated the mental and physical health status of older carers. It also sought information on older carers' levels of participation in health related and social activities and identification of barriers to participation in these types of activities. The results highlighted that carers responding to the survey experienced compromised physical and mental health. Many carers reported being unable to participate in social and health-type activities as they were unable to leave the care recipient. Of note, is that carers identified their own mental fragility and felt they needed further emotional support.

Evaluation of phenomenological findings in IS research : a study in developing web-based IS

This paper presents a phenomenological investigation of project managers’ experiences with the implementation of web-based employee service systems (ESS), a domain that has witnessed sharp growth in Australia in recent times. The rich, multidimensional account of project managers’ experiences with the implementation of ESS revealed the social obstacles and fragility of intraorganizational relationships that demanded a cautious and tactful approach. While arriving at such findings usually concludes the cyclical process of phenomenological study, Information Systems (IS) research usually demands some independent assessment of the empirical discovery, which led us to conducting a further study focusing on the evaluation of the collected and packaged project managers’ experience. This phenomenological evaluation is in the focus of this paper. By means of a small case study, this project engaged a number of professional teams to reflect upon the previously captured problem-solving experience and determine its applicability, usefulness and relevance in developing new web-based ESS products and services.