Traffic Control in Work Zones with Edge Drop-Offs, 2002

Pavement and shoulder edge drop-offs commonly occur in work zones as the result of overlays, pavement replacement, or shoulder construction. The depth of these elevation differentials can vary from approximately one inch when a flexible pavement overlay is applied to several feet where major reconstruction is undertaken. The potential hazards associated with pavement edge differentials depend on several factors including depth of the drop-off, shape of the pavement edge, distance from traveled way, vehicle speed, traffic mix, volume, and other factors. This research was undertaken to review current practices in other states for temporary traffic control strategies addressing lane edge differentials and to analyze crash data and resultant litigation related to edge drop-offs. An objective was to identify cost-effective practices that would minimize the potential for and impacts of edge drop crashes in work zones. Considerable variation in addressing temporary traffic control in work zones with edge drop-off exposure was found among the states surveyed. Crashes related to pavement edge drop-offs in work zones do not commonly occur in the state of Iowa, but some have resulted in significant tort claims and settlements. The use of benefit/cost analysis may provide guidance in selection of an appropriate mitigation and protection of edge drop-off conditions. Development and adoption of guidelines for design of appropriate traffic control for work zones that include edge drop-off exposure, particularly identifying effective use of temporary barrier rail, may be beneficial in Iowa.

Maintenance of Traffic for Innovative Geometric Design Work Zones, 2015

Currently there are no guidelines within the Manual on Uniform Traffic Control Devices (MUTCD) on construction phasing and maintenance of traffic (MOT) for retrofit construction and maintenance projects involving innovative geometric designs. The research presented in this report addressed this gap in existing knowledge by investigating the state of the practice of construction phasing and MOT for several types of innovative geometric designs including the roundabout, single point urban interchange (SPUI), diverging diamond interchange (DDI), restricted-crossing left turn (RCUT), median U-turn (MUT), and displaced left turn (DLT). This report provides guidelines for transportation practitioners in developing construction phasing and MOT plans for innovative geometric designs. This report includes MOT Phasing Diagrams to assist in the development of MOT strategies for innovative designs. The MOT Phasing Diagrams were developed through a review of literature, survey, interviews with practitioners, and review of plans from innovative geometric design projects. These diagrams are provided as a tool to assist in improving work zone safety and mobility through construction of projects with innovative geometric designs. The aforementioned synthesis of existing knowledge documented existing practices for these types of designs.

Detection and characterization of hydraulically active fractures in a carbonate aquifer: Results from self-potential, temperature and fluid conductivity logging along a 260-m-deep borehole in the Combioula hydrothermal system in the southwestern Swiss Alps

A geophysical and geochemical study has been conducted in a fractured carbonate aquifer located at Combioula in the southwestern Swiss Alps with the objective to detect and characterize hydraulically active fractures along a 260-m-deep borehole. Hydrochemical analyses, borehole diameter, temperature and fluid electrical conductivity logging data were integrated in order to relate electrokinetic self-potential signals to groundwater flow inside the fracture network. The results show a generally good, albeit locally variable correlation of variations of the self-potential signals with variations in temperature, fluid electrical conductivity and borehole diameter. Together with the hydrochemical evidence, which was found to be critical for the interpretation of the self-potential data, these measurements not only made it possible to detect the hydraulically active fractures but also to characterize them as zones of fluid gain or fluid loss. The results complement the available information from the corresponding litholog and illustrate the potential of electrokinetic self-potential signals in conjunction with temperature, fluid electrical conductivity and hydrochemical analyses for the characterization of fractured aquifers, and thus may offer a perspective for an effective quantitative characterization of this increasingly important class of aquifers and geothermal reservoirs.

Traffic Management Strategies for Merge Area in Rural Interstate Work Zones, CTRE 97-12, 1999

The Iowa Department of Transportation, like many other state transportation agencies, is experiencing growing congestion and traffic delays in work zones on rural interstate highways. The congestion results in unproductive and wasteful delays for both motorists and commercial vehicles. It also results in hazardous conditions where vehicle stopped in queues on rural interstate highways are being approached by vehicles upstream at very high speeds. The delays also result in driver frustration, making some drivers willing to take unsafe risks in an effort to bypass delays. To reduce the safety hazards and unproductive delays of congested rural interstate work zones, the Iowa Department of Transportation would like to improve its traffic management strategies at these locations. Applying better management practices requires knowledge of the traffic flow properties and driver behavior in and around work zones, and knowledge of possible management strategies. The project reported here and in a companion report documents research which seeks to better understand traffic flow behavior at rural interstate highway work zones and to estimate the traffic carrying capacity of work zone lane closures. In addition, this document also reports on technology available to better manage traffic in and around work zones.

Spine trabecular bone score subsequent to bone mineral density improves fracture discrimination in women.

Bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA) is used to diagnose osteoporosis and assess fracture risk. However, DXA cannot evaluate trabecular microarchitecture. This study used a novel software program (TBS iNsight; Med-Imaps, Geneva, Switzerland) to estimate bone texture (trabecular bone score [TBS]) from standard spine DXA images. We hypothesized that TBS assessment would differentiate women with low trauma fracture from those without. In this study, TBS was performed blinded to fracture status on existing research DXA lumbar spine (LS) images from 429 women. Mean participant age was 71.3 yr, and 158 had prior fractures. The correlation between LS BMD and TBS was low (r = 0.28), suggesting these parameters reflect different bone properties. Age- and body mass index-adjusted odds ratios (ORs) ranged from 1.36 to 1.63 for LS or hip BMD in discriminating women with low trauma nonvertebral and vertebral fractures. TBS demonstrated ORs from 2.46 to 2.49 for these respective fractures; these remained significant after lowest BMD T-score adjustment (OR = 2.38 and 2.44). Seventy-three percent of all fractures occurred in women without osteoporosis (BMD T-score > -2.5); 72% of these women had a TBS score below the median, thereby appropriately classified them as being at increased risk. In conclusion, TBS assessment enhances DXA by evaluating trabecular pattern and identifying individuals with vertebral or low trauma fracture. TBS identifies 66-70% of women with fracture who were not classified with osteoporosis by BMD alone.

TBS (Trabecular Bone Score) is More Sensitive Than BMD to Diabetes-Related Fracture Risk

Background:Type 2 diabetes (T2D) is associated with increased fracture risk but paradoxically greater BMD. TBS (trabecular bone score), a novel grey-level texture measurement extracted from DXA images, correlates with 3D parameters of bone micro-architecture. We evaluated the ability of lumbar spine (LS) TBS to account for the increased fracture risk in diabetes. Methods:29,407 women ≥50 years at the time of baseline hip and spine DXA were identified from a database containing all clinical BMD results for the Province of Manitoba, Canada. 2,356 of the women satisfied a well-validated definition for diabetes, the vast majority of whom (>90%) would have T2D. LS L14 TBS was derived for each spine DXA examination blinded to clinical parameters and outcomes. Health service records were assessed for incident non-traumatic major osteoporotic fracture codes (mean follow-up 4.7 years). Results:In linear regression adjusted for FRAX risk factors (age,BMI, glucocorticoids, prior major fracture, rheumatoid arthritis, COPD as a smoking proxy, alcohol abuse) and osteoporosis therapy, diabetes was associated with higher BMD for LS, femoral neck and total hip but lower LS TBS (all p<0.001). Similar results were seen after excluding obese subjects withBMI>30. In logistic regression (Figure), the adjusted odds ratio (OR) for a skeletal measurement in the lowest vs highest tertile was less than 1 for all BMD measurements but increased for LS TBS (adjusted OR 2.61, 95%CI 2.30-2.97). Major osteoporotic fractures were identified in 175 (7.4%) with and 1,493 (5.5%) without diabetes (p < 0.001). LS TBS predicted fractures in those with diabetes (adjusted HR 1.27, 95%CI 1.10-1.46) and without diabetes (HR 1.31, 95%CI 1.24-1.38). LS TBS was an independent predictor of fracture (p<0.05) when further adjusted for BMD (LS, femoral neck or total hip). The explanatory effect of diabetes in the fracture prediction model was greatly reduced when LS TBS was added to the model (indicating that TBS captured a large portion of the diabetes-associated risk), but was paradoxically increased from adding any of the BMD measurements. Conclusions:Lumbar spine TBS is sensitive to skeletal deterioration in postmenopausal women with diabetes, whereas BMD is paradoxically greater. LS TBS predicts osteoporotic fractures in those with diabetes, and captures a large portion of the diabetes-associated fracture risk. Combining LS TBS with BMD incrementally improves fracture prediction.

Bone mineral density (BMD), micro-architecture estimation (TBS) and vertebral fracture assessment (VFA) extracted from a single DXA device in combination with clinical risk factors improve significantly the identification of women at high risk of fracture.

Osteoporosis (OP) is a systemic skeletal disease characterized by a low bone mineral density (BMD) and a micro-architectural (MA) deterioration. Clinical risk factors (CRF) are often used as a MA approximation. MA is yet evaluable in daily practice by the trabecular bone score (TBS) measure. TBS is very simple to obtain, by reanalyzing a lumbar DXA-scan. TBS has proven to have diagnosis and prognosis values, partially independent of CRF and BMD. The aim of the OsteoLaus cohort is to combine in daily practice the CRF and the information given by DXA (BMD, TBS and vertebral fracture assessment (VFA)) to better identify women at high fracture risk. The OsteoLaus cohort (1400 women 50 to 80 years living in Lausanne, Switzerland) started in 2010. This study is derived from the cohort COLAUS who started in Lausanne in 2003. The main goal of COLAUS is to obtain information on the epidemiology and genetic determinants of cardiovascular risk in 6700 men and women. CRF for OP, bone ultrasound of the heel, lumbar spine and hip BMD, VFA by DXA and MA evaluation by TBS are recorded in OsteoLaus. Preliminary results are reported. We included 631 women: mean age 67.4 ± 6.7 years, BMI 26.1 ± 4.6, mean lumbar spine BMD 0.943 ± 0.168 (T-score − 1.4 SD), and TBS 1.271 ± 0.103. As expected, correlation between BMD and site matched TBS is low (r2 = 0.16). Prevalence of VFx grade 2/3, major OP Fx and all OP Fx is 8.4%, 17.0% and 26.0% respectively. Age- and BMI-adjusted ORs (per SD decrease) are 1.8 (1.2-2.5), 1.6 (1.2-2.1), and 1.3 (1.1-1.6) for BMD for the different categories of fractures and 2.0 (1.4-3.0), 1.9 (1.4-2.5), and 1.4 (1.1-1.7) for TBS respectively. Only 32 to 37% of women with OP Fx have a BMD < − 2.5 SD or a TBS < 1.200. If we combine a BMD < − 2.5 SD or a TBS < 1.200, 54 to 60% of women with an osteoporotic Fx are identified. As in the already published studies, these preliminary results confirm the partial independence between BMD and TBS. More importantly, a combination of TBS subsequent to BMD increases significantly the identification of women with prevalent OP Fx which would have been misclassified by BMD alone. For the first time we are able to have complementary information about fracture (VFA), density (BMD), micro- and macro architecture (TBS and HAS) from a simple, low ionizing radiation and cheap device: DXA. Such complementary information is very useful for the patient in the daily practice and moreover will likely have an impact on cost effectiveness analysis.

Defining risk thresholds for a 10-year probability of hip fracture model that combines clinical risk factors and quantitative ultrasound: results using the EPISEM cohort.

Using a large prospective cohort of over 12,000 women, we determined 2 thresholds (high risk and low risk of hip fracture) to use in a 10-yr hip fracture probability model that we had previously described, a model combining the heel stiffness index measured by quantitative ultrasound (QUS) and a set of easily determined clinical risk factors (CRFs). The model identified a higher percentage of women with fractures as high risk than a previously reported risk score that combined QUS and CRF. In addition, it categorized women in a way that was quite consistent with the categorization that occurred using dual X-ray absorptiometry (DXA) and the World Health Organization (WHO) classification system; the 2 methods identified similar percentages of women with and without fractures in each of their 3 categories, but the 2 identified only in part the same women. Nevertheless, combining our composite probability model with DXA in a case findings strategy will likely further improve the detection of women at high risk of fragility hip fracture. We conclude that the currently proposed model may be of some use as an alternative to the WHO classification criteria for osteoporosis, at least when access to DXA is limited.

Quantitative Ultrasound of the Heel and Fracture Risk Assessment: an Updated Meta-Analysis

Objectives: Quantitative ultrasound (QUS) is an attractive method for assessing fracture risk because it is portable, inexpensive, without ionizing radiation, and available in areas of the world where DXA is not readily accessible or affordable. However, the diversity of QUS scanners and variability of fracture outcomes measured in different studies is an important obstacle to widespread utilisation of QUS for fracture risk assessment. We aimed in this review to assess the predictive power of heel QUS for fractures considering different characteristics of the association (QUS parameters and fracture outcomes measured, QUS devices, study populations, and independence from DXA-measured bone density).Materials/Methods : We conducted an inverse-variance randomeffects meta-analysis of prospective studies with heel QUS measures at baseline and fracture outcomes in their follow-up. Relative risks (RR) per standard deviation (SD) of different QUS parameters (broadband ultrasound attenuation [BUA], speed of sound &SOS;, stiffness index &SI;, and quantitative ultrasound index [QUI]) for various fracture outcomes (hip, vertebral, any clinical, any osteoporotic, and major osteoporotic fractures) were reported based on study questions.Results : 21 studies including 55,164 women and 13,742 men were included with a total follow-up of 279,124 person-years. All four QUS parameters were associated with risk of different fractures. For instance, RR of hip fracture for 1 SD decrease of BUA was 1.69 (95% CI 1.43-2.00), SOS was 1.96 (95% CI 1.64-2.34), SI was 2.26 (95%CI 1.71-2.99), and QUI was 1.99 (95% CI 1.49-2.67). Validated devices from different manufacturers predicted fracture risks with a similar performance (meta-regression p-values>0.05 for difference of devices). There was no sign of publication bias among the studies. QUS measures predicted fracture with a similar performance in men and women. Meta-analysis of studies with QUS measures adjusted for hip DXA showed a significant and independent association with fracture risk (RR/SD for BUA =1.34 [95%CI 1.22-1.49]).Conclusions : This study confirms that QUS of the heel using validated devices predicts risk of different fracture outcomes in elderly men and women. Further research and international collaborations are needed for standardisation of QUS parameters across various manufacturers and inclusion of QUS in fracture risk assessment tools. Disclosure of Interest : None declared.

Logistics Management in China's Development Zones - Finnish Metal Industry Perspective

Alikehittynyt infrastruktuuri, tiukat säädökset ja säädösten tulkitseminen, sekä monimutkaiset verotuskäytännöt ovat aiheuttaneet ongelmia suomalaisille Alikehittynyt infrastruktuuri, tiukat säädökset ja säädösten tulkitseminen, sekä monimutkaiset verotuskäytännöt ovat aiheuttaneet ongelmia suomalaisille yrityksille Kiinassa. Tutkimuksen perusteella yritykset eivät pysty vaikuttamaan infrastruktuurin kehittymiseen tai säädösten implementointiin, mutta ylläpitämällä suhteita ja valitsemalla oikeat partnerit yritykset pystyvät hallitsemaan ongelma-alueitaan. Etenkin ulkomaalaisille yrityksille oikean logistiikkaoperaattorin valinta on tärkeätä ja huomioon ottaen palvelutason, kulttuuritaustan sekä kansainväliset operaatiot on ulkomaalaisten yritysten tehokkaampaa käyttää kansainvälisiä operaattoreita kuin paikallisia toimijoita, jotkaovat usein halvempia, mutta eivät pysty toimimaan kansainvälisellä tasolla. Vientiin keskittyneiden yritysten tulisi sijoittua vapaakauppa-alueille tai vientiin painottuneille teollisuusalueille. Kyseisillä alueilla liiketoiminta mannermaahan on rajoitettu, eivätkä alueet täten sovellu yrityksille, jotka ovat keskittyneet Kiinan markkinoille. Paikallisesti operoivien yritysten tulisi sijoittua normaaleihin teollisuuspuistoihin ja käyttää tullin valvomia varastoja tukemaan kansainvälisiä toimintojaan.Tulisi myös muistaa etteivät kiinalaiset teollisuuspuistot täytä kansainvälisiä kriteerejä, joten säädöksiin on tärkeätä tutustua huolella jamielipiteitä kerätä toisilta yrityksiltä. Kiinassa merkittävimmät logistiikkaongelmat ilmenevät tuonnin ja viennin yhteydessä, jolloin säädökset ja toimintamallit ovat kontrolloidumpia. Etenkin tullaus- ja arvonlisävero ongelmat liittyvät kiinteästi tuonti- ja vientiprosessiin. Tutkimuksen tulokset osoittivat, että tullausprosessi tehostuu yhteistyön ja koulutuksen kautta, mutta arvonlisäverosta aiheutuvien kustannusten minimointi vaatii logistiikkapuistojen käyttöä. Mikäli asiakas haluaa tehdä tullauksen kotiprovinssissaan tai yritys tekee kauppaa ALV -vapautettujen yritysten kanssa, tulisi logistiikkapuistojen käyttöä lisätä. Käytettäessä logistiikkapuistoja yritykset välttävät tuotteiden kuljetukset Hongkongiin jatakaisin säästäen huomattavasti kustannuksissa ja toimitusajoissa. Logistiikkapuistoja on myös mahdollista käyttää ratkaisuna kasvaviin ja viivästyviin ALV palautuksiin. Tutkimuksen tulosten mukaan toimintaympäristö ja vientipainotteinen valmistus ohjaavat 3PL yritysten valintaa ja vaihtoehtoisten logistiikkapalvelujen implementointia. Etabloiduttaessavapaakauppa-alueille vientiin ja tuontiin liittyvät ongelmatekijät vahvistuvat sekä rajoitukset kiinan liiketoimintaan kasvavat, mikä tekee yhteistyönkansainvälisten logistiikkaoperaattoreiden kanssa välttämättömäksi ja kannustaa hyödyntämään logistiikkapuistoja.

Prediction of hip fracture risk by quantitative ultrasound in more than 7000 Swiss women > or =70 years of age: comparison of three technologically different bone ultrasound devices in the SEMOF study.

To compare the prediction of hip fracture risk of several bone ultrasounds (QUS), 7062 Swiss women > or =70 years of age were measured with three QUSs (two of the heel, one of the phalanges). Heel QUSs were both predictive of hip fracture risk, whereas the phalanges QUS was not. INTRODUCTION: As the number of hip fracture is expected to increase during these next decades, it is important to develop strategies to detect subjects at risk. Quantitative bone ultrasound (QUS), an ionizing radiation-free method, which is transportable, could be interesting for this purpose. MATERIALS AND METHODS: The Swiss Evaluation of the Methods of Measurement of Osteoporotic Fracture Risk (SEMOF) study is a multicenter cohort study, which compared three QUSs for the assessment of hip fracture risk in a sample of 7609 elderly ambulatory women > or =70 years of age. Two QUSs measured the heel (Achilles+; GE-Lunar and Sahara; Hologic), and one measured the heel (DBM Sonic 1200; IGEA). The Cox proportional hazards regression was used to estimate the hazard of the first hip fracture, adjusted for age, BMI, and center, and the area under the ROC curves were calculated to compare the devices and their parameters. RESULTS: From the 7609 women who were included in the study, 7062 women 75.2 +/- 3.1 (SD) years of age were prospectively followed for 2.9 +/- 0.8 years. Eighty women reported a hip fracture. A decrease by 1 SD of the QUS variables corresponded to an increase of the hip fracture risk from 2.3 (95% CI, 1.7, 3.1) to 2.6 (95% CI, 1.9, 3.4) for the three variables of Achilles+ and from 2.2 (95% CI, 1.7, 3.0) to 2.4 (95% CI, 1.8, 3.2) for the three variables of Sahara. Risk gradients did not differ significantly among the variables of the two heel QUS devices. On the other hand, the phalanges QUS (DBM Sonic 1200) was not predictive of hip fracture risk, with an adjusted hazard risk of 1.2 (95% CI, 0.9, 1.5), even after reanalysis of the digitalized data and using different cut-off levels (1700 or 1570 m/s). CONCLUSIONS: In this elderly women population, heel QUS devices were both predictive of hip fracture risk, whereas the phalanges QUS device was not.

Forecasting coal resources and reserves in heterogeneous coal zones using 3D facies models (As Pontes Basin, NW Spain)

Forecasting coal resources and reserves is critical for coal mine development. Thickness maps are commonly used for assessing coal resources and reserves; however they are limited for capturing coal splitting effects in thick and heterogeneous coal zones. As an alternative, three-dimensional geostatistical methods are used to populate facies distributionwithin a densely drilled heterogeneous coal zone in the As Pontes Basin (NWSpain). Coal distribution in this zone is mainly characterized by coal-dominated areas in the central parts of the basin interfingering with terrigenous-dominated alluvial fan zones at the margins. The three-dimensional models obtained are applied to forecast coal resources and reserves. Predictions using subsets of the entire dataset are also generated to understand the performance of methods under limited data constraints. Three-dimensional facies interpolation methods tend to overestimate coal resources and reserves due to interpolation smoothing. Facies simulation methods yield similar resource predictions than conventional thickness map approximations. Reserves predicted by facies simulation methods are mainly influenced by: a) the specific coal proportion threshold used to determine if a block can be recovered or not, and b) the capability of the modelling strategy to reproduce areal trends in coal proportions and splitting between coal-dominated and terrigenousdominated areas of the basin. Reserves predictions differ between the simulation methods, even with dense conditioning datasets. Simulation methods can be ranked according to the correlation of their outputs with predictions from the directly interpolated coal proportion maps: a) with low-density datasets sequential indicator simulation with trends yields the best correlation, b) with high-density datasets sequential indicator simulation with post-processing yields the best correlation, because the areal trends are provided implicitly by the dense conditioning data.

The micro-architecture estimation by TBS discriminate women with and without osteoporotic fracture independently of age, BMI and BMD: The Osteo-Mobile Vaud cohort study.

Introduction: « Osteo-Mobile Vaud » is a mobile osteoporosis (OP) screening program. The women > 60 years living in the region Vaud will be offered OP screening with new equipment installed in a bus. The main goal is to evaluate the fracture risk with the combination of clinical risk factors (CRF) and informations extracted by a single DXA: bone mineral density (BMD), vertebral fracture assessment (VFA), and micro-architecture (MA) evaluation. MA is yet evaluable in daily practice by the Trabecular Bone Score (TBS) measure. TBS is a novel grey-level texture measurement reflecting bone MA based on the use of experimental variograms of 2D projection images. TBS is very simple to obtain, by reanalyzing a lumbar DXA-scan. TBS has proven to have diagnosis and prognosis value, partially independent of CRF and BMD. A 55-years follow- up is planned. Method: The Osteo-Mobile Vaud cohort (1500 women, > 60 years, living in the region Vaud) started in July 2010. CRF for OP, lumbar spine and hip BMD, VFA by DXA and MA evaluation by TBS are recorded. Preliminary results are reported. Results: In July 31th, we evaluated 510 women: mean age 67 years, BMI 26 kg/m². 72 women had one or more fragility fractures, 39 had vertebral fracture (VFx) grade 2/3. TBS decreases with age (-0.005 / year, p<0.001), and with BMI (-0.011 per kg/m², p<0.001). Correlation between BMD and site matched TBS is low (r=0.4, p<0.001). For the lowest T-score BMD, odds ratio (OR, 95% CI) for VFx grade 2/3 and clinical OP Fx are 1.8 (1.1-2.9) and 2.3 (1.5-3.4). For TBS, age-, BMI- and BMD adjusted ORs (per SD decrease) for VFx grade 2/3 and clinical OP Fx are 1.9 (1.2-3.0) and 1.8 (1.2-2.7). The TBS added value was independent of lumbar spine BMD or the lowest T-score (femoral neck, total hip or lumbar spine). Conclusion: As in the already published studies, these preliminary results confirm the partial independence between BMD and TBS. More importantly, a combination of TBS and BMD may increase significantly the identification of women with prevalent OP Fx. For the first time we are able to have complementary information about fracture (VFA), density (BMD), and micro-architecture (TBS) from a simple, low ionizing radiation and cheap device: DXA. The value of such informations in a screening program will be evaluated.

Assessment of the 10-year probability of osteoporotic hip fracture combining clinical risk factors and heel bone ultrasound: the EPISEM prospective cohort of 12,958 elderly women.

This study aimed to develop a hip screening tool that combines relevant clinical risk factors (CRFs) and quantitative ultrasound (QUS) at the heel to determine the 10-yr probability of hip fractures in elderly women. The EPISEM database, comprised of approximately 13,000 women 70 yr of age, was derived from two population-based white European cohorts in France and Switzerland. All women had baseline data on CRFs and a baseline measurement of the stiffness index (SI) derived from QUS at the heel. Women were followed prospectively to identify incident fractures. Multivariate analysis was performed to determine the CRFs that contributed significantly to hip fracture risk, and these were used to generate a CRF score. Gradients of risk (GR; RR/SD change) and areas under receiver operating characteristic curves (AUC) were calculated for the CRF score, SI, and a score combining both. The 10-yr probability of hip fracture was computed for the combined model. Three hundred seven hip fractures were observed over a mean follow-up of 3.2 yr. In addition to SI, significant CRFs for hip fracture were body mass index (BMI), history of fracture, an impaired chair test, history of a recent fall, current cigarette smoking, and diabetes mellitus. The average GR for hip fracture was 2.10 per SD with the combined SI + CRF score compared with a GR of 1.77 with SI alone and of 1.52 with the CRF score alone. Thus, the use of CRFs enhanced the predictive value of SI alone. For example, in a woman 80 yr of age, the presence of two to four CRFs increased the probability of hip fracture from 16.9% to 26.6% and from 52.6% to 70.5% for SI Z-scores of +2 and -3, respectively. The combined use of CRFs and QUS SI is a promising tool to assess hip fracture probability in elderly women, especially when access to DXA is limited.