PISCOM: a new procedure for epilepsy combining ictal SPECT and interictal PET.

PURPOSE: We present a modified version of the SISCOM procedure that uses interictal PET instead of interictal SPECT for seizure onset zone localization. We called this new nuclear imaging processing technique PISCOM (PET interictal subtracted ictal SPECT coregistered with MRI). METHODS: We retrospectively studied 23 patients (age range 4-61 years) with medically refractory epilepsy who had undergone MRI, ictal SPECT, interictal SPECT and interictal FDG PET and who had been seizure-free for at least 2 years after surgical treatment. FDG PET images were reprocessed (rFDG PET) to assimilate SPECT features for image subtraction. Interictal SPECT and rFDG PET were compared using statistical parametric mapping (SPM). PISCOM and SISCOM images were evaluated visually and using an automated volume of interest-based analysis. The results of the two studies were compared with each other and with the known surgical resection site. RESULTS: SPM showed no significant differences in cortical activity between SPECT and rFDG PET images. PISCOM and SISCOM showed equivalent results in 17 of 23 patients (74%). The seizure onset zone was successfully identified in 19 patients (83%) by PISCOM and in 17 (74%) by SISCOM: in 15 patients (65%) the two techniques showed concordant successful results. The volume of interest-based analysis showed no significant differences between PISCOM and SISCOM in identifying the extension of the seizure onset zone. However, PISCOM showed a lower amount of indeterminate activity due to propagation, background or artefacts. CONCLUSION: Preliminary findings of this initial proof-of-concept study suggest that perfusion and glucose metabolism in the cerebral cortex can be correlated and that PISCOM may be a valid technique for identification of the seizure onset zone. However, further studies are needed to validate these results.

Correlation between theoretical anatomical patterns of lymphatic drainage and lymphoscintigraphy findings during sentinel node detection in head and neck melanomas.

PURPOSE: In the diagnosis of head and neck melanoma, lymphatic drainage is complex and highly variable. As regional lymph node metastasis is one of the most important prognostic factors, lymphoscintigraphy can help map individual drainage patterns. The aim of this study was to compare the results of lymphoscintigraphy and sentinel lymph node (SLN) detection with theoretical anatomical patterns of lymphatic drainage based on the location of the primary tumour lesion in patients with head and neck melanoma. We also determined the percentage of discrepancies between our lymphoscintigraphy and the theoretical location of nodal drainage predicted by a large lymphoscintigraphic database, in order to explain recurrence and false-negative SLN biopsies. METHODS: In this retrospective study of 152 patients with head and neck melanoma, the locations of the SLNs on lymphoscintigraphy and detected intraoperatively were compared with the lymphatic drainage predicted by on-line software based on a large melanoma database. RESULTS: All patients showed lymphatic drainage and in all patients at least one SLN was identified by lymphoscintigraphy. Of the 152 patients, 4 had a primary lesion in areas that were not described in the Sydney Melanoma Unit database, so agreement could only be evaluated in 148 patients. Agreement between lymphoscintigraphic findings and the theoretical lymphatic drainage predicted by the software was completely concordant in 119 of the 148 patients (80.4 %, 95 % CI 73.3 - 86 %). However, this concordance was partial (some concordant nodes and others not) in 18 patients (12.2 %, 95 % CI 7.8 - 18.4 %). Discordance was complete in 11 patients (7.4 %, 95 % CI 4.2 - 12.8 %). CONCLUSION: In melanoma of the head and neck there is a high correlation between lymphatic drainage found by lymphoscintigraphy and the predicted drainage pattern and basins provided by a large reference database. Due to unpredictable drainage, preoperative lymphoscintigraphy is essential to accurately detect the SLNs in head and neck melanoma.

Prospective comparison of whole-body (18)F-FDG PET/CT and MRI of the spine in the diagnosis of haematogenous spondylodiscitis.

PURPOSE: To prospectively compare (18)F-FDG PET/CT and MRI in the diagnosis of haematogenous spondylodiscitis METHODS: The study included 26 patients (12 women, 14 men; mean age 59 ± 17 years) with clinical symptoms of infection of the spine. Patients who had had prior spinal surgery or any type of antibiotic therapy in the previous 3 months were excluded from the study. Whole-body PET/CT 60 min after injection of 4.07 MBq/kg of (18)F-FDG and an MRI scan of the spine was performed in all patients. SUVmax in an area surrounding the lesions with the suspicion of infection as well as a background SUVmean in a preserved area of the spine were calculated for quantification. Infection was diagnosed by microbiological documentation in cultures of image-guided spinal puncture fluid or blood. Infection was excluded if symptoms were absent without antimicrobial therapy during a follow-up of at least 6 months. RESULTS: Spondylodiscitis was confirmed in 18 of the 26 patients. Staphylococcus aureus was found in 8 patients, Mycobacterium tuberculosis in 4, Escherichia coli in 2 and other pathogens in 4. Of the remaining 8 patients, the diagnoses were degenerative spondyloarthropathy in 5 and vertebral fracture in 3. The sensitivity, specificity, and positive and negative predictive value were 83%, 88%, 94% and 70% for (18)F-FDG PET/CT, and 94%, 38%, 77% and 75% for MRI, respectively. The accuracies of (18)F-FDG PET/CT and MRI were similar (84% and 81%, respectively). The combination of (18)F-FDG PET/CT and MRI detected the infection in 100% of the patients with spondylodiscitis. (18)F-FDG uptake, quantified in terms of SUVmax corrected by the background SUVmean, was significantly higher in patients with spondylodiscitis than in those without infection (p < 0.001). CONCLUSION: Due to its high specificity, (18)F-FDG PET/CT should be considered as a first-line imaging procedure in the diagnosis of spondylodiscitis. Quantification of uptake in terms of SUVmax was able to discriminate infection of the spine from other processes in this series of patients.

Interim FDG PET/CT as a prognostic factor in diffuse large B-cell lymphoma.

PURPOSE: Interim (18)F-FDG PET performed early during the course of therapy in diffuse large B-cell lymphoma (DLBCL) is a good predictor of outcome. However, interpretation criteria for interim PET for the evaluation of tumour response are still not clearly defined. The study aim was to assess whether interim PET can predict overall survival (OS) and progression-free survival (PFS) in DLBCL patients following three different sets of parameters, two qualitative (visual) methods and one semiquantitative. METHODS: A total of 50 newly diagnosed DLBCL patients were prospectively enrolled in this study. All patients had a PET/CT scan at diagnosis and an interim PET/CT scan after the second or third cycle of chemotherapy. Three methods of evaluation for the interim PET/CT were used: a qualitative three-point scoring (3-PS) method, a qualitative 5-PS method and a semiquantitative method (ΔSUVmax). The degree of correlation between therapy response seen on FDG PET and PFS and OS was determined. RESULTS: The analysis of the visual 3-PS method showed no statistically significant difference in PFS and OS. The estimated 5-year PFS and OS were 79 % and 92 %, respectively, in patients with an interim PET scan showing uptake not greater than in the liver versus 50 % in patients with uptake greater than in the liver, and this difference was statistically significant. The optimal cut-off value of ΔSUVmax that could predict the PFS and OS difference in patients with DLBCL was 76 % (95 % CI 62.7-89.2 %) and 75 % (95 % CI, 54.6-95.4 %), respectively. CONCLUSION: Our results support the use of liver uptake as an indicator in the qualitative evaluation of interim PET, or a ΔSUVmax greater than 75 % in semiquantitative analysis. Interim PET may predict PFS and OS and could be considered in the prognostic evaluation of DLBCL.

Low bone mass and severity of cholestasis affect fracture risk in patients with primary biliary cirrhosis.

BACKGROUND & AIMS: The influence of osteoporosis and liver disease on fracture risk is not well characterized in patients with primary biliary cirrhosis (PBC). We studied a large series of women with PBC to assess the prevalence and risk factors for fractures and the fracture threshold. METHODS: In female patients with PBC (n = 185; age, 55.7 +/- 0.7 years; range 28-79 years), age, duration of PBC, menopausal status, and histologic stage and severity of liver disease were assessed. Vertebral and non-vertebral fractures were recorded in 170 and 172 patients, respectively. Osteoporosis and osteopenia were diagnosed based on densitometry analysis. RESULTS: The prevalences of vertebral, non-vertebral, and overall fractures were 11.2%, 12.2%, 20.8%, respectively. Osteoporosis was significantly more frequent in patients with PBC than in normal women. Osteoporosis was associated with age, weight, height, histologic stage, severity, and duration of liver damage; fractures were associated with osteoporosis, menopause, age, and height but not with severity of PBC. Osteoporosis was a risk factor for vertebral fracture (odds ratio [OR], 8.48; 95% confidence interval [CI]: 2.67-26.95). Lumbar T score <-1.5 (OR, 8.27; 95% CI: 1.84-37.08) and femoral neck T score <-1.5 (OR, 6.83; 95% CI: 1.48-31.63) were significant risk factors for vertebral fractures. CONCLUSIONS: Fractures, particularly vertebral fractures, are associated with osteoporosis, osteopenia, and T scores less than -1.5, whereas osteoporosis and osteopenia are associated with the severity of liver damage. Patients with T scores less than -1.5 might require additional monitoring and be considered for therapy to prevent fractures.

Diagnostic cutoff points for ¹²³I-MIBG myocardial scintigraphy in a Caucasian population with Parkinson's disease.

PURPOSE: Molecular imaging with (123)I-metaiodobenzylguanidine (MIBG) has been used in Parkinson's disease (PD), but there is no consensual index to discriminate between normal and PD patients in the Caucasian population. The purpose of this study was to determine diagnostic cutoff points in the quantification of MIBG cardiac uptake in our population of PD patients. We have also calculated the reproducibility over a range of interpretation expertise. METHODS: The study included 14 PD patients and 14 normal age- and sex-matched controls. Heart to mediastinum ratios (H/M) were calculated at 15 min (H/M15m) and 4 h (H/M4h) post-injection by three observers with different interpretation expertise, one of whom drew the regions of interest at three different times. The intraobserver and interobserver reliability was calculated (interclass correlation coefficient and coefficient of variability). Diagnosis was estimated by maximizing the Youden index for H/M and washout ratios. Discrimination ability was assessed by the area under the curve (AUC). Sensitivity and specificity were reported, using our thresholds. RESULTS: The parameter with the best diagnostic accuracy was the H/M4h ratio, with a major AUC (0.976 area under the receiver-operating characteristic curve). The threshold was 1.43 with a 95% confidence interval of 1.37-1.50. Using this threshold, the sensitivity and specificity were 93 and 100%. The interobserver and intraobserver variabilities measuring this ratio were 3.2 and 3.1%, respectively. CONCLUSION: The diagnostic cutoff point for (123)I-MIBG myocardial scintigraphy in a Caucasian population with PD was 1.43 for the H/M4h index, with a good sensitivity and specificity. The technique is easy to use, with a good reproducibility over a range of interpretation expertise.

Validation of FDG-PET/MRI coregistration in nonlesional refractory childhood epilepsy.

PURPOSE: To validate the use of 18F-fluorodeoxyglucose-positron emission tomography/magnetic resonance imaging (FDG-PET/MRI) coregistration for epileptogenic zone detection in children with MRI nonlesional refractory epilepsy and to assess its ability to guide a second interpretation of the MRI studies. METHODS: Thirty-one children with refractory epilepsy whose MRI results were nonlesional were included prospectively. All patients underwent presurgical evaluation following the standard protocol of our epilepsy unit, which included FDG-PET and FDG-PET/MRI coregistration. Cerebral areas of decreased uptake in PET and PET/MRI fusion images were compared visually and then contrasted with presumed epileptogenic zone localization, which had been obtained from other clinical data. A second interpretation of MRI studies was carried out, focusing on the exact anatomic region in which hypometabolism was located in FDG-PET/MRI fusion images. KEY FINDINGS: Both FDG-PET and FDG-PET/MRI detected hypometabolism in 67.8% of patients, with good concordance on a subject basis and on the cerebral region involved (κ statistic = 0.83 and 0.79, respectively). Hypometabolism detected by single PET, as well as by PET/MRI fusion images, was located in the same hemisphere, as indicated by electroclinical data in 58% of patients, and at the same place in 39% of cases. Of the patients who showed hypometabolism on PET/MRI, 43% also experienced changes in the guided second MRI interpretation, from nonlesional to subtle-lesional. SIGNIFICANCE: PET/MRI coregistration is an imaging variant that is at least as accurate as PET alone in detecting epileptogenic zone in pediatric nonlesional patients, and can guide a second look at MRI studies previously reported as nonlesional, turning a meaningful percentage into subtle-lesional.

Predicting non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement: evaluation of two scoring systems.

The aim of this study was to validate a nomogram and a scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node (SLN) involvement. A total of 516 breast cancer patients underwent sentinel lymph node biopsy at our institution from January 2001 to August 2006. A prospective database was used to identify breast cancer patients with a positive SLN biopsy examination who underwent a completion axillary lymph node dissection. A total of 114 patients were identified. The Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram and an axilla scoring system from Paris (Hôpital Tenon) were used to predict the probability of having non-SLN involvement. One hundred fourteen patients were included in the study. The areas under the receiver operating characteristics (ROC) curves were 0.671 (95% CI: 0.552-0.790) for the MSKCC nomogram and 0.703 (95% CI: 0.596-0.811) for the Tenon score. The univariate analysis shows that size of SLN metastases, the number of positive and negative SLN and the proportion of positive SLN were statistically significant. On multivariate logistic regression analysis, the size of SLN metastases and the proportion of positive SLN were statistically significant. The two scoring systems are similar according to their area under ROC curves, but should be improved to be valid and determinant to the general population. Meanwhile, the use of scoring systems could be applied in an individual manner in some patients.

18F-FDG PET/CT for early prediction of response to neoadjuvant chemotherapy in breast cancer.

PURPOSE: The aim of this study was to prospectively evaluate 18F-FDG PET/CT in predicting response to neoadjuvant chemotherapy in large primary breast cancer. METHODS: Fifty consecutive patients underwent PET/CT at baseline and after the second cycle. Baseline MRI was performed to establish tumour size. All findings were confirmed by histopathological analysis. Changes in maximum standardized uptake value (SUV(max)) between baseline study and after two cycles of neoadjuvant chemotherapy (epirubicin + cyclophosphamide + taxanes) were compared using response evaluation criteria in solid tumours (RECIST) criteria and the Miller and Payne (M&P) scale. RESULTS: The mean tumour size was 4.3 +/- 1.4 cm. Forty patients were considered responders and ten as non-responders. SUV(max) changes in patients with good prognosis (M&P grades 4-5) were higher than in patients with bad prognosis (M&P grades 1-3) (p = 0.025). SUV(max) changes between responders and non-responders following RECIST criteria were also statistically significant (p = 0.0028). A cut-off DeltaSUV value of 40% differentiates both groups, with a sensitivity of 77% and a specificity of 80%. CONCLUSION: 18F-FDG PET/CT can predict response to neoadjuvant chemotherapy at an early stage.

2009 EANM parathyroid guidelines.

The present guidelines were issued by the Parathyroid Task Group of the European Association of Nuclear Medicine. The main focus was imaging of primary hyperparathyroidism. Dual-tracer and single-tracer parathyroid scintigraphy protocols were discussed as well as the various modalities of image acquisition. Primary hyperparathyroidism is an endocrine disorder with high prevalence, typically caused by a solitary parathyroid adenoma, less frequently (about 15%) by multiple parathyroid gland disease (MGD) and rarely (1%) by parathyroid carcinoma. Patients with MGD may have a double adenoma or hyperplasia of three or all four parathyroid glands. Conventional surgery has consisted in routine bilateral neck exploration. The current trend is toward minimally invasive surgery. In this new era, the success of targeted parathyroid surgery depends not only on an experienced surgeon, but also on a sensitive and accurate imaging technique. Recognizing MGD is the major challenge for pre-operative imaging, in order to not direct a patient towards inappropriate minimal surgery. Scintigraphy should also report on thyroid nodules that may cause confusion with a parathyroid adenoma or require concurrent surgical resection. The two main reasons for failed surgery are ectopic glands and undetected MGD. Imaging is mandatory before re-operation, and scintigraphy results should be confirmed with a second imaging technique (usually US for a neck focus, CT or MRI for a mediastinal focus). Hybrid SPECT/CT instruments should be most helpful in this setting. SPECT/CT has a major role for obtaining anatomical details on ectopic foci. However, its use as a routine procedure before target surgery is still investigational. Preliminary data suggest that SPECT/CT has lower sensitivity in the neck area compared to pinhole imaging. Additional radiation to the patient should also be considered. The guidelines also discuss aspects related to radio-guided surgery of hyperparathyroidism and imaging of chronic kidney disease patients with secondary hyperparathyroidism.

Epileptogenic Zone Localization With 18FDG PET Using a New Dynamic Parametric Analysis.

Introduction: [18F]fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) is part of the regular preoperative work-up in medically refractory epilepsy. As a complement to visual evaluation of PET, statistical parametric maps can help in the detection of the epileptogenic zone (EZ). However, software packages currently available are time-consuming and little intuitive for physicians. We develop a user-friendly software (referred as PET-analysis) for EZ localization in PET studies that allows dynamic real-time statistical parametric analysis. To evaluate its performance, the outcome of PET-analysis was compared with the results obtained by visual assessment and Statistical Parametric Mapping (SPM). Methods: Thirty patients with medically refractory epilepsy who underwent presurgical 18F-FDG PET with good post-operative outcomes were included. The 18F-FDG PET studies were evaluated by visual assessment, with SPM8 and PET-analysis. In SPM, parametric T-maps were thresholded at corrected p < 0.05 and cluster size k = 50 and at uncorrected p < 0.001 and k = 100 (the most used parameters in the literature). Since PET-analysis rapidly processes different threshold combinations, T-maps were thresholded with multiple p-value and different clusters sizes. The presurgical EZ identified by visual assessment, SPM and PET-analysis was compared to the confirmed EZ according to post-surgical follow-up. Results: PET-analysis obtained 66.7% (20/30) of correctly localizing studies, comparable to the 70.0% (21/30) achieved by visual assessment and significantly higher (p < 0.05) than that obtained with the SPM threshold p < 0.001/k = 100, of 36.7% (11/30). Only one study was positive, albeit non-localizing, with the SPM threshold corrected p < 0.05/k = 50. Concordance was substantial for PET-analysis (κ = 0.643) and visual interpretation (κ = 0.622), being fair for SPM (κ = 0.242). Conclusion: Compared to SPM with the fixed standard parameters, PET-analysis may be superior in EZ localization with its easy and rapid processing of different threshold combinations. The results of this initial proof-of-concept study validate the clinical use of PET-analysis as a robust objective complementary tool to visual assessment for EZ localization.

Bone mineral density evolution in young premenopausal women with idiopathic osteoporosis.

Idiopathic osteoporosis is a frequent cause of osteoporosis in young premenopausal women. However, there are no data about the treatment of these patients. The aim of this study was to analyse the evolution of bone mineral density (BMD) in premenopausal women with idiopathic osteoporosis treated with a conservative approach. Retrospective study of 16 premenopausal women with idiopathic osteoporosis (aged 35.7+/-7 years) with a mean follow-up period of 3 years (1-6 years). BMD measurements at the lumbar spine and femoral neck were obtained in all patients at baseline and yearly (patients had one or more fragility fractures and/or a Z score < -2 in the lumbar spine or femur). Secondary causes of osteoporosis were excluded in all patients. Patients were treated with calcium and vitamin D to achieve a calcium intake of up to 1,500 mg/day and were advised to increase physical activity. A significant increase in lumbar and femoral BMD was observed after 2 and 3 years of follow-up, respectively (1.9+/-1.9% mean increase in lumbar spine, p= 0.021, at 2 years) (5.6+/-4.5% mean increase in femur, p=0.04, at 3 years). The serum total alkaline phosphatase (TAP) values increased at 2 years (122+/-46 vs 140+/-36 U/l, p=0.054). In addition, a negative correlation between baseline TAP serum values and lumbar BMD evolution at 2 years was observed (r=-0.748, p=0.013). No patient developed new skeletal fractures during the follow-up period. In young premenopausal women with idiopathic osteoporosis the conservative treatment with supplements of calcium and vitamin D associated with an increase of physical activity is associated with an increase in BMD without evidence of further skeletal fractures after more than 3 years of follow-up.

Temporomandibular joint soft-tissue pathology, II: Nondisc abnormalities.

The most important objective in a magnetic resonance imaging (MRI) study of the temporomandibular joint (TMJ) is to determine the location of disk, because the presence of a displaced disk is a critical sign of TMJ dysfunction. However, a high frequency of disk displacement appears in asymptomatic volunteers; thus, other MRI indirect signs of TMJ dysfunction can help in the diagnosis. Further studies using the latest MRI techniques allow a better understanding of the sources of joint pain and the discrepancy between imaging findings and patient symptoms. Evaluation of other MRI signs such as the presence of joint effusion, the rupture of retrodiscal ligaments, or the thickness of the attachment of the external pterygoid muscle can be used as indirect early signs of TMJ dysfunction, before osteoarthritic changes lead to a more advanced stage of the dysfunctional spectrum. In this article we show those MRI indirect signs of TMJ dysfunction, providing more reasons to separate anatomic variants of healthy individuals from a real internal derangement.

[The value of positron emission tomography/computed tomography (PET/CT) in the staging of diffuse large B-cell lymphoma]. / Utilidad de la tomografía por emisión de positrones/ tomografía computarizada (PET/TC) en el estudio de extensión en pacientes con linfoma B difuso de células grandes.

BACKGROUND AND OBJECTIVE: The aim of this study was to evaluate the role of positron emission tomography/computed tomography (PET/CT) in improving the staging and changing the management of aggressive lymphoma patients in comparison with the conventional imaging modalities (CT, and 67Ga scintigraphy). PATIENTS AND METHOD: Forty consecutive patients with diffuse large B-cell non Hodgkin lymphoma, were prospectively evaluated. All 40 patients underwent a whole body FDG PET/CT and conventional staging techniques (chest and abdomen CT, 67Ga scintigraphy) were studied before therapy. Sixty minutes after the intravenous administration of 370 MBq FDG, a whole body PET/CT was acquired. We hypothesize that PET/CT improves the diagnostic staging of lymphoma and changes the clinical management of patients. RESULTS: PET/CT and CT were concordant in 28 patients (65%). However, PET/CT detected more lesions than CT in 11 patients (27.5%). Only in one patient, CT revealed more extensive disease than PET/CT. Additional information of PET/CT had lead to a change in staging (upstaging) in 6 patients (15%), in turn leading to a change in treatment strategy in 1 patient. PET/CT and 67Ga scintigraphy were concordant in 23 patients (60.5%). PET/CT detected more lesions than 67Ga scintigraphy in 14 patients (42%). PET/CT results changed staging (upstaging) in 4 patients (15%), leading to a change of treatment strategy in one patient. CONCLUSIONS: The impression is that PET/CT detected more lesions than conventional examination, but this rarely translates into changes of staging and treatment strategy in aggressive lymphoma.

Bilateral Paget disease of the calcaneus diagnosed by conventional bone scintigraphy.

An 85-year-old woman who had an invasive ductal carcinoma of the breast and elevated alkaline phosphatases (420 U/L) was referred for Tc-99m MDP bone scintigraphy for initial evaluation of skeletal metastases. Bone symptoms were limited to chronic pain in both knees. A bone scan revealed pagetoid findings in both calcanei. Feet and toes on plain x-rays of the calcaneus were unremarkable. Findings were stable in the 2-year follow up, excluding other potential diagnosis as extensive metastases or stress fractures.

Diagnostic Accuracy of 18F-FDG PET/CT in Infective Endocarditis and Implantable Cardiac Electronic Device Infection: A Cross-Sectional Study.

Early diagnosis of infective endocarditis (IE) is based on the yielding of blood cultures and echocardiographic findings. However, they have limitations and sometimes the diagnosis is inconclusive, particularly in patients with prosthetic valves (PVs) and implantable cardiac electronic devices (ICEDs). The primary aim of this study was to evaluate the diagnostic accuracy of 18F-FDG PET/CT in patients with suspected IE and ICED infection. METHODS: A prospective study with 80 consecutive patients with suspected IE and ICED infection (65 men and 15 women with a mean age of 68 ± 13 y) between June 2013 and May 2015 was performed in our hospital. The inclusion criteria were clinically suspected IE and ICED infection at the following locations: native valve (NV) (n = 21), PV (n = 29), or ICED (n = 30) (automatic implantable defibrillator [n = 11] or pacemaker [n = 19]). Whole-body 18F-FDG PET/CT with a myocardial uptake suppression protocol with unfractionated heparin was performed in all patients. The final diagnosis of infection was established by the IE Study Group according to the clinical, echocardiographic, and microbiologic findings. RESULTS: A final diagnosis of infection was confirmed in 31 patients: NV (n = 6), PV (n = 12), and ICED (n = 13). Sensitivity, specificity, positive predictive value, and negative predictive value for 18F-FDG PET/CT were 82%, 96%, 94%, and 87%, respectively. 18F-FDG PET/CT was false-negative in all cases with infected NV. 18F-FDG PET/CT was able to reclassify 63 of 70 (90%) patients initially classified as possible IE by modified Duke criteria. In 18 of 70 cases, 18F-FDG PET/CT changed possible to definite IE (26%) and in 45 of 70 cases changed possible to rejected IE (64%). Additionally, 18F-FDG PET/CT identified 8 cases of septic embolism and 3 of colorectal cancer in patients with a final diagnosis of IE. CONCLUSION: 18F-FDG PET/CT proved to be a useful diagnostic tool in suspected IE and ICED infection and should be included in the diagnostic algorithm for early diagnosis. 18F-FDG PET/CT is not useful in the diagnosis of IE in NV but should be also considered in the initial assessment of this complex scenario to rule out extracardiac complications and possible neoplasms.

Changes in bone mineral metabolism parameters, including FGF23, after discontinuing cinacalcet at kidney transplantation.

Little is known about the effects of the administration of cinacalcet in dialytic patients who are scheduled for kidney transplantation, and in particular about the changes in FGF23 and other mineral metabolism parameters after surgery compared with recipients not on cinacalcet at kidney transplantation. We performed a prospective observational cohort study with recruitment of consecutive kidney transplant recipients at our institution. Patients were classified according to whether they were under treatment with cinacalcet before transplantation. Bone mineral metabolism parameters, including C-terminal FGF23, were measured at baseline, on day 15, and at 1, 3, and 6 months after transplantation. In previously cinacalcet-treated patients, cinacalcet therapy was discontinued on the day of surgery and was not restarted after transplantation. A total of 48 kidney transplant recipients, 20 on cinacalcet at surgery and 28 cinacalcet non-treated patients, completed the follow-up. Serum phosphate declined significantly in the first 15 days after transplantation with no differences between the two groups, whereas cinacalcet-treated patients showed higher FGF23 levels, although not significant. After transplantation, PTH and serum calcium were significantly higher in cinacalcet-treated patients. We conclude that patients receiving cinacalcet on dialysis presented similar serum phosphate levels but higher PTH and serum calcium levels during the initial six months after kidney transplantation than cinacalcet non-treated patients. The group previously treated with cinacalcet before transplantation showed higher FGF23 levels without significant differences, so further studies should investigate its relevance in the management of these patients.

Is there a role for PET/CT with esophagogastric junction adenocarcinoma?

The value of 18F-FDG PET/CT in the initial diagnosis and in the locoregional staging of esophagogastric junction adenocarcinoma is not fully established. However, 18F-FDG PET/CT is widely accepted as the best modality for identification of suspected metastases in staging of the disease. Results published in the literature suggest that 18F-FDG PET/CT may provide useful information for response assessment to neoadjuvancy and to differentiate responding and nonresponding tumors. We review the potential role of 18F-FDG PET/CT imaging in staging, restaging, and prognostic value after chemoradiation therapy in esophagogastric junction adenocarcinoma.

Rapid calcitriol increase and persistent calcidiol insufficiency in the first 6 months after kidney transplantation.

INTRODUCTION: Vitamin D deficiency or insufficiency is prevalent in kidney transplant recipients. Little is known about post-transplantation changes in vitamin D forms, which are essential for bone health and other health outcomes. The aim was to measure the levels of calcidiol and calcitriol during the first 6 months after kidney transplantation and examine their relation with other bone mineral metabolic parameters. PATIENTS AND METHODS: A prospective study was performed on 98 patients recruited between April 2010 and June 2011. Calcidiol and calcitriol levels were measured at baseline and at days 15, 30, 90, and 180 after kidney transplantation. RESULTS: Serum calcidiol levels remained persistently low: 14.3 (9-22) ng/ml at baseline and 16.3 (10.1-20.6) ng/ml at 6 months (P=0.641). At 6 months, calcidiol levels showed an inverse correlation with simultaneously measured parathyroid hormone levels. Calcidiol showed a trend to be higher in patients transplanted in spring but with no statistically significant difference. Calcitriol levels increased from 17 (13-23.7) pg/ml at baseline to 24 (16-32) pg/ml (P=0.002) in the first 2 weeks after transplantation and reached 37 (25-50) pg/ml (P=0.000) after 6 months. During the follow-up, calcitriol levels showed a significant inverse correlation with baseline fibroblast growth factor-23 levels. At month 6, calcitriol levels were inversely correlated with baseline fibroblast growth factor-23 levels and directly correlated with calcidiol levels. CONCLUSION: In most patients, calcidiol levels remain low 6 months after kidney transplantation, whereas calcitriol levels rapidly return to normal. Lower calcidiol blood levels promoted lower calcitriol blood levels and higher parathyroid hormone concentrations.

Clinical characteristics and etiologic factors of premenopausal osteoporosis in a group of Spanish women.

OBJECTIVES: To analyze the clinical characteristics and the principal causes of osteoporosis in premenopausal women. METHODS: This study included 52 osteoporotic premenopausal women ages 20-51 years (mean 36.2 +/- 7) who were referred to an outpatient rheumatology department for osteoporosis evaluation. Bone mass assessment, automated biochemical profile, urinary calcium excretion, and bone marker assays were performed on all patients. Hormonal measurements were made when a specific etiology was not readily apparent. The diagnosis of osteoporosis was defined by the presence of atraumatic vertebral fractures and/or by densitometric criteria. Previous skeletal fractures, weight, height, body mass index (BMI), age at menarche, and family history of osteoporosis also were recorded. RESULTS: Twenty-nine patients (56%) had idiopathic osteoporosis and 23 (44%) had secondary osteoporosis. Fifteen patients (29%) had vertebral fractures and 12 had previous peripheral fractures. Patients with secondary osteoporosis showed higher BMI (23.2 +/- 3 v 21.2 +/- 2, P =.02) and lower femoral Z-scores of bone mineral density (BMD) (-2.1 +/- 0.6 v -1.5 +/- 0.9, P =.02) than those with idiopathic disease. The most frequent causes of secondary osteoporosis included Cushing syndrome, pregnancy osteoporosis, and osteogenesis imperfecta. Nearly half of the patients (48%) with idiopathic osteoporosis had a family history of osteoporosis. In addition, 11 patients (38%) with idiopathic osteoporosis had associated hypercalciuria. Except for an increase in urinary calcium excretion (248 +/- 53 v 143 +/- 47 mg/24 h, P <.0001), no other significant differences in the remaining variables analyzed were found between hypercalciuric and normocalciuric patients with idiopathic osteoporosis. CONCLUSIONS: Idiopathic osteoporosis was the most frequent diagnosis of pre-menopausal osteoporosis in our unit. These patients showed lower BMI and higher femoral neck Z-scores than patients with secondary causes. A family history of osteoporosis and hypercalciuria were factors frequently associated with this disorder.