Introduction: After surgical stabilization of osteoporosis- related fractures, patients often do not receive any osteoporosis medication for fracture risk reduction according to current guidelines. Aims: This well- known problem should be reduced through interdisciplinary projects. Patients who have faced an osteoporosis- related fracture should be managed bedside at the surgical departments in order to add drug therapies for osteoporosis to the surgical management and, if necessary, order additional diagnostic measures. Results: During a pilot project that lasted for 3 months, a total number of 77 patients (63 women, 14 men) were admitted to this fracture liaison duty service. Five patients denied any special medical consultation. Although the majority of the 72 patients revealed a significantly increased fracture risk based on FRAX analysis, only some of them already had an established osteoporosis therapy (vitamin D 29.2 %, calcium 26.4 %, specific osteoporosis medication 19.4 %). In 66 of 72 consulted patients an osteological recommendation could be given, in 7 of these cases under the condition that an additional osteodensitometry will be performed. The given recommendations tried to include the specific clinical conditions of the patients into the decision making, thus all currently available therapeutic options of osteoporosis therapy were subscribed. In 5 patients no evidence of osteoporosis was present and in only one patient a decision could not be made due to the lack of adequate clinical information. Conclusion: The fracture liaison duty bedside at the surgical departments improved patient care according to current consensus statements mainly in terms of a more interdisciplinary management which then also included differentiated advice for long- term osteoporosis medication for further fracture risk reduction. Standardization and further improvements of algorithms in the diagnostic and therapeutic workup of patients with osteoporosis after falls will most likely further improve range and effectiveness of such interdisciplinary patient managements, which might be the topic for further projects.

Background: Numerous studies have shown that osteoporosis is both under diagnosed and under treated in patients with fragility fractures. We describe the use of an electronic automated referral system to enable multidisciplinary assessment and treatment of osteoporosis in patients admitted with fragility fracture of the hip. Methods: An electronic referral system was developed from the hospital's trauma software database. This automatically refers patients admitted with fragility fracture of the hip to osteoporosis services. Data were collected prospectively from May to July 2007, when referral was dependent on members of the orthopaedic team and from August to October 2007, after the implementation of the electronic referral system. Primary outcomes were presence of a referral to osteoporosis services, organisation of bone density scan and follow up appointment in patients less than 75 years, and treatment with osteoporosis medication in patients greater than 75 years of age. Results: There were a total of 90 patients, 47 in the non-intervention group and 43 in the intervention group. In the non-intervention group 8/47 patients (17 %) were referred to osteoporosis services whilst 43/43 (100 %) were referred in the intervention group. Of patients greater than 75 years, 10/32 (31.3 %) were started on a bisphosphonate in the non-intervention group compared to 28/34 (82.4 %) in the intervention group. Of patients less than 75 years, 1/15 (7 %) in the non-intervention group had a DEXA scan booked and appropriate follow up arranged, compared to 7/9 (78 %) in the intervention group. There was significant difference between both groups in all outcomes (p < 0.0001). Conclusion: We present an electronic system which facilitates delivery of osteoporosis services and significantly improves management of osteoporosis in patients admitted with fragility fracture. We recommend the use of such programs to facilitate multidisciplinary assessment and treatment of osteoporosis in orthopaedic trauma patients.

PURPOSE:The purpose of this prospective study was to determine the diagnostic impact and influence on patient treatment of posttherapeutic (131)I SPECT-CT when the findings on planar posttherapeutic whole-body scintigraphy (ptWBS) were inconclusive.MATERIALS AND METHODS:A total of 53 SPECT-CT scans were performed in 41 patients with thyroid cancer after high-dose (131)I therapy (2.944 to 7.526 GBq (131)I) because of diagnostic uncertainty on ptWBS. Physiological uptake in the salivary glands, gastric mucosa, gut, nasal mucosa, urinary tract and liver were considered to be normal. Any other foci of increased (131)I uptake, except iodine uptake clearly located in the thyroid bed, were considered to be abnormal. The data were evaluated on a lesion and a patient basis.RESULTS:Regarding neck lesions, SPECT-CT provided a diagnostic impact in 26/90 lesions (28.9%) and confirmed the diagnosis in 64/90 lesions (71.1%). On a patient basis, SPECT-CT changed N status in 12/33 patients (36.4%), provided a diagnostic impact in 21/33 patients (63.6%) and led to a treatment change in 8/33 patients (24.2%). Regarding lesions distant from the neck, SPECT-CT confirmed the diagnosis in 62/71 lesions (87.3%) and had a diagnostic impact in 9/71 lesions (12.7%). On a patient basis, SPECT-CT changed M status in 4/19 patients (21.1%), had a diagnostic impact in 14/19 patients (73.7%) and led to a treatment change in 2/19 patients (10.5%). Considering all patients, SPECT-CT led to a treatment change in 10/41 patients (24.4%).CONCLUSION:Integrated SPECT-CT is a useful tool, especially in cases of diagnostic uncertainty and helps to individualize patient management.

Aim: Gaucher disease type 1 (GD-1) is the most prevalent lysosomal storage disorder and frequently causes osteopenia and osteoporosis. Adequate vitamin D levels are essential for bone health. The present study retrospectively analyzed 25-hydroxyvitamin D (25[OH]D) in outpatients with GD-1.Patients and methods: Sixty GD-1 patients living at home and with residence in southern or central England (34 men, 26 women), aged 17-85 years (mean 45.0 years) were seen at routine follow-up visits (range: 1-9, mean: 4.4) between January 2003 and July 2007. Overall, 264 blood samples, collected at different seasons of the year, were present for laboratory testing. The retrospective interpretation of vitamin D deficiency was based on different cut-off levels of 25(OH)D (<25 nmol/L, <50 nmol/L, <80 nmol/L) and the seasons of the year. Vitamin D sufficiency was defined as 25(OH)D >80 nmol/L.Results: The mean +/- SD of 25(OH)D was 58.2 +/- 30.3. Degrees of vitamin D deficiency (<25 nmol/L, <50 nmol/L, <80 nmol/L) were present in 9.1%, 44.3%, 83.0%, vitamin D sufficiency (>80 nmol/L) in only 17.0%, respectively. A significant seasonal variation of 25(OH)D was present. Results of vitamin D deficiency for December-May were 15.7%, 63.8%, 92.9%, and for June-November 2.9%, 26.3%, 73.7%. The 25(OH)D values representing the seasonal nadir observed during the season December-May showed a significant correlation with T-scores and Z-scores of the lumbar spine and hip. Parathyroid hormone and 25(OH)D were inversely correlated.Conclusions: Vitamin D deficiency is frequent among GD-1 patients. To optimize treatment of GD-1 vitamin D supplementation should be recommended. (C) 2008 Elsevier Inc. All rights reserved.

The aim was to compare two thyroglobulin-immunoradiometric assays (Tg-IRMA) in the follow-up of patients with differentiated thyroid carcinoma (DTC) in order to set up interassay correlation, correlation to clinical background, and to determine whether a lower functional sensitivity (kit A: 0.5 ng/mL, kit B: 0.3 ng/mL) would allow an earlier detection of recurrences. Three hundred eight samples from 181 patients with DTC were investigated. The clinical interpretation of the Tg-IRMA results was based on comprehensive imaging and the clinical history before and during the study period. Groups were formed against this background and against the thyrotropin (TSH) levels of the samples (LT4- on and LT4-off). During a follow-up period that lasted until September 1998, the clinical situation was reevaluated in order to determine any changes in the patients' clinical status. The two assays presented a good interassay correlation of 0.838. Both assays had a high and comparably good sensitivity in the detection of recurrence of malignancy or distant metastases. Patients in remission had, in most cases, nonmeasurable or Tg values below 1 ng/mL. Kit B presented slightly measurable Tg results in a larger number of patients in remission; however, during the follow-up most of these slightly measurable Tg results were not reproducible, thus being most likely artifacts. Consequently, the functional sensitivity of 0.3 ng/mL of kit B showed no advantages in terms of an earlier tumor detection and seems to be unacceptably low. Negative consequences may be an increase in the number of investigations during the follow-up, which may be disconcerting for both the clinicians and the patients.

Bone manifestations are frequent in Gaucher disease (GD), the most prevalent lysosomal storage disorder. Currently, therapy with enzyme replacement (ERT) or substrate reduction (SRT) is available. We investigated changes of laboratory parameters associated with bone metabolism in GD patients switching from ERT to SRT. Seven GD patients consecutively treated with ERT and SRT were studied. All patients had different degrees of bone involvement. Laboratory results were acquired at the time of change from ERT to SRT (0 months) and while on SRT (6 months, 12-18 months). Markers of GD activity remained stable or showed statistically insignificant increases. Six patients had stable skeletal manifestations and reported no bone-associated symptoms. One patient presented progressive bone manifestations on magnetic resonance imaging and experienced increasing bone pain. Osteocalcin, alkaline phosphatase, and C-terminal telopeptide of collagen I were initially within the lower part of the normal range and decreased during SRT (alkaline phosphatase P = 0.0169, osteocalcin nonsignificant, C-terminal telopeptide of collagen I nonsignificant). Tartrate-resistant acid phosphatase 5b was initially normal or slightly increased, and macrophage colony-stimulating factor was within the normal lower range; both parameters remained stable. Interleukin-6 was elevated only in the patient with progressive bone disease. Macrophage inflammatory protein 1alpha (MIP-1alpha) was elevated without change after switching to SRT. MIP-1beta was within the normal range, and no values were above 85 ng/mL, indicative of active skeletal disease. From a clinical and metabolic point of view, most skeletal manifestations and bone-associated laboratory parameters remain stable after switch from ERT to SRT.

Gaucher disease is the most prevalent inherited, lysosomal storage disease and is caused by deficient activity of the enzyme beta-glucocerebrosidase. Bone and bone marrow alterations are frequent in the most prevalent non-neuronopathic form of Gaucher disease. Imaging of bone manifestations in Gaucher disease is performed by a variety of imaging methods, conventional X-ray and MRI as the most frequently and most important ones. However, different modalities of scintigraphic imaging have also been used. This article gives an overview on scintigraphic imaging with respect to bone manifestations in Gaucher disease discussing the advantages and limitations of scintigraphic imaging in comparison to other imaging methods.

The aim of this study was to determine the additional value of SPECT/CT in sentinel node scintigraphy in breast cancer. Furthermore, it was our question to determine, whether the low-dose computed tomography component (LD-CT) can be used for axillary lymph node staging of clinically negative patients. Patients, methods: 51 patients with invasive breast cancer < 3 cm in diameter were included in our prospective investigation. SPECT/CT was performed on a dedicated scanner 30 minutes after subareolar injection of Tc-99m-Nonocoll. Axillary staging with CT(LD) was performed using standard CT-criteria. SLN were allocated to an axillary level using SPECT alone and SPECT/CT. Additionally, the number of SLN on CT(LD) corresponding to the scintigraphic hot node was notified for each patient and compared to the number of SLN found with the gamma probe. Results: In 45/51 evaluable patients SLN could be localised in level I in 43 patients and in level 11 in two patients (all positive) using SPECT-CT, whereas a clear allocation could not be obtained by SPECT alone. The number of SLN was discrepant between SPECT and CT(LD) in 13/45 patients. The number of SIN detected with the gamma probe (n = 68) not significantly differed from the number of SLN detected by CT(ID) (n = 65) but was significantly higher than with SPECT (n = 51). CT(LD) yielded a sensitivity of 35.7%, a specificity of 83.9%, a positive predictive value (PPT) of 50%, a negative predictive value (NPV) of 74.3% and a diagnostic accuracy of 68.9% for axillary staging with CT(ID). Conclusion: The additional information of SPECT/CT allows a more accurate characterization of the SN concerning size, depth and anatomical location. CT(LD) when performed during 99mTc-Nonocoll sentinel-SPECT/CT is not suitable for axillary staging in breast cancer patients with clinical negative axilla due to its low sensitivity and moderate specificity. Therefore, it does not influence the decision for SNB or AND. The limited resolution of SPECT leads to an underestimation of the number of SLN compared to CT(LD) and the gamma probe.

Suppressive thyroid hormone therapy in men with DTC increased bone degradation and induced significant changes in the OPG/RANKL system. These changes include, besides the risk of osteoporosis, possible negative effects on the vascular function and an increased risk of cardiovascular disease.

The aim of our study was a direct comparison of the ability of positron-emission tomography with FDG-PET and of magnetic resonance imaging (MRI) to determine whether breast lesions were benign or malignant and of the two imaging methods capability of depicting eventual multifocal disease. We performed both PET and MRI in 36 patients (40 lesions) who were scheduled for surgery because of suggestive mammographic, sonographic and/or clinical findings. A final histological classification was available for all lesions. Tumour size ranged from 5 to 45 mm (mean 16.7 mm). Sensitivity for lesions, sensitivity for patients, specificity for lesions and specificity for patients were 68.0%, 76.2%, 73.3%, and 73.3% for PET and 92.0%, 95.2%, 73.3%, and 73.3% for MRI, respectively. MRI was more sensitive than FDG-PET in disclosing malignant breast tumours and was also more accurate than FDG-PET in the assessment of multifocal disease. The lower sensitivity of FDG-PET than of MRI seems to be due to difficulties in reliable imaging of carcinomas smaller than 10 mm and of lobular carcinomas.

BACKGROUND The aim of this retrospective study was to evaluate the accuracy of fluorine-18 fluorodeoxyglucose positron emission tomography (18F-FDG-PET) images, which were interpreted under daily routine conditions, in patients with Hodgkin's disease (HD) or non-Hodgkin lymphoma (NHL) for restaging after chemotherapy and/or radiotherapy. For this purpose, 18F-FDG-PET results were compared with morphological imaging methods and the patients' clinical background. METHODS 121 PET images of 93 lymphoma patients (44 HD, 49 NHL) were investigated after chemotherapy/radiotherapy. For PET imaging, 160-200 MBq 18F-FDG was administered intravenously, followed by an infusion of 20 mg Furosemid in 250 mL saline. Whole-body 18F-FDG-PET images were obtained using a partial-ring PET scanner without attenuation correction. The morphological imaging consisted in computed tomography and ultrasound (CT/US) in all patients, additional MRI in some patients, and iliac crest biopsy in cases of suspicious bone marrow involvement. The standard of reference was composed of biopsy data, clinical status at the time of investigation, and follow-up of at least 12 months. The PET images were evaluated for their sensitivity, specificity and accuracy based on written reports, which were compiled from other imaging data and the clinical history of the patients. RESULTS Sensitivity, specificity, and accuracy of 18F-FDG-PET was 91 %, 81 %, and 85 %; of CT/US, 88 %, 35 %, 56 %, respectively. Major sources of error in 18F-FDG-PET were due to asymmetric muscular hypermetabolism and inflammatory lesions misinterpreted as persistent viable lymphoma tissue. Furthermore, secondary malignancies other than lymphomas were another reason for misinterpretations of 18F-FDG-PET studies. CONCLUSIONS 18F-FDG-PET showed a comparable sensitivity but a higher specificity and accuracy compared with CT/US. To achieve a high accuracy in 18F-FDG-PET, the nuclear medicine specialist needs imaging and clinical data as background information, which can only be acquired through close co-operation with the referring clinicians. Pharmacological muscular relaxation in the course of 18F-FDG-PET imaging may be advisable, as nonspecific muscular hypermetabolism was one of the problems at the image readings and a source of incorrect 18F-FDG-PET interpretations.

Background. The aim of this study was to evaluate the usefulness of fluorine-18-fluorodeoxyglucose positron emission tomography (18F-FDG PET) in the preoperative assessment of suspicious thyroid nodules. Methods. A total of 43 patients were examined before surgical resection. In all patients, imaging was obtained at 70 minutes after the intravenous administration of 180 MBq 18F-FDG. Standard uptake values (SUVs) were calculated. Results. A total of 16 patients with thyroid carcinomas (11 papillary, 3 follicular, 2 anaplastic), 23 thyroid adenomas (11 microfollicular, 10 Hurthle cell, 2 macrofollicular), and 4 patients with degenerative goiter were found. 18F-FDG uptake in Hurthle cell adenoma, thyroid cancer, microfollicular adenoma, degenerative goiter, and macrofollicular adenoma was 4.4 ± 2.2, 3.7 ± 1.9, 1.6 ± 0.3, 1.2 ± 0.2, and 0.9 ± 0.1, respectively. Significant differences were observed between thyroid carcinomas and both microfollicular adenomas and degenerative goiters (P < 0.05), and between Hurthle cell adenomas and both microfollicular adenomas as well as degenerative goiter (P < 0.05). For diagnosis of thyroid carcinoma, 100% sensitivity, 63% specificity, and 100% negative predictive value was found when a cutoff value for SUV of 2 was used. Conclusions. Our results indicate that thyroid carcinomas, in contrast to most benign thyroid nodules, demonstrate significantly increased glucose metabolism. 18F-FDG PET is unlikely to differentiate successfully all benign tumors from malignant tumors, but it can help select patients who need surgery, especially if cytology is inconclusive or malignancy cannot be excluded. (Surgery 2003;133:294-9.)

Aim. To evaluate the role of F-18-fluorodeoxyglucose positron-emission tomography (F-18 FDG PET) in the follow-up of breast carcinoma in case of clinical suspicion of local recurrence or distant metastases and/or tumor marker increase in correlation to conventional imaging. Material and Methods. Retrospective analysis of the results of F-18 FDG PET (ECAT ART®, Siemens CTI MS) of 62 patients (age 58.5 ± 12.8) with surgically resected breast carcinoma (time interval after surgery, 86 ± 82 months, mean follow-up 24 ± 12.6 months). Patient- and lesion-based comparison with conventional imaging (CI) including mammography (MG), ultrasonography (US), computerized tomography (CT), magnetic resonance imaging (MRI), radiography (XR) and bone scintigraphy (BS). Furthermore, we evaluated the influence on tumor stage and therapeutic strategy. A visual qualitative evaluation of lesions was performed. Results. On a patient base, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy for detecting local recurrence or distant metastases were calculated to be 97%, 82%, 87%, 96% and 90% compared with 84%, 60%, 73%, 75% and 74% with CI. On a lesion base, significantly more lymph node (84 vs. 23, P < 0.05) and fewer bone metastases (61 vs. 97, P < 0.05) could be detected by using F-18 FDG PET compared with CI. Sclerotic bone lesions were predominantly detected by BS. On the other hand, there were several patients with more FDG positive bone lesions and also mixed FDG positive/Tc-99m methylenediphosphonate (MDP) negative and FDG negative/Tc-99m MDP positive metastases. In case of normal tumor markers, sensitivity, specificity, PPV, NPV and accuracy for detecting local recurrence or distant metastases were calculated to be 100%, 85.0%, 78.6%, 100% and 90.3% for FDG PET and 80%, 50%, 50%, 80% and 61.5% for CI. An upstaging could be observed in 9.7% (6/62) and downstaging in 12.9% (8/62), leading to a change in therapeutic regimen in 13 patients (21%). Conclusions. F-18 FDG PET demonstrates apparent advantages in the diagnosis of metastases in patients with breast carcinoma, compared with conventional imaging on a patient base. On a lesion base, significantly more lymph node and less bone metastases can be detected by using F-18 FDG PET compared with conventional imaging, including bone scintigraphy. In patients with clinical suspicion but negative tumor marker profile, too, F-18 FDG PET seems to be a reliable imaging tool for detection of tumor recurrence or metastases. Considering the high predictive value of F-18 FDG PET, tumor stage and therapeutic strategy will be reconsidered in several patients.

AIM:Patients with differentiated thyroid carcinoma (DTC) must receive suppressive levothyroxine (LT(4)) therapy for the rest of their lives. The literature, however, presents conflicting results on how this affects bone metabolism. The aim of this study was to assess the influence of the estrogen status and LT(4) therapy, in particular LT(4) dosage in micrograms per kilograms (microg/kg), on bone metabolism in female patients with DTC.MATERIAL AND METHODS:Three markers of bone metabolism (C-terminal telopeptide of type I collagen in serum [SCTx]; N-terminal telopeptide of type I collagen in urine [U-NTx]; and osteocalcin [OC]) were investigated in four groups: group REF (healthy premenopausal female controls), group DTC-ES (premenopausal women with DTC and normal estrogen levels), group DTC-ED (postmenopausal women with DTC and estrogen deficiency), and group DTC-HRT (postmenopausal women with DTC undergoing hormone replacement therapy [HRT]). All patients with DTC were on a well-adjusted suppressive LT(4) therapy with TSH levels 0.1 mU/L or less.RESULTS:In group DTC-ES bone turnover was comparable to group REF, whereas in group DTC-ED, all three markers were significantly increased as compared to groups REF and DTC-ES. In group DTC-HRT, the HRT normalized U-NTx and OC. However, in this group S-CTx was not completely normalized by HRT in all patients, although also significantly lowered compared to group DTC-ED. The analysis of LT(4 )dosage per kilogram showed that premenopausal DTC-patients had increased markers of bone metabolism if LT(4) dosage exceeded 2.6 microg/kg. Estrogen-deficient patients with DTC, however, had a much lower critical LT(4) dosage, above which increased markers of bone metabolism were seen.CONCLUSION:A well-adjusted suppressive LT(4) therapy of less than 2.6 microg/kg and normal estrogen levels do not seem to increase bone metabolism in estrogen-sufficient patients with DTC. The normalization of an estrogen deficiency by HRT or other antiresorptive therapies and minimal suppressive dosages of LT(4) are attempts to optimize the care of patients with DTC. In postmenopausal patients with DTC and patients with DTC who require LT(4) dosages in excess of 2.6 microg/kg, the information provided by markers of bone metabolism may help to prevent bone damage.

Summary Aim: Retrospective evaluation of Tc-99m ciprofloxacin (infecton) scintigraphy consecutively performed in a series of patients clinically suspected for peripheral osteomyelitis (OM), spondylodiscitis (SD) and fever of unknown origin (FUO). Methods: A total of 20 patients clinically suspected for OM (n = 12), SD (n = 3) and FUO (n = 5) were included in our retrospective analysis. The additional criterion was a positive 3-phase bone scan for OM, or a 2-phase bone scan in case of SD. Planar whole body scans and static acquisitions were performed 1 and 4 h after application of 370 MBq Tc-99m ciprofloxacin. In 10 patients with suspected OM, additional immunoscintigraphy using Tc-99m labelled monoclonal antibodies (Mab BW 250/183) was performed and the correlation of infecton to bloodpool and antigranulocyte scintigraphy was analysed. Results: OM: Bacterial infection was confirmed in 8 of 15 lesions. Infecton demonstrated true positive (TP) results in 7 of 8, true negative (TN) results in 2 of 7, false positive (FP) results in 5 of 7 patients and one false negative (FN) result. A strong correlation could be demonstrated between T/NT ratios of infecton and bloodpool Tc-99m medronate imaging (r = 0.84, 0.88) and between infecton and BW 250/183 (r = 0.92, 0.90). Using a threshold of 2.0 for T/NT ratio, only TP results could be observed whereas a T/NT in the range of 1.0-2.0 could not discriminate between septic and aseptic inflammation. Concordant results with Mab BW 250/183 could only be observed in 5 of 10 patients (4 TP, 1 TN) by showing 4 FP and 1 FN lesions with IF. Conclusion: Non-specific uptake of infecton can be observed in a variety of clinical situations with moderate uptake, by showing a strong correlation with blood-pool imaging. Nevertheless, intense uptake may be specific for septic inflammation.