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Cronin O, Subedi D, Forsyth L, Goodman K, Lewis SC, Keerie C, Walker A, Porteous M, Cetnarskyj R, Ranganath LR, Selby PL, Hampson G, Chandra R, Ho S, Tobias JH, Young-Min SA, McKenna MJ, Crowley RK, Fraser WD, Tang J, Gennari L, Nuti R, Brandi ML, Del Pino-Montes J, Devogelaer JP, Durnez A, Isaia GC, Di Stefano M, Rubio JB, Guanabens N, Seibel MJ, Walsh JP, Kotowicz MA, Nicholson GC, Duncan EL, Major G, Horne A, Gilchrist NL, Ralston SH. Characteristics of Early Paget's Disease in SQSTM1 Mutation Carriers: Baseline Analysis of the ZiPP Study Cohort. J Bone Miner Res 2020; 35:1246-1252. [PMID: 32176830 DOI: 10.1002/jbmr.4007] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/25/2020] [Accepted: 03/10/2020] [Indexed: 12/26/2022]
Abstract
Mutations in SQSTM1 are strongly associated with Paget's disease of bone (PDB), but little is known about the clinical characteristics of those with early disease. Radionuclide bone scans, biochemical markers of bone turnover, and clinical characteristics were analyzed in SQSTM1 mutation carriers who took part in the Zoledronic acid in the Prevention of Paget's disease (ZiPP) study. We studied 222 individuals, of whom 54.9% were female, with mean ± SE age of 50.1 ± 0.6 years. Twelve SQSTM1 mutations were observed, including p.Pro392Leu, which was present in 141 of 222 (63.5%) subjects. Bone scan examination revealed evidence of PDB in 20 subjects (9.0%), ten of whom (50%) had a single affected site. Participants with lesions were older than those without lesions but the difference was not significant (53.6 ± 9.1 versus 49.8 ± 8.9; p = .07). The mean age of participants with lesions was not significantly different from the age at which their parents were diagnosed with PDB (55 years versus 59 years, p = .17). All individuals with lesions were asymptomatic. Serum concentrations of total alkaline phosphatase (ALP) normalized to the upper limit of normal in each center were higher in those with lesions (0.75 ± 0.69 versus 0.42 ± 0.29 arbitary units; p < .0001). Similar findings were observed for other biochemical markers of bone turnover, but the sensitivity of ALP and other markers in detecting lesions was poor. Asymptomatic PDB is present in about 9% of SQSTM1 mutation carriers by the fifth decade. Further follow-up of this cohort will provide important information on the natural history of early PDB and its response to treatment. © 2020 The Authors. Journal of Bone and Mineral Research published by American Society for Bone and Mineral Research.
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Affiliation(s)
- Owen Cronin
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK
| | - Deepak Subedi
- Department of Radiology and Nuclear Medicine, Western General Hospital, Edinburgh, UK
| | - Laura Forsyth
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK
| | - Kirsteen Goodman
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK
| | - Allan Walker
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK
| | - Mary Porteous
- South East Scotland Molecular Genetics Service, Western General Hospital, Edinburgh, UK
| | | | | | - Peter L Selby
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK
| | - Geeta Hampson
- Department of Chemical Pathology and Metabolic Bone Clinic, Department of Rheumatology, Guy's and St. Thomas' Hospital, London, UK
| | - Rama Chandra
- Clinical Biochemistry, King's College Hospital, London, UK
| | - Shu Ho
- The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, UK
| | - Jon H Tobias
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Malachi J McKenna
- Endocrinology Department, St. Vincent's University Hospital, Dublin, Republic of Ireland.,St Vincent's University Hospital and University College Dublin, Dublin, Republic of Ireland
| | - Rachel K Crowley
- Endocrinology Department, St. Vincent's University Hospital, Dublin, Republic of Ireland.,St Vincent's University Hospital and University College Dublin, Dublin, Republic of Ireland
| | - William D Fraser
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Jonathan Tang
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, UK
| | - Luigi Gennari
- Department of Medicine, Surgery and Neurosciences, University of Sienna, Sienna, Italy
| | - Rannuccio Nuti
- Department of Medicine, Surgery and Neurosciences, University of Sienna, Sienna, Italy
| | - Maria-Luisa Brandi
- Department of Internal Medicine, University Hospital of Careggi, Florence, Italy
| | | | | | - Anne Durnez
- Clinique Universitaires Saint-Luc, Brussels, Belgium
| | - Giovanni Carlo Isaia
- Geriatrics and Metabolic Bone Diseases, AOU San Giovanni Battista di Torino Corso, Torino, Italy
| | - Marco Di Stefano
- Geriatrics and Metabolic Bone Diseases, AOU San Giovanni Battista di Torino Corso, Torino, Italy
| | | | - Nuria Guanabens
- Department of Rheumatology, Hospital Clinic, CIBERehd, Barcelona, Spain
| | - Markus J Seibel
- Department of Endocrinology and Metabolism, Concord Repatriation General Hospital, Sydney, Australia
| | - John P Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Australia.,Medical School, The University of Western Australia, Crawley, Australia
| | - Mark A Kotowicz
- Department of Endocrinology and Diabetes, Deakin University, Geelong, Australia
| | - Geoffrey C Nicholson
- Rural Clinical School Research Centre, Darlin Heights, The University of Queensland, Brisbane, Australia
| | - Emma L Duncan
- Endocrinology Department, Royal Brisbane and Woman's Hospital, Herston, Australia.,Translational Genomics Group, Institute of Health and Biomedical Innovation, Faculty of Health, Queensland University of Technology, Translational Research Institute, Princess Alexandra Hospital, Woolloongabba, Australia.,Faculty of Medicine, University of Queensland, Herston, Australia
| | - Gabor Major
- Rheumatology, Bone and Joint Institute, Royal Newcastle Center, New Lambton Heights, Australia.,University of Newcastle, Callaghan, Australia
| | - Anne Horne
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Nigel L Gilchrist
- The CGM Research Trust, The Princess Margaret Hospital, Christchurch, New Zealand
| | - Stuart H Ralston
- Rheumatic Diseases Unit, Western General Hospital, Edinburgh, UK.,Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Nine Edinburgh Bioquarter, Edinburgh, UK.,Centre for Genomic and Experimental Medicine, Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital, Edinburgh, UK
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2
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Cundy T, Que L, Hassan IM, Hughes L. Bisphosphonate-Induced Deterioration of Osteomalacia in Undiagnosed Adult Fanconi Syndrome. JBMR Plus 2020; 4:e10374. [PMID: 32803107 PMCID: PMC7422711 DOI: 10.1002/jbm4.10374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/28/2020] [Accepted: 05/26/2020] [Indexed: 12/16/2022] Open
Abstract
We describe two women with a misdiagnosed fracturing bone disease who were treated erroneously with i.v. zoledronate. Over the next year, they suffered marked clinical and radiographic deterioration in skeletal disease. Both were eventually diagnosed with hypophosphatemic osteomalacia secondary to acquired Fanconi syndrome (caused by light-chain myeloma in one case and tenofovir treatment in the other). Appropriate treatment with phosphate supplementation was instituted with clinical improvement. These cases illustrate the importance of not missing osteomalacia in adults presenting with fractures, and the potentially damaging effects of treatment with long-acting inhibitors of bone resorption in these circumstances. © 2020 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Tim Cundy
- Department of Endocrinology Greenlane Clinical Centre Auckland New Zealand
| | - Lorna Que
- Nuclear Medicine, Department of Radiology Auckland City Hospital Auckland New Zealand
| | - Ibrahim M Hassan
- Nuclear Medicine, Department of Radiology Auckland City Hospital Auckland New Zealand
| | - Louise Hughes
- Department of Anatomical Pathology Concord Hospital Sydney Australia
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3
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Nuclear Medicine Imaging Techniques of the Musculoskeletal System. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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4
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Jennings E, Buckberry J, Brickley MB. Radiographically recognizable? An investigation into the appearance of osteomalacic pseudofractures. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2018; 23:26-31. [PMID: 30527918 DOI: 10.1016/j.ijpp.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 06/09/2023]
Abstract
Pseudofractures, lucent bands that occur due to a build-up of osteoid, are a key feature of osteomalacia. In paleopathology, pseudofractures are often marked by small, linear cracks in the cortex of the bone surrounded by irregular, bony spicule formation. Radiography can be used to help diagnose pseudofractures, both clinically and in paleopathology. A detailed understanding of the radiographic appearance of pseudofractures and their development is, therefore, necessary to aid a diagnosis of vitamin D deficiency. The present study examined the clinical literature to determine current ideas on the appearance of pseudofractures with the aim of applying this knowledge to paleopathology. A radiographic study of the characteristics of pseudofractures was performed on five individuals with clear skeletal features of osteomalacia from archaeological sites in Canada and the United Kingdom dating to the medieval period (5th to 15th centuries) and the 18th to 19th century. Results show that the radiographic appearance of pseudofractures could potentially reveal information about the cause of the deficiency and the chronicity of pseudofractures. This type of information has the potential to further our understanding of the lived experiences of archaeological individuals with osteomalacia.
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Affiliation(s)
- Emma Jennings
- Department of Anthropology, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Jo Buckberry
- Department of Archaeological and Forensic Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Megan B Brickley
- Department of Anthropology, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
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Krishna Mohan VS, Narayan ML, Mukka A, Bachimanchi B, Chowhan AK, Devi BV, Vaikkakara S, Sachan A. Atypical Parathyroid Adenoma with Multiple Brown Tumors as Initial Presentation: A Rare Entity. Indian J Nucl Med 2017; 32:133-136. [PMID: 28533644 PMCID: PMC5439188 DOI: 10.4103/0972-3919.202234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Brown tumors seen in hyperparathyroidism are rare, non-neoplastic lesions because of abnormal bone metabolism, and they can mimic benign bone tumors or malignancy. Although biopsy is considered as the gold standard for diagnosis, it can be inconclusive. As the diagnosis of brown tumors is often challenging, a high index of suspicion is essential for diagnosis. We present a case of 21-year-old woman who presented with multiple painful bony lesions, which were initially misdiagnosed as fibrous dysplasia. Due to persistent bone pain and deterioration in her physical mobility, she was referred to tertiary care centre. After thorough clinical workup, she underwent Tc-99m methylene diphosphonate bone scintigraphy that raised strong clinical suspicion of hyperparathyroidism and brown tumors. Subsequently, Tc-99m-methoxy isobutyl isonitrile (MIBI) parathyroid scintigraphy revealed a solitary MIBI avid focal lesion, suggestive of left inferior parathyroid adenoma. Later parathyroidectomy was performed and histopathological examination confirmed it as atypical parathyroid adenoma.
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Affiliation(s)
- V S Krishna Mohan
- Department of Nuclear Medicine and PET CT, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Manishi L Narayan
- Department of Nuclear Medicine and PET CT, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Arun Mukka
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Bharath Bachimanchi
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Amit Kumar Chowhan
- Department of Pathology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - B Vijayalakshmi Devi
- Department of Radiology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Suresh Vaikkakara
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Alok Sachan
- Department of Endocrinology, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
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6
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Zhao Y, Wang Q. Bone uptake of Tc-99m MIBI in patients with hyperparathyroidism. Ann Nucl Med 2014; 28:349-55. [PMID: 24519437 DOI: 10.1007/s12149-014-0818-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 01/23/2014] [Indexed: 01/27/2023]
Abstract
OBJECTIVE The study aimed to investigate the incidence of bone uptake of tracer on Tc-99m MIBI imaging and explore its influencing factors and significance for diagnosis of metabolic bone disease (MBD) in patients with hyperparathyroidism (HPT). METHODS Seventy-nine consecutive patients with histopathologically confirmed HPT (63 primary and 16 secondary) who had preoperative Tc-99m MIBI imaging were retrospectively evaluated. Serum calcium (Ca), phosphorus (P), and intact parathyroid hormone (iPTH) were measured for all patients, and serum alkaline phosphatase (ALP) was measured for 62 patients. Of the 79 patients, 50 underwent bone mineral density (BMD) examination and 30 underwent bone scintigraphy. The incidence and characteristics of abnormal bone uptake of MIBI were recorded. Mann-Whitney test was performed to determine if serum iPTH, Ca, P, ALP, and BMD were different between the patients with and without MIBI bone uptake. Logistic regression analysis was used to analyze the factors that influence the bone uptake of MIBI. The concordance rate between Tc-99m MIBI imaging and bone scintigraphy in delineating MBD was calculated. RESULTS Tc-99m MIBI imaging disclosed the abnormal bone uptake of tracer in 22 (27.8 %) patients. Of them, 19 showed diffusely increased activity in skeleton, 2 showed focal uptake in brown tumors, and one showed both above patterns. Patients with bone uptake MIBI had higher level of serum iPTH (Z = -4.34, P < 0.001) and ALP (Z = -3.50, P < 0.001) than those without bone uptake. Logistic regression analysis also showed that bone uptake of MIBI was correlated with serum iPTH (OR = 4.42, P < 0.001) and ALP (OR = 3.21, P = 0.002). Among the 30 patients that underwent bone scintigraphy, 76.7 % patients showed signs of MBD, and the concordance rate between Tc-99m MIBI imaging and bone scintigraphy was 60 % for detecting MBD. CONCLUSIONS Bone uptake of MIBI in patients with HPT is commonly related to a high level of iPTH and ALP; it probably reflects an active stage of MBD, and it should be monitored during the conventional Tc-99m MIBI scintigraphy.
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Affiliation(s)
- Yunyun Zhao
- Department of Nuclear Medicine, Peking University People's Hospital, No.11 Xizhimen South Avenue, Xicheng District, Beijing, 100044, China
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7
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Abstract
Conventional radiography can detect most fractures, evaluate their healing, and visualize characteristic skeletal abnormalities for some metabolic bone diseases. Dual-energy X-ray absorptiometry (DXA) is used to measure areal bone mineral density (BMD) in order to diagnose osteoporosis, estimate fracture risk, and monitor changes in BMD over time. Vertebral fracture assessment by DXA can diagnose vertebral fractures with less ionizing radiation, greater patient convenience, and lower cost than conventional radiography. Quantitative computed tomography (QCT) measures volumetric BMD separately in cortical and trabecular bone compartments. High resolution peripheral QCT and high resolution magnetic resonance imaging are noninvasive research tools that assess the microarchitecture of bone. The use of these technologies and others has been associated with special challenges in men compared with women, provided insights into differences in the pathogenesis of osteoporosis in men and women, and enhanced understanding of the mechanisms of action of osteoporosis treatments.
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Affiliation(s)
- E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, 300 Oak Street NE, Albuquerque, NM 87106, USA.
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8
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Cook GJ, Gnanasegaran G, Chua S. Miscellaneous Indications in Bone Scintigraphy: Metabolic Bone Diseases and Malignant Bone Tumors. Semin Nucl Med 2010; 40:52-61. [DOI: 10.1053/j.semnuclmed.2009.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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9
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Nishida H, Kaida H, Ishibashi M, Hiromatsu Y, Baba K, Iida S, Okuda S. Usefulness of bone uptake ratio of bone scintigraphy in hemodialysis patients. Ann Nucl Med 2009; 19:91-4. [PMID: 15909487 DOI: 10.1007/bf03027386] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE It is important to estimate the bone metabolism in patients with renal osteodystrophy. The methods of estimation must be noninvasive, accurate, and able to measure repeatedly. METHODS The regions of interest on bone scintigraphy were drawn over the radius in 22 hemodialysis patients (10 males, 12 females). The bone/soft tissue ratio (B/ST ratio) was calculated for all patients. The bone soft tissue ratio of both skull (S) and radius (R) was obtained from the resultant count ratios. We investigated the correlation between intact parathyroid hormone (PTH), alkaline phosphatase (ALP) and the uptake ratios S and R. RESULTS Intact PTH had a significantly linear correlation with R (r = 0.745, p < 0.0001) and S (r = 0.702, p = 0.0001). ALP also had a significantly linear correlation with R (r = 0.537, p = 0.009) and S (r = 0.772, p < 0.0001). CONCLUSION The measurement of the bone soft tissue ratio of radius on bone scintigraphy was crucial for estimating renal osteodystrophy.
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Affiliation(s)
- Hidemi Nishida
- Department of Nephrology and Dialysis Unit, Kurume University School of Medicine, Fukuoka, Japan.
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10
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Abstract
Bone scintigraphy and X-ray are complementary in the assessment of Paget's disease. Whereas bone scintigraphy allows visualization of the whole skeleton and 'hot spots', X-ray enables visualization of more detailed images of the pagetic bone lesion. X-ray may be invaluable in the diagnosis of osteomalacia, especially in children. As osteomalacia is characterized by impaired bone mineralization, the use of bone density measures may lead to misinterpretation of the condition as osteoporosis. Dual-energy X-ray absorptiometry at the femoral neck is the 'gold standard' for the assessment of osteoporosis. However, all devices are useful to predict the risk of fracture. In the future, high-resolution computer tomography and magnetic resonance imaging may become valuable clinical tools, capturing the architectural aspect of bone strength and improving fracture prediction models.
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Affiliation(s)
- Glenn Haugeberg
- Norwegian University of Science and Technology, MTFS, Department of Neuroscience, Division of Rheumatology, N-7489 Trondheim, Norway.
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11
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12
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Musculoskeletal radionuclide imaging. Clin Nucl Med 2006. [DOI: 10.1201/b13348-31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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13
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Abstract
The clinical evaluation of the osteoporotic patient should include a careful assessment of risk factors for low bone mass, falls, and fractures; quantitation of BMD; a thorough medical history and physical examination; and a targeted set of laboratory, radiographic, and other diagnostic studies as indicated. Among the elderly, vitamin D deficiency ranks high as one of the most underdiagnosed and yet reversible causes of osteoporosis. Regardless of age, every patient with low bone mass or fractures deserves an evaluation to uncover reversible, treatable disorders and to detect serious underlying illnesses.
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Affiliation(s)
- Carolyn Becker
- Metabolic Bone Unit, Division of Endocrinology, Toni Stabile Osteoporosis Center, Columbia Presbyterian Medical Center, New York, NY, USA.
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14
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Schmaldienst S, Dittrich E, Pietschmann P, Niederle B, Becherer A, Watschinger B. A patient with evidence of two underlying diseases causing hypercalcaemia. Nephrol Dial Transplant 2001; 16:2423-5. [PMID: 11733639 DOI: 10.1093/ndt/16.12.2423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S Schmaldienst
- Department of Internal Medicine III, Division of Nephrology and Dialysis, University of Vienna, Vienna, Austria.
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15
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Aktas A, Elahi N. Bone scan findings in patients with chronic renal failure having symptoms related to bone: correlation with parathyroid hormone levels. Transplant Proc 1999; 31:3309-11. [PMID: 10616488 DOI: 10.1016/s0041-1345(99)00807-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- A Aktas
- Department of Nuclear Medicine, Baskent University School of Medicine, Ankara, Turkey. melekk@Baskent 1.h.baskent.edu.tr
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16
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Abstract
Paget's disease of bone is important in geriatric populations because it is the second most common bone disorder after osteoporosis. In older people, it may be responsible for chronic back pain and joint pain, skeletal deformities, hearing loss, and cranial nerve compression. Paget's disease can reduce both function and mobility in the older people. In addition to newer tests for assessing the activity of Paget's disease, effective therapy is available in the form of salmon calcitonin for nasal administration and new third generation bisphosphonates. Frequently, treatment can reverse the course of the disease. For these reasons, it is feasible for the physician to adopt an aggressive approach to diagnosis and treatment. The objective should be to relieve pain, improve mobility, and forestall debilitating complications. This review will focus on the manifestations and clinical management of Paget's disease. Two cases are presented that illustrate common management problems in older patients.
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Affiliation(s)
- M A Ankrom
- Department of Medicine, Johns Hopkins University, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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17
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Kigami Y, Yamamoto I, Ohnishi H, Takada M, Matsushita R, Hamanaka Y, Ota T, Morita R. Relationship between skeletal uptake of 99mTc-HMDP and bone mineral density in elderly women. Ann Nucl Med 1998; 12:15-20. [PMID: 9559957 DOI: 10.1007/bf03165411] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The relationship between bone mineral density in elderly women and the pattern of skeletal uptake of 99mTc-HMDP, especially in regard to skull uptake, was investigated. The whole-body skeletal uptake (WBSU) and whole-body skeletal tracer distribution patterns were studied in 86 disease-free women on bone scintigraphy with 99mTc-hydroxy-methylene-diphosphonate (HMDP). Bone scans were quantified by setting regions of interest (ROI) and bone mineral density (BMD) was assessed by dual-energy X-ray absorptiometry in all patients. WBSU and the skeletal distribution pattern were compared with bone mineral densities of the entire skeleton as well as selected regions. WBSU was high in the elderly and negatively correlated with regional bone mineral densities (r = -0.403 to -0.534). Among the regions, uptake by the skull increased with age more than in other regions in women and had the highest negative correlation with the bone mineral density. The skull uptake correlated negatively with total body BMD (r = -0.583) and with lumbar BMD (r = -0.561, p < 0.0001). Our results show that increased radionuclide uptake in bone scintigraphy, especially skull uptake was associated with decreased bone mineral density in elderly women, so that, increased skull uptake in elderly women would be a scintigraphic sign of post-menopausal or senile osteopenia.
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Affiliation(s)
- Y Kigami
- Department of Radiology, Shiga University of Medical Science, Otsu, Japan
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18
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Musculoskeletal. Clin Nucl Med 1998. [DOI: 10.1007/978-1-4899-3356-0_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Abstract
The bone scan has well-recognized appearances in metabolic bone diseases, with its main clinical value found in focal conditions or the focal complications of disease. In clinical practice, the bone scan is most widely used to detect fractures in osteoporosis and pseudofractures in osteomalacia and to evaluate Paget's disease.
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Affiliation(s)
- P J Ryan
- Department of Nuclear Medicine, Guy's Hospital London and Medway Hospital, Gillingham, UK
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20
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Abstract
Patients with a wide variety of rheumatological conditions can be usefully investigated by nuclear medicine techniques and particularly by bone scintigraphy. This aspect of nuclear medicine work is increasing and the trend can be expected to continue. The principal conditions that can be imaged are sports medicine injuries, osteomyelitis, avascular necrosis, reflex sympathetic dystrophy syndrome, enthesopathies and bio-mechanical stress lesions, inflammatory arthropathies, metabolic bone disease and miscellaneous bone conditions such as costo-chondritis. Single photon emission tomography (SPECT) has provided new indications for bone scintigraphy such as the evaluation of spondylolysis and facet syndrome in the spine and of meniscal tears and ligamental lesions.
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Affiliation(s)
- P J Ryan
- Medway Hospital Trust, Gillingham, Kent, UK
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21
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Abstract
The isotope bone scan continues to be the most widely performed nuclear medicine investigation in the UK. The detection of skeletal metastases remains the most common clinical indication. However, the use of the bone scan is changing as it becomes subject to cost pressures, competing imaging modalities, and altering clinical indications. Overall, fewer studies are being performed for investigation of skeletal metastases, but this decrease in numbers has been compensated by increasing use in benign orthopaedic conditions. Advances such as correlative imaging and single photon emission computer tomography have increased its value and provided new clinical roles. Quantitation has still not achieved widespread usage, although it continues to be helpful to investigate sacroiliitis. Bone positron emission tomography imaging is now possible, although definite clinical roles have yet to be identified. Bone densitometry using dual x-ray absorptiometry is rapidly increasing in availability and usage throughout the UK, and this can be expected to continue to increase over the next few years.
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Affiliation(s)
- P J Ryan
- Nuclear Medicine Department, Medway Hospital, Gillingham, Kent, UK
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22
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Affiliation(s)
- P Burckhardt
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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23
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de Jonge FA, Pauwels EK, Hamdy NA. Scintigraphy in the clinical evaluation of disorders of mineral and skeletal metabolism in renal failure. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1991; 18:839-55. [PMID: 1743208 DOI: 10.1007/bf00175066] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In patients with renal bone disease skeletal and extra-skeletal abnormalities can be visualised using conventional bone scintigraphy. Some of these abnormalities are associated with characteristic scintigraphic appearances, which are reviewed in detail, and the possible mechanisms involved are discussed. Specific imaging with iodine 123 serum amyloid P component and iodine 131 beta 2-microglobulin is also discussed in the diagnosis of beta 2-microglobulin amyloidosis specific to patients on dialysis. In the light of available evidence, it appears that bone scintigraphy plays, so far, a limited role in the clinical evaluation of skeletal and extra-skeletal abnormalities in chronic renal failure. The potential role of bone scintigraphy in identifying patients with aluminium-related bone disease needs to be investigated further, and in this respect special attention must be given to the problem of high soft-tissue activity associated with impaired renal function. Timing haemodialysis sessions before scintigraphic imaging deserves wider recognition as it reduces high soft-tissue activity, thereby allowing bone uptake to be assessed more accurately. Specific imaging of amyloidosis resulting from beta 2-microglobulin deposition is a promising technique, but the relative value of the two proposed radiopharmaceuticals needs further clarification.
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Affiliation(s)
- F A de Jonge
- Department of Diagnostic Radiology (Division of Nuclear Medicine), University Hospital Leiden, The Netherlands
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Rico H, Merono E, Del Olmo J, Revilla M. The value of bone scintigraphy in the follow-up of vertebral osteoporosis. Clin Rheumatol 1991; 10:298-301. [PMID: 1790640 DOI: 10.1007/bf02208694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In an open study, we have assessed the bone/soft tissue uptake index in recent osteoporotic vertebral collapse using scintigraphy. The evolution of these cases was followed-up at 6 months in 22 patients treated with 100 IU of salmon calcitonin plus 500 mg of elemental calcium/10 days per month and in 18 patients treated with 500 mg of elemental calcium only on a daily basis. There were no index differences between groups prior to treatment. At six months, the group treated with calcitonin plus calcium showed a significant decrease from 10.2 +/- 6.4 to 3.2 +/- 1.1 (p less than 0.001), while the calcium only group did not show any significant changes (12.1 +/- 6.6 vs 9.2 +/- 4.6), considering that there were significant differences between groups (p less than 0.001). On a mid-term basis, these results have shown the values of the bone/soft tissue index in the follow-up of osteoporotic vertebral collapse.
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Affiliation(s)
- H Rico
- Department of Medicine, Alcala de Henares University, Madrid, Spain
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Fogelman I. Bone scanning and photon absorptiometry in metabolic bone disease. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1988; 2:59-86. [PMID: 3044333 DOI: 10.1016/s0950-351x(88)80008-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Bone scan imaging with the current bone-seeking radiopharmaceuticals, the technetium-99m labelled diphosphonates, provides a functional display of skeletal metabolism and has dramatically improved our ability to investigate skeletal pathology. While the role of bone scanning in metastatic disease was recognized early, and welcomed by oncologists and other specialists alike, in the field of metabolic bone disease the realization of its potential value has been slower, with perhaps more reluctant acceptance. Nevertheless, the skeleton remains an extremely difficult organ to investigate, and a familiarity with bone scanning should be an essential part of the investigational armamentarium for anyone with an interest in the metabolic bone disorders. The measurement of bone mineral by photon absorptiometry is a relatively new technique, which is rapidly gaining acceptance. The ability to accurately detect and quantify changes in bone mass is potentially of considerable value in the diagnosis and management of osteoporosis. The technique provides us with an extremely important and powerful research tool but, at the present time, its role in clinical practice has yet to be established.
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Hordon LD, Francis RM, Marshall DH, Smith AH, Peacock M. Are scintigrams of the spine useful in vertebral osteoporosis? Clin Radiol 1986; 37:487-9. [PMID: 3757422 DOI: 10.1016/s0009-9260(86)80065-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
To determine whether technetium diphosphonate scintigraphy could be used to date vertebral crush fractures, serial scintigrams and radiographs were obtained on two groups of 27 osteoporotic patients. Although radiologically crushed vertebrae were significantly associated with areas of increased isotope uptake on the scintigrams (p less than 0.001), this did not depend on the age of the crush fracture. Some radiologically uncrushed vertebrae, particularly in the lumbar spine, also showed increased isotope uptake.
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Abstract
In the management of patients with metabolic bone disease, nuclear medicine laboratories offer two nontraumatic procedures of potential clinical importance: bone mineral measurements and bone scintigraphy. Bone mineral measurements from the radius, lumbar spine, and hip obtained with use of absorptiometry or computed tomography can be used to predict the risk of fracture at these skeletal sites, can determine the severity of bone loss for the assessment of a benefit-versus-risk ratio on which appropriate therapy can be based, and can substantiate the effectiveness of therapy over time. Bone scintigraphy with use of labeled diphosphonate allows assessment of focal and, in defined circumstances, of total skeletal bone turnover in patients with normal kidney function. Both of these techniques have been used successfully in studies of population groups for the evaluation of trends. Their application to the management of individual patients is currently being evaluated.
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McKillop JH, Fogelman I. Bone scintigraphy in benign bone disease. BMJ : BRITISH MEDICAL JOURNAL 1984; 288:264-6. [PMID: 6419889 PMCID: PMC1444049 DOI: 10.1136/bmj.288.6413.264] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Abstract
The bone scan may be of value in the assessment of patients with metabolic bone disease. However the superiority of the bone scan when compared to radiology in conditions such as renal osteodystrophy, osteomalacia, primary hyperparathyroidism, and osteoporosis requires substantiation with the newer radiopharmaceuticals which have a higher affinity for bone. Two methods of quantitating skeletal uptake of tracer have been assessed to try to remove the subjective aspect of bone scan evaluation. Measurements of bone to soft tissue ratios have proved clinically disappointing, but 24 hour whole body retention of diphosphonate appears to provide a sensitive index of increased bone turnover.
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Fogelman I, Carr D. A comparison of bone scanning and radiology in the assessment of patients with symptomatic Paget's disease. EUROPEAN JOURNAL OF NUCLEAR MEDICINE 1980; 5:417-21. [PMID: 7215363 DOI: 10.1007/bf00261784] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Bone scans and X-rays from 23 subjects with symptomatic Paget's disease were evaluated. One-hundred and twenty-seven sites of Pagetoid involvement were found, of which 120 (94.5%) were recognised on the bone scan as compared to 94 (74%) on X-ray. The anatomical distribution and relationship of lesions on scan and X-ray to the patient's symptoms are also discussed. It is concluded that the bone scan is more sensitive than radiology in detecting Paget's disease and only rarely will a lesion that is seen on X-ray not be visualised by scanning.
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