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Jin Y, Huang K, Shao T. [ 18F]Fluorodeoxyglucose ([ 18F]FDG) positron emission tomography and conventional imaging modalities in the diagnosis of diabetic foot osteomyelitis: a meta-analysis. Clin Radiol 2024; 79:e1142-e1151. [PMID: 38880677 DOI: 10.1016/j.crad.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Abstract
AIM This meta-analysis aimed to evaluate the comparative diagnostic efficacy of [18F]Fluorodeoxyglucose positron emission tomography ([18F]FDG PET) and conventional imaging, MRI, and white blood cell (WBC) scintigraphy in detecting foot osteomyelitis among diabetic patients. MATERIALS AND METHODS An exhaustive search was conducted within the PubMed and Embase databases to identify publications available up until February 2024. Studies were included if they evaluated the diagnostic efficacy of [18F]FDG PET or the comparative diagnostic performance between PET and (MRI or WBC scintigraphy). Two researchers independently assessed the quality of the included studies, utilizing the Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool. RESULTS Nine retrospective or prospective studies involving 605 patients were included in the meta-analysis. For [18F]FDG PET, the overall sensitivity was 0.83(95% CI: 0.69-0.94), while the overall specificity was 0.92(95% CI: 0.86-0.97). In the head-to-head comparison, no significant difference of sensitivity was found between [18F]FDG PET and MRI (0.72 vs. 0.68, P=0.81), as well as between [18F]FDG PET and WBC scintigraphy (0.57 vs. 0.66, P=0.64). In addition, specificity was also found to be no significant difference between [18F]FDG PET and MRI (0.90 vs. 0.82, P=0.27), as well as [18F]FDG PET and WBC scintigraphy (0.81 vs. 0.93, P=0.09). CONCLUSION [18F]FDG PET demonstrates similar sensitivity and specificity to MRI and WBC scintigraphy in detecting foot osteomyelitis among diabetic patients. MRI, often cited as a primary choice in guidelines, might be preferred due to its lower cost and lower dose. Further larger sample prospective studies are needed to confirm these findings.
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Affiliation(s)
- Y Jin
- Infectious Disease Department, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - K Huang
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - T Shao
- Infectious Disease Department, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China.
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2
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Lauri C, Noriega-Álvarez E, Chakravartty RM, Gheysens O, Glaudemans AWJM, Slart RHJA, Kwee TC, Lecouvet F, Panagiotidis E, Zhang-Yin J, Martinez JLL, Lipsky BA, Uccioli L, Signore A. Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance. Eur J Nucl Med Mol Imaging 2024; 51:2229-2246. [PMID: 38532027 PMCID: PMC11178575 DOI: 10.1007/s00259-024-06693-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/14/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings. METHODS This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria. RESULTS Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging. CONCLUSION These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.
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Affiliation(s)
- Chiara Lauri
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
| | - Edel Noriega-Álvarez
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular Imaging, University Hospital of Guadalajara, Guadalajara, Spain
| | - Riddhika M Chakravartty
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Radiology Department, Shrewsbury and Telford Hospitals NHS Trust, Shrewsbury, UK
| | - Olivier Gheysens
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine and Molecular imaging, University Hospitals Leuven, Leuven, Belgium
| | - Andor W J M Glaudemans
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria.
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
| | - Thomas C Kwee
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frédéric Lecouvet
- Department of Radiology, Institut de Recherche Expérimentale et Clinique Cliniques, Universitaires Saint-Luc, Université Catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Emmanouil Panagiotidis
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Department/PET CT, Theagenio Cancer Center, Thessaloniki, Greece
| | - Jules Zhang-Yin
- Bone & Joint Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Department of Nuclear Medicine, Clinique Sud Luxembourg, Vivalia, Arlon, Belgium
| | | | - Benjamin A Lipsky
- Emeritus Professor of Medicine, University of Washington, Seattle, USA
- Green Templeton College, University of Oxford, Oxford, UK
| | - Luigi Uccioli
- Diabetes and Endocrinology Section, CTO Hospital of Rome, Rome, Italy
- Department of Biomedicine and prevention, Tor Vergata University, Rome, Italy
| | - Alberto Signore
- Inflammation and Infection Committee of the European Association of Nuclear Medicine (EANM), Vienna, Austria
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, "Sapienza" University of Rome, Rome, Italy
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Singh SB, Bhandari S, Siwakoti S, Bhatta R, Raynor WY, Werner TJ, Alavi A, Hess S, Revheim ME. Is Imaging Bacteria with PET a Realistic Option or an Illusion? Diagnostics (Basel) 2023; 13:diagnostics13071231. [PMID: 37046449 PMCID: PMC10093025 DOI: 10.3390/diagnostics13071231] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/14/2023] [Accepted: 03/22/2023] [Indexed: 04/14/2023] Open
Abstract
The application of [18F]-fluorodeoxyglucose ([18F]FDG) as a radiotracer to detect sites of inflammation (either due to bacterial infection or primary inflammation) has led to exploring the role of PET in visualizing bacteria directly at sites of infection. However, the results from such efforts are controversial and inconclusive so far. We aimed to assess the limitations of PET as an effective modality in the diagnosis of bacterial infections. Inflammation due to bacterial infections can be visualized by using [18F]FDG-PET. However, the non-specificity of [18F]FDG makes it undesirable to visualize bacteria as the underlying cause of inflammation. Hence, more specific radiotracers that possibly bind to or accumulate in bacteria-specific receptors or enzymes are being explored. Several radiotracers, including 2-deoxy-2-[18F]fluorosorbitol ([18F]FDS), 6-[18F]-fluoromaltose, [11C]para-aminobenzoic acid ([11C]PABA), radiolabeled trimethoprim (11C-TMP) and its analog fluoropropyl-trimethoprim (18F-FPTMP), other radiolabeled sugars, and antimicrobial drugs have been used to image microorganisms. Unfortunately, no progress has been made in translating the results to routine human use; feasibility and other factors have constrained their success in clinical settings. In the current article, we discuss the limitations of direct bacterial visualization with PET tracers, but emphasize the important role of [18F]FDG-PET as the only option for detecting evidence of infection.
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Affiliation(s)
- Shashi B Singh
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Sadikshya Bhandari
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45200, Nepal
| | - Shisir Siwakoti
- Kathmandu University School of Medical Sciences, Dhulikhel Hospital, Dhulikhel 45200, Nepal
| | - Rabi Bhatta
- Universal College of Medical Sciences, Bhairahawa 32900, Nepal
| | - William Y Raynor
- Department of Radiology, Rutgers Robert Wood Johnson Medical School, 1 Robert Wood Johnson Place, MEB #404, New Brunswick, NJ 08901, USA
| | - Thomas J Werner
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Soren Hess
- Department of Radiology and Nuclear Medicine, Hospital Southwest Jutland, 6700 Esbjerg, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, 5230 Odense, Denmark
| | - Mona-Elisabeth Revheim
- The Intervention Center, Division of Technology and Innovation, Oslo University Hospital, 0424 Oslo, Norway
- Division for Radiology and Nuclear Medicine, Oslo University Hospital, 0424 Oslo, Norway
- Norway and Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, 0315 Oslo, Norway
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Abikhzer G, Le H, Israel O. Hybrid imaging of Diabetic Foot Infections. Semin Nucl Med 2023; 53:86-97. [PMID: 36089528 DOI: 10.1053/j.semnuclmed.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/15/2022] [Indexed: 01/28/2023]
Abstract
Diabetic foot infections, a common but diagnostically challenging clinical presentation, requires the difficult differentiation between soft tissue-only infection, diabetic neuropathic osteoarthropathy, osteomyelitis or a combination of these pathological processes. While there are clinical predictors for osteomyelitis and simple bedside tests available, imaging is often required for accurate diagnosis. A variety of anatomic and molecular imaging tests are in clinical use, each with its advantages and disadvantages. This review will provide an overview of the different available imaging modalities and their diagnostic criteria, emphasizing the role of hybrid imaging for the accurate diagnosis of osteomyelitis.
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Affiliation(s)
- Gad Abikhzer
- Department of Radiology and Nuclear Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada.
| | - Huy Le
- Department of Radiology and Nuclear Medicine, Jewish General Hospital, Montreal, Quebec, Canada; Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | - Ora Israel
- B. and R. Rapaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
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Hulsen DJW, Mitea C, Arts JJ, Loeffen D, Geurts J. Diagnostic value of hybrid FDG-PET/MR imaging of chronic osteomyelitis. Eur J Hybrid Imaging 2022; 6:15. [PMID: 35909200 PMCID: PMC9339446 DOI: 10.1186/s41824-022-00125-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 01/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Magnetic resonance imaging (MRI) and 2-[18F]-fluoro-2-deoxy-d-glucose (18F-FDG) Positron Emission Tomography, paired with Computed Tomography (PET/CT) are commonly used modalities in the complicated diagnostic work-up of osteomyelitis. PET/MRI is a relatively novel hybrid modality with suggested applications in bone infection imaging, based on expert opinion and previous qualitative research. 18F-FDG PET/MRI has the advantages of reduced radiation dose, more soft tissue information, and is deemed more valuable for surgical planning compared to 18F-FDG PET/CT. The goal of this study is to quantitatively assess the diagnostic value of hybrid 18F-FDG PET/MRI for chronic osteomyelitis. Methods A retrospective analysis was performed by a nuclear medicine physician and radiologist on 36 patients with 18F-FDG PET/MRI scans for suspected osteomyelitis. Sensitivity, specificity, and accuracy were determined with the clinical assessment by the orthopaedic surgeon (based on subsequent intraoperative microbiology or long-term follow-up) as the ground truth. Standardized uptake values (SUV) were measured and analysed by means of receiver operating characteristics (ROC). Results This first study to quantitatively report the diagnostic value of 18F-FDG PET/MRI yielded a sensitivity, specificity, and accuracy of 78%, 100%, and 86% respectively. Area under the ROC curve was .736, .755, and .769 for the SUVmax, target to background ratio, and SUVmax_ratio respectively. These results are in the same range and not statistically different compared to diagnostic value for 18F-FDG PET/CT imaging of osteomyelitis in literature. Conclusions Based on the aforementioned advantages of 18F-FDG PET/MRI and the diagnostic value reported here, the authors propose 18F-FDG PET/MRI as an alternative to 18F-FDG PET/CT in osteomyelitis diagnosis, if available.
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Abstract
The authors define molecular imaging, according to the Society of Nuclear Medicine and Molecular Imaging, as the visualization, characterization, and measurement of biological processes at the molecular and cellular levels in humans and other living systems. Although practiced for many years clinically in nuclear medicine, expansion to other imaging modalities began roughly 25 years ago and has accelerated since. That acceleration derives from the continual appearance of new and highly relevant animal models of human disease, increasingly sensitive imaging devices, high-throughput methods to discover and optimize affinity agents to key cellular targets, new ways to manipulate genetic material, and expanded use of cloud computing. Greater interest by scientists in allied fields, such as chemistry, biomedical engineering, and immunology, as well as increased attention by the pharmaceutical industry, have likewise contributed to the boom in activity in recent years. Whereas researchers and clinicians have applied molecular imaging to a variety of physiologic processes and disease states, here, the authors focus on oncology, arguably where it has made its greatest impact. The main purpose of imaging in oncology is early detection to enable interception if not prevention of full-blown disease, such as the appearance of metastases. Because biochemical changes occur before changes in anatomy, molecular imaging-particularly when combined with liquid biopsy for screening purposes-promises especially early localization of disease for optimum management. Here, the authors introduce the ways and indications in which molecular imaging can be undertaken, the tools used and under development, and near-term challenges and opportunities in oncology.
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Affiliation(s)
- Steven P. Rowe
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Martin G. Pomper
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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7
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Rachh SS, Basu S, Alavi A. Fluorodeoxyglucose PET/Computed Tomography in Evaluation of Prosthetic Joints and Diabetic Foot: A Comparative Perspective with Other Functional Imaging Modalities. PET Clin 2022; 17:517-531. [PMID: 35717105 DOI: 10.1016/j.cpet.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Infection imaging has been an important part of nuclear medicine practice. Infections in prosthetic joints and diabetic foot are associated with devastating complications, posing substantial challenge for both diagnosis and overall management. For many years, conventional nuclear medicine techniques have been used to frame a painful joint arthroplasty or diabetic foot infection. The various functional nuclear imaging modalities used include labeled leukocyte imaging, combined leukocyte-marrow scintigraphy, antigranulocyte antibody scintigraphy, 3-phase bone scintigraphy, and fluorodeoxyglucose PET/computed tomography, yet no single method has proved to be highly sensitive and specific and at the same time safe, simple, and time-effective.
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Affiliation(s)
- Swati Sodagar Rachh
- Department of Nuclear Medicie, Gujarat Cancer & Research Institute, Civil Hospital Campus, Asarwa, Ahmedabad 380016, India; Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre (B.A.R.C), Tata Memorial Centre Annexe, Parel, Mumbai, India; Homi Bhabha National Institute, Mumbai, India.
| | - Abass Alavi
- Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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8
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PET imaging in MSK infections. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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9
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Lauri C, Capriotti G, Uccioli L, Signore A. PET imaging in diabetic foot infections. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00083-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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10
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Lauri C, Capriotti G, Uccioli L, Signore A. Gamma-camera imaging of diabetic foot infections. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00165-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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11
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:11552. [PMID: 34768982 PMCID: PMC8584017 DOI: 10.3390/ijms222111552] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 12/27/2022] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Andrew P. Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA;
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Robert W. Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Dane K. Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.B.); (L.C.)
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA;
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (J.L.F.); (L.L.)
| | - Orhan K. Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA; (K.R.); (A.S.); (A.C.)
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12
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Rubitschung K, Sherwood A, Crisologo AP, Bhavan K, Haley RW, Wukich DK, Castellino L, Hwang H, La Fontaine J, Chhabra A, Lavery L, Öz OK. Pathophysiology and Molecular Imaging of Diabetic Foot Infections. Int J Mol Sci 2021; 22:ijms222111552. [PMID: 34768982 DOI: 10.3390/ijms222111552.pmid:34768982;pmcid:pmc8584017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/16/2021] [Accepted: 10/20/2021] [Indexed: 05/27/2023] Open
Abstract
Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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Affiliation(s)
- Katie Rubitschung
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Amber Sherwood
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Andrew P Crisologo
- Department of Plastic Surgery, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267-0558, USA
| | - Kavita Bhavan
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Robert W Haley
- Department of Internal Medicine, Epidemiology Division, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Dane K Wukich
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Laila Castellino
- Department of Internal Medicine, Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Helena Hwang
- Department of Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Avneesh Chhabra
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
| | - Orhan K Öz
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8542, USA
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Jiang Y, Fang S, Zhang X, Feng J, Ruan Q, Zhang J. Radiolabeling and evaluation of a novel [ 99mTcN] 2+ complex with deferoxamine dithiocarbamate as a potential agent for bacterial infection imaging. Bioorg Med Chem Lett 2021; 43:128102. [PMID: 33984471 DOI: 10.1016/j.bmcl.2021.128102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 01/17/2023]
Abstract
In order to find a 99mTc-labeled deferoxamine radiotracer for bacterial infection imaging, deferoxamine dithiocarbamate (DFODTC) was successfully synthesized and it was radiolabeled with [99mTcN]2+ core to prepare the 99mTcN(DFODTC)2 complex. 99mTcN(DFODTC)2 was obtained with high radiochemical purity without further purification. The complex was lipophilic and exhibited good in vitro stability. According to the result of bacterial binding study, the binding of 99mTcN(DFODTC)2 to bacteria was specific. Biodistribution in mice study indicated that 99mTcN(DFODTC)2 had a higher uptake in bacterial infection tissues than in turpentine-induced abscesses at 120 min after injection, which showed that the radiotracer could differentiate between bacterial infection and sterile inflammation. SPECT/CT images showed that there was a clear accumulation in infection sites, suggesting that 99mTcN(DFODTC)2 could be a potential bacterial infection imaging radiotracer.
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Affiliation(s)
- Yuhao Jiang
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China
| | - Si'an Fang
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China
| | - Xuran Zhang
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China
| | - Junhong Feng
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China
| | - Qing Ruan
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China
| | - Junbo Zhang
- Key Laboratory of Radiopharmaceuticals of Ministry of Education, College of Chemistry, Beijing Normal University, Beijing 100875, PR China.
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An easy and practical guide for imaging infection/inflammation by [ 18F]FDG PET/CT. Clin Transl Imaging 2021; 9:283-297. [PMID: 34095006 PMCID: PMC8169407 DOI: 10.1007/s40336-021-00435-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/19/2021] [Indexed: 10/26/2022]
Abstract
Aim The aim of this mini-review was to summarize the role of positron emission tomography/computed tomography (PET/CT) with 18Fluorine-fluorodeoxyglucose ([18F]FDG) in inflammatory and infective processes, based on the published scientific evidence. Methods We analysed clinical indications, patient preparation, image acquisition protocols, image interpretation, pitfalls and how to make the report of cardio-vascular diseases, musculoskeletal diseases and other inflammatory and infective systemic diseases.Results of this analysis are shown in practical tables, easy to understand for daily routine consultation. Conclusions Despite [18F]FDG is currently used in several inflammatory and infective diseases, standardized interpretation criteria are still needed in most cases. It is, therefore, foreseen the execution of multicentre clinical studies that, by adopting the same acquisition and interpretation criteria, may contribute to the standardization of this imaging modality.
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15
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Synthesis and Evaluation of Novel Norfloxacin Isonitrile 99mTc Complexes as Potential Bacterial Infection Imaging Agents. Pharmaceutics 2021; 13:pharmaceutics13040518. [PMID: 33918583 PMCID: PMC8069222 DOI: 10.3390/pharmaceutics13040518] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/17/2022] Open
Abstract
To develop potential technetium-99m single-photon emission computed tomography (SPECT) imaging agents for bacterial infection imaging, the novel norfloxacin isonitrile derivatives CN4NF and CN5NF were synthesized and radiolabeled with a [99mTc][Tc(I)]+ core to obtain [99mTc]Tc-CN4NF and [99mTc]Tc-CN5NF. These compounds were produced in high radiolabeling yields and showed hydrophilicity and good stability in vitro. The bacterial binding assay indicated that [99mTc]Tc-CN4NF and [99mTc]Tc-CN5NF were specific to bacteria. Compared with [99mTc]Tc-CN4NF, biodistribution studies of [99mTc]Tc-CN5NF showed a higher uptake in bacteria-infected tissues than in turpentine-induced abscesses, indicating that [99mTc]Tc-CN5NF could distinguish bacterial infection from sterile inflammation. In addition, [99mTc]Tc-CN5NF had higher abscess/blood and abscess/muscle ratios. SPECT image of [99mTc]Tc-CN5NF showed that there was a clear accumulation in the infection site, suggesting that it could be a potential bacterial infection imaging radiotracer.
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Iyengar KP, Jain VK, Awadalla Mohamed MK, Vaishya R, Vinjamuri S. Update on functional imaging in the evaluation of diabetic foot infection. J Clin Orthop Trauma 2021; 16:119-124. [PMID: 33680832 PMCID: PMC7919944 DOI: 10.1016/j.jcot.2020.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot infection is a preventable complication of diabetes mellitus. It is an essential component of diabetic foot disease, which is characterised by a triad of neuropathy, ischaemia and infection. These factors may lead to foot ulceration, sepsis and amputation resulting in increased morbidity and poor quality of life. Confirming or excluding infection can be difficult especially when routine laboratory tests and plain radiographs are inconclusive. Early diagnosis and localization of diabetic foot infection is extremely important to institute timely, appropriate therapy. Structural imaging using computed tomography and magnetic resonance imaging all have individual applications towards the diagnostic workup of this condition but have their own limitations. Scintigraphic detection is based on physiochemical changes and hence provides a functional evaluation of bone pathology. We describe the evolution of functional nuclear medicine imaging including immunoscintigraphy in diabetic foot infection and highlight current applications of physiological 18-Fluoro-deoxyglucose positron emission tomography (18-FDG-PET) and computed tomography (18-FDG-PET/CT) in such patients. 18-FDG-PET/CT is a promising modality for imaging diabetic foot infection. Future studies will allow standardisation of technological details and options of 18-FDG-PET/CT interpretation in diabetic foot infection.
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Affiliation(s)
- Karthikeyan P. Iyengar
- Trauma and Orthopaedic Surgeon, Southport and Ormskirk NHS Trust, Southport, PR8 6PN, UK
| | - Vijay K. Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, Dr Ram Manohar Lohia Hospital, New Delhi 110001, India,Corresponding author.
| | | | - Raju Vaishya
- Department of Orthopaedics, Indraprastha Apollo Hospital, Sarita Vihar, Mathura Road, 110076, New Delhi, India
| | - Sobhan Vinjamuri
- Nuclear Medicine, Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK
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17
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Casali M, Lauri C, Altini C, Bertagna F, Cassarino G, Cistaro A, Erba AP, Ferrari C, Mainolfi CG, Palucci A, Prandini N, Baldari S, Bartoli F, Bartolomei M, D’Antonio A, Dondi F, Gandolfo P, Giordano A, Laudicella R, Massollo M, Nieri A, Piccardo A, Vendramin L, Muratore F, Lavelli V, Albano D, Burroni L, Cuocolo A, Evangelista L, Lazzeri E, Quartuccio N, Rossi B, Rubini G, Sollini M, Versari A, Signore A. State of the art of 18F-FDG PET/CT application in inflammation and infection: a guide for image acquisition and interpretation. Clin Transl Imaging 2021; 9:299-339. [PMID: 34277510 PMCID: PMC8271312 DOI: 10.1007/s40336-021-00445-w] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/19/2021] [Indexed: 02/06/2023]
Abstract
AIM The diagnosis, severity and extent of a sterile inflammation or a septic infection could be challenging since there is not one single test able to achieve an accurate diagnosis. The clinical use of 18F-fluorodeoxyglucose ([18F]FDG) positron emission tomography/computed tomography (PET/CT) imaging in the assessment of inflammation and infection is increasing worldwide. The purpose of this paper is to achieve an Italian consensus document on [18F]FDG PET/CT or PET/MRI in inflammatory and infectious diseases, such as osteomyelitis (OM), prosthetic joint infections (PJI), infective endocarditis (IE), prosthetic valve endocarditis (PVE), cardiac implantable electronic device infections (CIEDI), systemic and cardiac sarcoidosis (SS/CS), diabetic foot (DF), fungal infections (FI), tuberculosis (TBC), fever and inflammation of unknown origin (FUO/IUO), pediatric infections (PI), inflammatory bowel diseases (IBD), spine infections (SI), vascular graft infections (VGI), large vessel vasculitis (LVV), retroperitoneal fibrosis (RF) and COVID-19 infections. METHODS In September 2020, the inflammatory and infectious diseases focus group (IIFG) of the Italian Association of Nuclear Medicine (AIMN) proposed to realize a procedural paper about the clinical applications of [18F]FDG PET/CT or PET/MRI in inflammatory and infectious diseases. The project was carried out thanks to the collaboration of 13 Italian nuclear medicine centers, with a consolidate experience in this field. With the endorsement of AIMN, IIFG contacted each center, and the pediatric diseases focus group (PDFC). IIFG provided for each team involved, a draft with essential information regarding the execution of [18F]FDG PET/CT or PET/MRI scan (i.e., indications, patient preparation, standard or specific acquisition modalities, interpretation criteria, reporting methods, pitfalls and artifacts), by limiting the literature research to the last 20 years. Moreover, some clinical cases were required from each center, to underline the teaching points. Time for the collection of each report was from October to December 2020. RESULTS Overall, we summarized 291 scientific papers and guidelines published between 1998 and 2021. Papers were divided in several sub-topics and summarized in the following paragraphs: clinical indications, image interpretation criteria, future perspectivess and new trends (for each single disease), while patient preparation, image acquisition, possible pitfalls and reporting modalities were described afterwards. Moreover, a specific section was dedicated to pediatric and PET/MRI indications. A collection of images was described for each indication. CONCLUSIONS Currently, [18F]FDG PET/CT in oncology is globally accepted and standardized in main diagnostic algorithms for neoplasms. In recent years, the ever-closer collaboration among different European associations has tried to overcome the absence of a standardization also in the field of inflammation and infections. The collaboration of several nuclear medicine centers with a long experience in this field, as well as among different AIMN focus groups represents a further attempt in this direction. We hope that this document will be the basis for a "common nuclear physicians' language" throughout all the country. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s40336-021-00445-w.
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Affiliation(s)
- Massimiliano Casali
- Nuclear Medicine Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Chiara Lauri
- grid.7841.aNuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, Rome, Italy
| | - Corinna Altini
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Francesco Bertagna
- grid.412725.7Nuclear Medicine, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Gianluca Cassarino
- grid.5608.b0000 0004 1757 3470Nuclear Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | | | - Anna Paola Erba
- grid.5395.a0000 0004 1757 3729Regional Center of Nuclear Medicine, Department of Translational Research and Advanced Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Cristina Ferrari
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Ciro Gabriele Mainolfi
- grid.4691.a0000 0001 0790 385XDepartment of Advanced Biomedical Sciences, University “Federico II”, Naples, Italy
| | - Andrea Palucci
- grid.415845.9Department of Nuclear Medicine, “Ospedali Riuniti di Torrette” Hospital, Ancona, Italy
| | - Napoleone Prandini
- grid.418324.80000 0004 1781 8749Nuclear Medicine Unit, Department of Diagnostic Imaging, Centro Diagnostico Italiano, Milan, Italy
| | - Sergio Baldari
- grid.10438.3e0000 0001 2178 8421Nuclear Medicine Unit, Department of Biomedical and Dental Sciences and of Morpho-Functional Imaging, University of Messina, Messina, Italy
| | - Francesco Bartoli
- grid.5395.a0000 0004 1757 3729Regional Center of Nuclear Medicine, Department of Translational Research and Advanced Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Mirco Bartolomei
- grid.416315.4Nuclear Medicine Unit, Oncological Medical and Specialists Department, University Hospital of Ferrara, Ferrara, Italy
| | - Adriana D’Antonio
- grid.4691.a0000 0001 0790 385XDepartment of Advanced Biomedical Sciences, University “Federico II”, Naples, Italy
| | - Francesco Dondi
- grid.412725.7Nuclear Medicine, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Patrizia Gandolfo
- grid.418324.80000 0004 1781 8749Nuclear Medicine Unit, Department of Diagnostic Imaging, Centro Diagnostico Italiano, Milan, Italy
| | - Alessia Giordano
- grid.4691.a0000 0001 0790 385XDepartment of Advanced Biomedical Sciences, University “Federico II”, Naples, Italy
| | - Riccardo Laudicella
- grid.10438.3e0000 0001 2178 8421Nuclear Medicine Unit, Department of Biomedical and Dental Sciences and of Morpho-Functional Imaging, University of Messina, Messina, Italy
| | | | - Alberto Nieri
- grid.416315.4Nuclear Medicine Unit, Oncological Medical and Specialists Department, University Hospital of Ferrara, Ferrara, Italy
| | | | - Laura Vendramin
- grid.5608.b0000 0004 1757 3470Nuclear Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Francesco Muratore
- Rheumatology Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Valentina Lavelli
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Domenico Albano
- grid.412725.7Nuclear Medicine, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Luca Burroni
- grid.415845.9Department of Nuclear Medicine, “Ospedali Riuniti di Torrette” Hospital, Ancona, Italy
| | - Alberto Cuocolo
- grid.4691.a0000 0001 0790 385XDepartment of Advanced Biomedical Sciences, University “Federico II”, Naples, Italy
| | - Laura Evangelista
- grid.5608.b0000 0004 1757 3470Nuclear Medicine Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Elena Lazzeri
- grid.5395.a0000 0004 1757 3729Regional Center of Nuclear Medicine, Department of Translational Research and Advanced Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Natale Quartuccio
- grid.419995.9Nuclear Medicine Unit, A.R.N.A.S. Civico di Cristina and Benfratelli Hospitals, Palermo, Italy
| | - Brunella Rossi
- Nuclear Medicine Unit, Department of Services, ASUR MARCHE-AV5, Ascoli Piceno, Italy
| | - Giuseppe Rubini
- grid.7644.10000 0001 0120 3326Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari, Bari, Italy
| | - Martina Sollini
- grid.417728.f0000 0004 1756 8807Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Annibale Versari
- Nuclear Medicine Unit, Azienda Unità Sanitaria Locale IRCCS, Reggio Emilia, Italy
| | - Alberto Signore
- grid.7841.aNuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, Rome, Italy
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Llewellyn A, Jones-Diette J, Kraft J, Holton C, Harden M, Simmonds M. Imaging tests for the detection of osteomyelitis: a systematic review. Health Technol Assess 2020; 23:1-128. [PMID: 31670644 DOI: 10.3310/hta23610] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Osteomyelitis is an infection of the bone. Medical imaging tests, such as radiography, ultrasound, magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) and positron emission tomography (PET), are often used to diagnose osteomyelitis. OBJECTIVES To systematically review the evidence on the diagnostic accuracy, inter-rater reliability and implementation of imaging tests to diagnose osteomyelitis. DATA SOURCES We conducted a systematic review of imaging tests to diagnose osteomyelitis. We searched MEDLINE and other databases from inception to July 2018. REVIEW METHODS Risk of bias was assessed with QUADAS-2 [quality assessment of diagnostic accuracy studies (version 2)]. Diagnostic accuracy was assessed using bivariate regression models. Imaging tests were compared. Subgroup analyses were performed based on the location and nature of the suspected osteomyelitis. Studies of children, inter-rater reliability and implementation outcomes were synthesised narratively. RESULTS Eighty-one studies were included (diagnostic accuracy: 77 studies; inter-rater reliability: 11 studies; implementation: one study; some studies were included in two reviews). One-quarter of diagnostic accuracy studies were rated as being at a high risk of bias. In adults, MRI had high diagnostic accuracy [95.6% sensitivity, 95% confidence interval (CI) 92.4% to 97.5%; 80.7% specificity, 95% CI 70.8% to 87.8%]. PET also had high accuracy (85.1% sensitivity, 95% CI 71.5% to 92.9%; 92.8% specificity, 95% CI 83.0% to 97.1%), as did SPECT (95.1% sensitivity, 95% CI 87.8% to 98.1%; 82.0% specificity, 95% CI 61.5% to 92.8%). There was similar diagnostic performance with MRI, PET and SPECT. Scintigraphy (83.6% sensitivity, 95% CI 71.8% to 91.1%; 70.6% specificity, 57.7% to 80.8%), computed tomography (69.7% sensitivity, 95% CI 40.1% to 88.7%; 90.2% specificity, 95% CI 57.6% to 98.4%) and radiography (70.4% sensitivity, 95% CI 61.6% to 77.8%; 81.5% specificity, 95% CI 69.6% to 89.5%) all had generally inferior diagnostic accuracy. Technetium-99m hexamethylpropyleneamine oxime white blood cell scintigraphy (87.3% sensitivity, 95% CI 75.1% to 94.0%; 94.7% specificity, 95% CI 84.9% to 98.3%) had higher diagnostic accuracy, similar to that of PET or MRI. There was no evidence that diagnostic accuracy varied by scan location or cause of osteomyelitis, although data on many scan locations were limited. Diagnostic accuracy in diabetic foot patients was similar to the overall results. Only three studies in children were identified; results were too limited to draw any conclusions. Eleven studies evaluated inter-rater reliability. MRI had acceptable inter-rater reliability. We found only one study on test implementation and no evidence on patient preferences or cost-effectiveness of imaging tests for osteomyelitis. LIMITATIONS Most studies included < 50 participants and were poorly reported. There was limited evidence for children, ultrasonography and on clinical factors other than diagnostic accuracy. CONCLUSIONS Osteomyelitis is reliably diagnosed by MRI, PET and SPECT. No clear reason to prefer one test over the other in terms of diagnostic accuracy was identified. The wider availability of MRI machines, and the fact that MRI does not expose patients to harmful ionising radiation, may mean that MRI is preferable in most cases. Diagnostic accuracy does not appear to vary with the potential cause of osteomyelitis or with the body part scanned. Considerable uncertainty remains over the diagnostic accuracy of imaging tests in children. Studies of diagnostic accuracy in children, particularly using MRI and ultrasound, are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42017068511. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alexis Llewellyn
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | | | - Melissa Harden
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK
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19
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Diez AIG, Fuster D, Morata L, Torres F, Garcia R, Poggio D, Sotes S, Del Amo M, Isern-Kebschull J, Pomes J, Soriano A, Brugnara L, Tomas X. Comparison of the diagnostic accuracy of diffusion-weighted and dynamic contrast-enhanced MRI with 18F-FDG PET/CT to differentiate osteomyelitis from Charcot neuro-osteoarthropathy in diabetic foot. Eur J Radiol 2020; 132:109299. [PMID: 33032207 DOI: 10.1016/j.ejrad.2020.109299] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/11/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE To compare the diagnostic accuracy of diffusion-weighted imaging (DWI) and dynamic contrast-enhanced-magnetic resonance imaging (DCE-MRI) involving two region of interest (ROI) sizes with 18-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) to differentiate diabetic foot osteomyelitis (DFO) from Charcot neuro-osteoarthropathy (CN). METHOD Thirty-one diabetic patients were included in this prospective study. Two readers independently evaluated DWI (apparent diffusion coefficient [ADC] and high-b-value signal pathological-to-normal bone ratio [DWIr]) and DCE-MRI parameters (Ktrans, Kep, Ve, internal area under the gadolinium curve at 60 s [iAUC60] and time intensity curve [TIC]) using two different ROI sizes, and 18F-FDG PET/CT parameters (visual assessment, SUVmax, delayed SUVmax, and percentage changes between SUVmax and delayed SUVmax). Techniques were compared by univariate analysis using the area under the receiver operating characteristic curve [AUC]. Reliability was analyzed with Kappa and Intraclass correlation [ICC]. RESULTS DWIr, Ktrans and iAUC60 showed better diagnostic accuracy (AUC = 0.814-0.830) and reliability (ICC > 0.9) for large than for small ROIs (AUC = 0.736-0.750; ICC = 0.6 in Ktrans, 0.8 in DWIr and iAUC60). TIC showed moderate diagnostic performance (AUC = 0.739-0.761) and reliability (κ 0.7). Visual assessment of 18F-FDG PET/CT demonstrated a significantly higher accuracy (AUC = 0.924) than MRI parameters. Semi-quantitative 18F-FDG PET/CT parameters did not provide significant improvement over visual analysis (AUC = 0.848-0.903). CONCLUSION DWIr, Ktrans and iAUC60 allowed reliable differentiation of DFO and CN, particularly for large ROIs. Visual assessment of 18F-FDG PET/CT was the most accurate technique for differentiation.
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Affiliation(s)
- Ana I Garcia Diez
- Department of Radiology; August Pi i Sunyer Biomedical Research Institute (IDIBAPS).
| | | | - Laura Morata
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Infectious Diseases.
| | | | | | | | | | | | | | | | - Alex Soriano
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Service of Infectious Diseases.
| | - Laura Brugnara
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS); Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM).
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20
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Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. Eur J Radiol 2020; 131:109215. [PMID: 32862106 DOI: 10.1016/j.ejrad.2020.109215] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 07/09/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Osteomyelitis is an infection of the bone which can occur in people with diabetic foot ulcers. It can be diagnosed using X-rays, ultrasound, scintigraphy, magnetic resonance imaging (MRI), single photon emission computed tomography (SPECT) and positron emission tomography (PET). OBJECTIVES To review the evidence on the diagnostic accuracy of imaging tests to diagnose osteomyelitis in people with diabetic foot ulcers. METHODS We conducted a systematic review and meta-analysis. MEDLINE, EMBASE and other databases were searched to July 2018. Risk of bias was evaluated. Diagnostic accuracy was estimated using bivariate meta-analyses. RESULTS Thirty-six studies were included in the meta-analysis. Eight studies were at high risk of bias MRI had high diagnostic accuracy (22 studies: 96.4 % sensitivity (95 % CI 90.7-98.7); 83.8 % specificity (76.0-89.5)). PET scans also had high accuracy (6 studies: 84.3 % sensitivity (52.8-96.3); 92.8 % specificity (75.7-98.2)), and possibly also SPECT, but with few studies (3 studies: 95.6 % sensitivity (76.0-99.3); 55.1 % specificity (19.3-86.3)). Scintigraphy (17 studies: 84.2 % sensitivity (76.8-89.6); 67.7 % specificity (56.2-77.4)), and X-rays (16 studies: 61.9 % sensitivity (50.5-72.1); 78.3 % specificity (62.9-88.5)) had generally inferior diagnostic accuracy. CONCLUSIONS MRI and PET both reliably diagnose osteomyelitis in diabetic foot ulcer patients. SPECT may also have good diagnostic accuracy, although evidence is limited. This review confirms most current guidelines, showing that MRI may be the preferable test in most cases, given its wider availability and the lack of potentially harmful ionising radiation.
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Romanò CL, Petrosillo N, Argento G, Sconfienza LM, Treglia G, Alavi A, Glaudemans AW, Gheysens O, Maes A, Lauri C, Palestro CJ, Signore A. The Role of Imaging Techniques to Define a Peri-Prosthetic Hip and Knee Joint Infection: Multidisciplinary Consensus Statements. J Clin Med 2020; 9:jcm9082548. [PMID: 32781651 PMCID: PMC7466174 DOI: 10.3390/jcm9082548] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 02/07/2023] Open
Abstract
Diagnosing a peri-prosthetic joint infection (PJI) remains challenging despite the availability of a variety of clinical signs, serum and synovial markers, imaging techniques, microbiological and histological findings. Moreover, the one and only true definition of PJI does not exist, which is reflected by the existence of at least six different definitions by independent societies. These definitions are composed of major and minor criteria for defining a PJI, but most of them do not include imaging techniques. This paper highlights the pros and cons of available imaging techniques—X-ray, ultrasound, computed tomography (CT), Magnetic Resonance Imaging (MRI), bone scintigraphy, white blood cell scintigraphy (WBC), anti-granulocyte scintigraphy, and fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), discusses the added value of hybrid camera systems—single photon emission tomography/computed tomography (SPECT/CT), PET/CT and PET/MRI and reports consensus answers on important clinical questions that were discussed during the Third European Congress on Inflammation/Infection Imaging in Rome, December 2019.
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Affiliation(s)
- Carlo Luca Romanò
- Gruppo di Studio SIOT Infezioni-Clinica San Gaudenzio-Novara-Gruppo Policlinico di Monza, University of Milan, 20100 Milan, Italy;
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infective Diseases “L. Spallanzani”, 00144 Rome, Italy;
| | | | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy;
- Department of Biomedical Sciences for Health, University of Milan, 20123 Milan, Italy
| | - Giorgio Treglia
- Nuclear Medicine and PET/CT Center, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale Via Lugano 4F, CH-6500 Bellinzona, Switzerland;
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, 1011 Lausanne, Switzerland
| | - Abass Alavi
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 1904, USA;
| | - Andor W.J.M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands;
| | - Olivier Gheysens
- Department of Nuclear Medicine, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
| | - Alex Maes
- Department of Nuclear Medicine, AZ Groeninge, Kortrijk Belgium and Department of Imaging and Pathology @ KULAK, KU Leuven campus Kulak, 8500 Kortrijk, Belgium;
| | - Chiara Lauri
- Nuclear Medicine Unit Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Christopher J. Palestro
- Department of Radiology Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549, USA;
| | - Alberto Signore
- Nuclear Medicine Unit Department of Medical-Surgical Sciences and of Translational Medicine, Faculty of Medicine and Psychology, “Sapienza” University of Rome, 00161 Rome, Italy;
- Correspondence:
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22
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Diabetic Foot Infections: The Diagnostic Challenges. J Clin Med 2020; 9:jcm9061779. [PMID: 32521695 PMCID: PMC7355769 DOI: 10.3390/jcm9061779] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/15/2020] [Accepted: 05/27/2020] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot infections (DFIs) are severe complications of long-standing diabetes, and they represent a diagnostic challenge, since the differentiation between osteomyelitis (OM), soft tissue infection (STI), and Charcot’s osteoarthropathy is very difficult to achieve. Nevertheless, such differential diagnosis is mandatory in order to plan the most appropriate treatment for the patient. The isolation of the pathogen from bone or soft tissues is still the gold standard for diagnosis; however, it would be desirable to have a non-invasive test that is able to detect, localize, and evaluate the extent of the infection with high accuracy. A multidisciplinary approach is the key for the correct management of diabetic patients dealing with infective complications, but at the moment, no definite diagnostic flow charts still exist. This review aims at providing an overview on multimodality imaging for the diagnosis of DFI and to address evidence-based answers to the clinicians when they appeal to radiologists or nuclear medicine (NM) physicians for studying their patients.
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Lauri C, Glaudemans AW, Campagna G, Keidar Z, Muchnik Kurash M, Georga S, Arsos G, Noriega-Álvarez E, Argento G, Kwee TC, Slart RH, Signore A. Comparison of White Blood Cell Scintigraphy, FDG PET/CT and MRI in Suspected Diabetic Foot Infection: Results of a Large Retrospective Multicenter Study. J Clin Med 2020; 9:jcm9061645. [PMID: 32486304 PMCID: PMC7356770 DOI: 10.3390/jcm9061645] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/16/2022] Open
Abstract
Diabetic foot infections (DFIs) represent one of the most frequent and disabling morbidities of longstanding diabetes; therefore, early diagnosis is mandatory. The aim of this multicenter retrospective study was to compare the diagnostic accuracy of white blood cell scintigraphy (WBC), 18F-fluorodeoxyglucose positron emission tomography/computed tomography ((18F) FDG PET/CT), and Magnetic Resonance Imaging (MRI) in patients with suspected DFI. Images and clinical data from 251 patients enrolled by five centers were collected in order to calculate the sensitivity, specificity, and accuracy of WBC, FDG, and MRI in diagnosing osteomyelitis (OM), soft-tissue infection (STI), and Charcot osteoarthropathy. In OM, WBC acquired following the European Society of Nuclear Medicine (EANM) guidelines was more specific and accurate than MRI (91.9% vs. 70.7%, p < 0.0001 and 86.2% vs. 67.1%, p = 0.003, respectively). In STI, both FDG and WBC achieved a significantly higher specificity than MRI (97.9% and 95.7% vs. 83.6%, p = 0.04 and p = 0.018, respectively). In Charcot, both MRI and WBC demonstrated a significantly higher specificity and accuracy than FDG (88.2% and 89.3% vs. 62.5%, p = 0.0009; 80.3% and 87.9% vs. 62.1%, p < 0.02, respectively). Moreover, in Charcot, WBC was more specific than MRI (89.3% vs. 88.2% p < 0.0001). Given the limitations of a retrospective study, WBC using EANM guidelines was shown to be the most reliable imaging modality to differentiate between OM, STI, and Charcot in patients with suspected DFI.
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Affiliation(s)
- Chiara Lauri
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Andor W.J.M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Giuseppe Campagna
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
| | - Zohar Keidar
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Marina Muchnik Kurash
- Department of Nuclear Medicine, Rambam Health Care Campus, 3109601 Haifa, Israel; (Z.K.); (M.M.K.)
| | - Stamata Georga
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Georgios Arsos
- 3rd Department of Nuclear Medicine, Aristotle University Medical School, Papageorgiou General Hospital, 56403 Thessaloniki, Greece; (S.G.); (G.A.)
| | - Edel Noriega-Álvarez
- Department of Nuclear Medicine, University Hospital of Ciudad Real, 13005 Ciudad Real, Spain;
| | - Giuseppe Argento
- Radiology Unit, Sant’Andrea University Hospital, 00189 Rome, Italy;
| | - Thomas C. Kwee
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
| | - Riemer H.J.A. Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, 7500 Enschede, The Netherlands
| | - Alberto Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and of Translational Medicine, “Sapienza” University of Rome, 00161 Rome, Italy; (C.L.); (G.C.)
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, 9700 Groningen, The Netherlands; (A.W.J.M.G.); (T.C.K.); (R.H.J.A.S.)
- Correspondence: ; Tel.: +39-06-3377-6191
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24
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Leone A, Vitiello C, Gullì C, Sikora AK, Macagnino S, Colosimo C. Bone and soft tissue infections in patients with diabetic foot. Radiol Med 2019; 125:177-187. [DOI: 10.1007/s11547-019-01096-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/09/2019] [Indexed: 11/24/2022]
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Chou TH, Stacy MR. Clinical Applications for Radiotracer Imaging of Lower Extremity Peripheral Arterial Disease and Critical Limb Ischemia. Mol Imaging Biol 2019; 22:245-255. [PMID: 31482412 DOI: 10.1007/s11307-019-01425-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Peripheral arterial disease (PAD) is an atherosclerotic occlusive disease of the non-coronary vessels that is characterized by lower extremity tissue ischemia, claudication, increased prevalence of lower extremity wounds and amputations, and impaired quality of life. Critical limb ischemia (CLI) represents the severe stage of PAD and is associated with additional risk for wound formation, amputation, and premature death. Standard clinical tools utilized for assessing PAD and CLI primarily focus on anatomical evaluation of peripheral vascular lesions or hemodynamic assessment of the peripheral circulation. Evaluation of underlying pathophysiology has traditionally been achieved by radiotracer-based imaging, with many clinical investigations focusing on imaging of skeletal muscle perfusion and cases of foot infection/inflammation such as osteomyelitis and Charcot neuropathic osteoarthropathy. As advancements in hybrid imaging systems and radiotracers continue to evolve, opportunities for molecular imaging of PAD and CLI are also emerging that may offer novel insight into associated complications such as peripheral atherosclerosis, alterations in skeletal muscle metabolism, and peripheral neuropathy. This review summarizes the pros and cons of radiotracer-based techniques that have been utilized in the clinical environment for evaluating lower extremity ischemia and common pathologies associated with PAD and CLI.
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Affiliation(s)
- Ting-Heng Chou
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA
| | - Mitchel R Stacy
- Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, 575 Children's Crossroad, WB4131, Columbus, OH, 43215, USA. .,Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
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26
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Furuya MY, Temmoku J, Fujita Y, Matsuoka N, Asano T, Sato S, Kobayashi H, Watanabe H, Migita K. Vasculo-Behçet disease complicated by conversion disorder diagnosed with 18F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography (PET/CT). Fukushima J Med Sci 2019; 65:55-60. [PMID: 31327803 DOI: 10.5387/fms.2019-07] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Vasculitis in Behçet's disease, termed "vasculo-Behçet's disease," is a major cause of mortality and morbidity. We report a case of vasculo-Behçet's disease complicated by conversion disorder, in which 18F-fluoro-deoxy-glucose positron emission tomography combined with computed tomography (FDG PET/CT) was useful for the diagnosis. A twenty-two-year-old woman recently diagnosed with tonsillitis presented with fever, right foot pain, left equinovarus foot, and numbness in both hands and feet. Laboratory data showed elevated levels of c-reactive protein (CRP). The patient was positive for HLA B51; pathergy testing was also positive. Nerve conduction velocity and electromyography were normal. MRI showed swelling of the left crural muscle group. PET/CT showed intense FDG uptake in the left popliteal artery, demonstrating active vasculitis. The patient was diagnosed with vasculo-Behçet's disease and treated with corticosteroids, colchicine, and infliximab, which led to obvious improvement of the MRI findings and reduction in CRP. However, left equinovarus foot and numbness in the extremities persisted. She also developed aphonia. They were attributed to psychogenic dystonia and conversion disorder, and psychiatric treatment was effective in relieving those symptoms. We suggest that PET/CT may be useful for the early diagnosis of medium-sized vessel vasculitis in patients with Behçet's disease.
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Affiliation(s)
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroko Kobayashi
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine
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Heidari N, Oh I, Li Y, Vris A, Kwok I, Charalambous A, Rogero R. What Is the Best Method to Differentiate Acute Charcot Foot From Acute Infection? Foot Ankle Int 2019; 40:39S-42S. [PMID: 31322932 DOI: 10.1177/1071100719859892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
RECOMMENDATION Differentiation between acute Charcot neuroarthropathy (CN) and acute infection/osteomyelitis is complex and requires multiple (>1) diagnostic criteria. These criteria include an emphasis on the presence of neuropathy, history, and physical examination. The absence of skin wounds and resolution of swelling/erythema with elevation makes the likelihood of infection very low. In unclear cases, laboratory testing, histologic examination and culturing of bone specimens, scintigraphy, and imaging, especially magnetic resonance imaging (MRI), may be of benefit. LEVEL OF EVIDENCE Moderate. DELEGATE VOTE Agree: 100%, Disagree: 0%, Abstain: 0% (Unanimous, Strongest Consensus).
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Affiliation(s)
- Nima Heidari
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Irvin Oh
- 2 Department of Orthopaedics and Rehabilitation University of Rochester, Rochester, NY, USA
| | - Yueyang Li
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexandros Vris
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Iris Kwok
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Alexander Charalambous
- 1 Department of Orthopaedics, The Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ryan Rogero
- 3 Rothman Orthopaedic Institute, Philadelphia, PA, USA
- 4 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Sollini M, Trenti N, Malagoli E, Catalano M, Di Mento L, Kirienko A, Berlusconi M, Chiti A, Antunovic L. [18F]FDG PET/CT in non-union: improving the diagnostic performances by using both PET and CT criteria. Eur J Nucl Med Mol Imaging 2019; 46:1605-1615. [DOI: 10.1007/s00259-019-04336-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 04/15/2019] [Indexed: 12/13/2022]
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Consensus document for the diagnosis of prosthetic joint infections: a joint paper by the EANM, EBJIS, and ESR (with ESCMID endorsement). Eur J Nucl Med Mol Imaging 2019; 46:971-988. [PMID: 30683987 PMCID: PMC6450843 DOI: 10.1007/s00259-019-4263-9] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/02/2019] [Indexed: 12/13/2022]
Abstract
Background For the diagnosis of prosthetic joint infection, real evidence-based guidelines to aid clinicians in choosing the most accurate diagnostic strategy are lacking. Aim and Methods To address this need, we performed a multidisciplinary systematic review of relevant nuclear medicine, radiological, orthopaedic, infectious, and microbiological literature to define the diagnostic accuracy of each diagnostic technique and to address and provide evidence-based answers on uniform statements for each topic that was found to be important to develop a commonly agreed upon diagnostic flowchart. Results and Conclusion The approach used to prepare this set of multidisciplinary guidelines was to define statements of interest and follow the procedure indicated by the Oxford Centre for Evidence-based Medicine (OCEBM). Electronic supplementary material The online version of this article (10.1007/s00259-019-4263-9) contains supplementary material, which is available to authorized users.
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30
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Pawaskar A, Basu S, Jahangiri P, Alavi A. In Vivo Molecular Imaging of Musculoskeletal Inflammation and Infection. PET Clin 2018; 14:43-59. [PMID: 30420221 DOI: 10.1016/j.cpet.2018.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In vivo molecular imaging detects biologic processes at molecular level and provides diagnostic information at an earlier time point during disease onset or repair. It offers definite advantage over anatomic imaging in terms of improved sensitivity and ability to quantify. Radionuclide molecular imaging has been widely used in clinical practice. This article discusses the role of radionuclide imaging in various infective and inflammatory diseases affecting musculoskeletal system with a focus on PET. It appears that, as more data become available, combined PET/MR imaging could emerge as a front runner in the imaging of musculoskeletal infection and inflammation.
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Affiliation(s)
- Alok Pawaskar
- Oncolife Cancer Centre, Satara, Maharashtra 415519, India; Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Centre Annexe, Parel, Mumbai, Maharashtra 400012, India; Homi Bhabha National Institute, Mumbai, Maharashtra, India.
| | - Pegah Jahangiri
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
| | - Abass Alavi
- Division of Nuclear Medicine, Hospital of University of Pennsylvania, Philadelphia, PA, USA
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31
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Al-Zaghal A, Raynor W, Khosravi M, Guermazi A, Werner TJ, Alavi A. Applications of PET Imaging in the Evaluation of Musculoskeletal Diseases Among the Geriatric Population. Semin Nucl Med 2018; 48:525-534. [DOI: 10.1053/j.semnuclmed.2018.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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32
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Signore A, Jamar F, Israel O, Buscombe J, Martin-Comin J, Lazzeri E. Clinical indications, image acquisition and data interpretation for white blood cells and anti-granulocyte monoclonal antibody scintigraphy: an EANM procedural guideline. Eur J Nucl Med Mol Imaging 2018; 45:1816-1831. [PMID: 29850929 PMCID: PMC6097781 DOI: 10.1007/s00259-018-4052-x] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 05/06/2018] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Radiolabelled autologous white blood cells (WBC) scintigraphy is being standardized all over the world to ensure high quality, specificity and reproducibility. Similarly, in many European countries radiolabelled anti-granulocyte antibodies (anti-G-mAb) are used instead of WBC with high diagnostic accuracy. The EANM Inflammation & Infection Committee is deeply involved in this process of standardization as a primary goal of the group. AIM The main aim of this guideline is to support and promote good clinical practice despite the complex environment of a national health care system with its ethical, economic and legal aspects that must also be taken into consideration. METHOD After the standardization of the WBC labelling procedure (already published), a group of experts from the EANM Infection & Inflammation Committee developed and validated these guidelines based on published evidences. RESULTS Here we describe image acquisition protocols, image display procedures and image analyses as well as image interpretation criteria for the use of radiolabelled WBC and monoclonal antigranulocyte antibodies. Clinical application for WBC and anti-G-mAb scintigraphy is also described. CONCLUSIONS These guidelines should be applied by all nuclear medicine centers in favor of a highly reproducible standardized practice.
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Affiliation(s)
- A Signore
- Nuclear Medicine Unit, Department of Medical-Surgical Sciences and Translational Medicine, "Sapienza" University of Rome, Ospedale S. Andrea, Via di Grottarossa 1035, 00189, Rome, Italy.
| | - F Jamar
- Department of Nuclear Medicine, Université Catholique de Louvain, Brussels, Belgium
| | - O Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - J Buscombe
- Department of Nuclear Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - J Martin-Comin
- Nuclear Medicine Department, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - E Lazzeri
- Regional Center of Nuclear Medicine, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Lauri C, Tamminga M, Glaudemans AWJM, Juárez Orozco LE, Erba PA, Jutte PC, Lipsky BA, IJzerman MJ, Signore A, Slart RHJA. Detection of Osteomyelitis in the Diabetic Foot by Imaging Techniques: A Systematic Review and Meta-analysis Comparing MRI, White Blood Cell Scintigraphy, and FDG-PET. Diabetes Care 2017; 40:1111-1120. [PMID: 28733376 DOI: 10.2337/dc17-0532] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/03/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diagnosing bone infection in the diabetic foot is challenging and often requires several diagnostic procedures, including advanced imaging. We compared the diagnostic performances of MRI, radiolabeled white blood cell (WBC) scintigraphy (either with 99mTc-hexamethylpropyleneamineoxime [HMPAO] or 111In-oxine), and [18F]fluorodeoxyglucose positron emission tomography (18F-FDG-PET)/computed tomography. RESEARCH DESIGN AND METHODS We searched Medline and Embase as of August 2016 for studies of diagnostic tests on patients known or suspected to have diabetes and a foot infection. We performed a systematic review using criteria recommended by the Cochrane Review of a database that included prospective and retrospective diagnostic studies performed on patients with diabetes in whom there was a clinical suspicion of osteomyelitis of the foot. The preferred reference standard was bone biopsy and subsequent pathological (or microbiological) examination. RESULTS Our review found 6,649 articles; 3,894 in Medline and 2,755 in Embase. A total of 27 full articles and 2 posters was selected for inclusion in the analysis. The performance characteristics for the 18F-FDG-PET were: sensitivity, 89%; specificity, 92%; diagnostic odds ratio (DOR), 95; positive likelihood ratio (LR), 11; and negative LR, 0.11. For WBC scan with 111In-oxine, the values were: sensitivity, 92%; specificity, 75%; DOR, 34; positive LR, 3.6; and negative LR, 0.1. For WBC scan with 99mTc-HMPAO, the values were: sensitivity, 91%; specificity, 92%; DOR, 118; positive LR, 12; and negative LR, 0.1. Finally, for MRI, the values were: sensitivity, 93%; specificity, 75%; DOR, 37; positive LR, 3.66, and negative LR, 0.10. CONCLUSIONS The various modalities have similar sensitivity, but 18F-FDG-PET and 99mTc-HMPAO-labeled WBC scintigraphy offer the highest specificity. Larger prospective studies with a direct comparison among the different imaging techniques are required.
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Affiliation(s)
- Chiara Lauri
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and of Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Menno Tamminga
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Luis Eduardo Juárez Orozco
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Paola A Erba
- Department of Nuclear Medicine, University of Pisa, Pisa, Italy
| | - Paul C Jutte
- Department of Orthopedics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Benjamin A Lipsky
- Division of Medical Sciences, Green Templeton College, University of Oxford, Oxford, U.K.,Department of Medicine, University of Washington, Seattle, WA
| | - Maarten J IJzerman
- Department of Health Technology and Services Research, MIRA Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, the Netherlands
| | - Alberto Signore
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.,Nuclear Medicine Unit, Faculty of Medicine and Psychology, Department of Medical-Surgical Sciences and of Translational Medicine, Sapienza University of Rome, Rome, Italy
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands .,Department of Biomedical Photonic Imaging, University of Twente, Enschede, the Netherlands
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Utility of PET/CT with fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes for diagnosing diabetic foot osteomyelitis in patients with Charcot's neuroarthropathy. Nucl Med Commun 2017; 37:1253-1259. [PMID: 27749777 DOI: 10.1097/mnm.0000000000000603] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Diabetic foot osteomyelitis (DFO) is difficult to diagnose in the presence of Charcot's neuroarthropathy (CN) and bone biopsy is not always possible. We aimed to assess the efficacy of PET/computed tomography using F-fluoride (F-fluoride PET/CT) and fluorine-18-fluorodeoxyglucose-labeled autologous leukocytes (F-FDG-LL PET/CT) in comparison with contrast-enhanced MRI (CEMRI) for the detection of DFO. PATIENTS AND METHODS Thirty-two patients with chronic CN and foot ulcer suspected of having DFO were prospectively evaluated. All patients underwent radiography, CEMRI, F-fluoride PET/CT, and F-FDG-LL PET/CT of the feet. Bone biopsy and microbiological culture from the suspected site of osteomyelitis was considered the gold standard. RESULTS Twenty-three patients fulfilled the inclusion criteria. Bone culture was suggestive of DFO in 12 patients. CEMRI identified 10 of the 12 cases of osteomyelitis. F-fluoride PET/CT and F-FDG-LL PET/CT showed increased tracer uptake (SUVmax=22.7±18.1 and 8.4±4.7, respectively) at the clinically involved site in 10 of the 12 patients (TP). Among 11 biopsy-negative patients, CEMRI reported DFO in four (false positive); there were no false positives with F-FDG-LL PET/CT. The sensitivity and specificity of F-FDG-LL PET/CT was 83.3 and 100% compared with 83.3 and 63.6% for CEMRI, respectively, for the diagnosis of DFO in the background of CN. CONCLUSION F-FDG-LL PET/CT has high specificity for the diagnosis of DFO in complicated diabetic foot. The F-fluoride PET/CT helps in the characterization the extent of underlying CN. An early and accurate diagnosis with F-FDG-LL PET/CT aids the rational initiation of antibiotics for DFO.
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Wenter V, Albert NL, Brendel M, Fendler WP, Cyran CC, Bartenstein P, Friederichs J, Müller JP, Militz M, Hacker M, Hungerer S. [ 18F]FDG PET accurately differentiates infected and non-infected non-unions after fracture fixation. Eur J Nucl Med Mol Imaging 2016; 44:432-440. [PMID: 27704194 PMCID: PMC5591625 DOI: 10.1007/s00259-016-3528-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/13/2016] [Indexed: 11/28/2022]
Abstract
Purpose Complete fracture healing is crucial for good patient outcomes. A major complication in the treatment of fractures is non-union. The pathogenesis of non-unions is not always clear, although implant-associated infections play a significant role, especially after surgical treatment of open fractures. We aimed to evaluate the value of [18F]FDG PET in suspected infections of non-union fractures. Methods We retrospectively evaluated 35 consecutive patients seen between 2000 and 2015 with suspected infection of non-union fractures, treated at a level I trauma center. The patients underwent either [18F]FDG PET/CT (N = 24), [18F]FDG PET (N = 11) plus additional CT (N = 8), or conventional X-ray (N = 3). Imaging findings were correlated with final diagnosis based on intraoperative culture or follow-up. Results In 13 of 35 patients (37 %), infection was proven by either positive intraoperative tissue culture (N = 12) or positive follow-up (N = 1). [18F]FDG PET revealed 11 true-positive, 19 true-negative, three false-positive, and two false-negative results, indicating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 85 %, 86 %, 79 %, 90 %, and 86 %, respectively. The SUVmax was 6.4 ± 2.7 in the clinically infected group and 3.0 ± 1.7 in the clinically non-infected group (p <0.01). The SUVratio was 5.3 ± 3.3 in the clinically infected group and 2.6 ± 1.5 in the clinically non-infected group (p <0.01). Conclusion [18F]FDG PET differentiates infected from non-infected non-unions with high accuracy in patients with suspected infections of non-union fractures, for whom other clinical findings were inconclusive for a local infection. [18F]FDG PET should be considered for therapeutic management of non-unions.
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Affiliation(s)
- Vera Wenter
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Nathalie L Albert
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Matthias Brendel
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | | | - Clemens C Cyran
- Institute for Clinical Radiology, University of Munich, Munich, Germany
| | - Peter Bartenstein
- Department of Nuclear Medicine, University of Munich, Munich, Germany
| | - Jan Friederichs
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Jan-Philipp Müller
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Matthias Militz
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, University of Vienna, Währinger Gürtel 18-20, Floor 5L, 1090, Vienna, Austria.
| | - Sven Hungerer
- Department of Reconstructive Arthroplasty, BG Trauma Center Murnau, Murnau, Germany.,Paracelsus Medical University, PMU Salzburg, Salzburg, Austria
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Palestro CJ. Radionuclide Imaging of Musculoskeletal Infection: A Review. J Nucl Med 2016; 57:1406-12. [PMID: 27390160 DOI: 10.2967/jnumed.115.157297] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 06/29/2016] [Indexed: 12/12/2022] Open
Abstract
There are numerous imaging tests for diagnosing musculoskeletal infection. Radiographs are routinely performed, because even when not diagnostic, they provide an anatomic overview of the region of interest that could influence subsequent procedure selection and interpretation. MRI is sensitive and provides superb anatomic detail. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. (67)Ga is used primarily for spondylodiskitis. Although in vitro labeled leukocyte imaging is the radionuclide test of choice for complicating osteomyelitis such as diabetic pedal osteomyelitis and prosthetic joint infection, it is not useful for spondylodiskitis. Antigranulocyte antibodies and antibody fragments have limitations and are not widely available. (111)In-biotin is useful for spondylodiskitis. Radiolabeled synthetic fragments of the antimicrobial peptide ubiquicidin are promising infection-specific agents. (18)F-FDG is the radiopharmaceutical of choice for spondylodiskitis. Its role in diabetic pedal osteomyelitis and prosthetic joint infection is not established. Preliminary data suggest (68)Ga may be useful in musculoskeletal infection. (124)I-fialuridine initially showed promise as an infection-specific radiopharmaceutical, but subsequent investigations were disappointing. The development of PET/CT and SPECT/CT imaging systems, which combine anatomic and functional imaging, has revolutionized diagnostic imaging. These hybrid systems are redefining the diagnostic workup of patients with suspected or known infection and inflammation by improving diagnostic accuracy and influencing patient management.
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Leone A, Cassar-Pullicino VN, Semprini A, Tonetti L, Magarelli N, Colosimo C. Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot. Skeletal Radiol 2016; 45:735-54. [PMID: 26883537 DOI: 10.1007/s00256-016-2339-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/10/2016] [Accepted: 01/17/2016] [Indexed: 02/02/2023]
Abstract
Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.
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Affiliation(s)
- Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy.
| | - Victor N Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Alessia Semprini
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Laura Tonetti
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Nicola Magarelli
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
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Love C, Palestro CJ. Nuclear medicine imaging of bone infections. Clin Radiol 2016; 71:632-46. [PMID: 26897336 DOI: 10.1016/j.crad.2016.01.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/24/2015] [Accepted: 01/04/2016] [Indexed: 02/08/2023]
Abstract
Osteomyelitis is a broad group of infectious diseases that involve the bone and/or bone marrow. It can arise haematogenously, via extension from a contiguous infection, or by direct inoculation during surgery or trauma. The diagnosis is not always obvious and imaging tests are frequently performed as part of the diagnostic work-up. Commonly performed radionuclide tests include technetium-99m ((99m)Tc)-diphosphonate bone scintigraphy (bone), and gallium-67 ((67)Ga) and in vitro labelled leukocyte (white blood cell; WBC) imaging. Although they are useful, each of these tests has limitations. Bone scintigraphy is sensitive but not specific, especially when underlying osseous abnormalities are present. (67)Ga accumulates in tumour, trauma, and in aseptic inflammation; furthermore, there is typically an interval of 1-3 days between radiopharmaceutical injection of and imaging. Currently, this agent is used primarily for spinal infections. Except for the spine, WBC imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. The in vitro leukocyte labelling process requires skilled personnel, is laborious, and is not always available. Complementary marrow imaging is usually required to maximise accuracy. Not surprisingly, alternative radiopharmaceuticals are continuously being investigated. Radiolabelled anti-granulocyte antibodies and antibody fragments, investigated as in vivo leukocyte labelling agents, have their own limitations and are not widely available. (111)In-biotin is useful for diagnosing spinal infections. Radiolabelled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, have shown promise as infection specific radiopharmaceuticals. 2-[(18)F]-fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) with or without computed tomography (CT) is very useful in musculoskeletal infection. Sensitivities of more than 95% and specificities ranging from 75-99% have been reported in acute and subacute bone and soft-tissue infection. FDG is the radionuclide test of choice for spinal infection. It is sensitive, has a high negative predictive value, and can differentiate degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of FDG for diagnosing diabetic pedal osteomyelitis and prosthetic joint infection are inconclusive and its role for these indications remains to be determined. Other PET radiopharmaceuticals that are under investigation as infection imaging agents include gallium-68 citrate ((68)Ga) and iodine-124 fialuridine ((124)I -FIAU).
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Affiliation(s)
- C Love
- Division of Nuclear Medicine, PET/CT Center, Montefiore Medical Center, 1695A Eastchester Road, Bronx, NY 11755, USA.
| | - C J Palestro
- Division of Nuclear Medicine & Molecular Imaging, Northwell Health, Manhasset & New Hyde Park, NY, USA
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The diagnostic value of [18F]FDG PET for the detection of chronic osteomyelitis and implant-associated infection. Eur J Nucl Med Mol Imaging 2015; 43:749-61. [DOI: 10.1007/s00259-015-3221-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 10/07/2015] [Indexed: 10/22/2022]
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Glaudemans AW, Israel O, Slart RH. Pitfalls and Limitations of Radionuclide and Hybrid Imaging in Infection and Inflammation. Semin Nucl Med 2015; 45:500-12. [DOI: 10.1053/j.semnuclmed.2015.02.005] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
Radionuclide procedures frequently are performed as part of the diagnostic workup of osteomyelitis. Bone scintigraphy accurately diagnoses osteomyelitis in bones not affected by underlying conditions. Degenerative joint disease, fracture, and orthopedic hardware decrease the specificity of the bone scan, making it less useful in these situations. Gallium-67 scintigraphy was often used as an adjunct to bone scintigraphy for diagnosing osteomyelitis. However, now it is used primarily for spinal infections when (18)F-FDG imaging cannot be performed. Except for the spine, in vitro-labeled leukocyte imaging is the nuclear medicine test of choice for diagnosing complicating osteomyelitis. Leukocytes accumulate in bone marrow as well as in infection. Performing complementary bone marrow imaging with (99m)Tc-sulfur colloid facilitates the differentiation between osteomyelitis and normal marrow and improves test overall accuracy. Antigranulocyte antibodies and antibody fragments, such as (99m)Tc-besilesomab and (99m)Tc-sulesomab, were developed to eliminate the disadvantages associated with in vitro-labeled leukocytes. These agents, however, have their own shortcomings and are not widely available. As biotin is used as a growth factor by certain bacteria, (111)In-biotin is useful to diagnose spinal infections. Radiolabeled synthetic fragments of ubiquicidin, a naturally occurring human antimicrobial peptide that targets bacteria, can differentiate infection from sterile inflammation and may be useful to monitor response to treatment. (18)F-FDG is extremely useful in the diagnostic workup of osteomyelitis. Sensitivity in excess of 95% and specificity ranging from 75%-99% have been reported. (18)F-FDG is the radionuclide test of choice for spinal infection. The test is sensitive, with a high negative predictive value, and reliably differentiates degenerative from infectious vertebral body end-plate abnormalities. Data on the accuracy of (18)F-FDG for diagnosing diabetic pedal osteomyelitis are contradictory, and its role for this indication remains to be determined. Initial investigations suggested that (18)F-FDG accurately diagnoses prosthetic joint infection; more recent data indicate that it cannot differentiate infection from other causes of prosthetic failure. Preliminary data on the PET agents gallium-68 and iodine-124 fialuridine indicate that these agents may have a role in diagnosing osteomyelitis.
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Affiliation(s)
- Christopher J Palestro
- Department of Radiology Hofstra, NorthShore-LIJ School of Medicine, Hempstead, NY; Division of Nuclear Medicine and Molecular Imaging, North Shore Long Island Jewish Health System, Manhasset & New Hyde Park, NY.
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Hess S, Hansson SH, Pedersen KT, Basu S, Høilund-Carlsen PF. FDG-PET/CT in Infectious and Inflammatory Diseases. PET Clin 2014; 9:497-519, vi-vii. [DOI: 10.1016/j.cpet.2014.07.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Treglia G, Sadeghi R, Annunziata S, Zakavi SR, Caldarella C, Muoio B, Bertagna F, Ceriani L, Giovanella L. Diagnostic performance of Fluorine-18-Fluorodeoxyglucose positron emission tomography for the diagnosis of osteomyelitis related to diabetic foot: a systematic review and a meta-analysis. Foot (Edinb) 2013; 23:140-8. [PMID: 23906976 DOI: 10.1016/j.foot.2013.07.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2013] [Revised: 07/01/2013] [Accepted: 07/04/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To systematically review and meta-analyse published data about the diagnostic performance of Fluorine-18-Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) in osteomyelitis related to diabetic foot. METHODS A comprehensive literature search of studies on (18)F-FDG-PET and PET/CT in patients with diabetic foot was performed. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-) and diagnostic odds ratio (DOR) and area under the summary ROC curve of (18)F-FDG-PET and PET/CT in patients with osteomyelitis related to diabetic foot were calculated. RESULTS Nine studies comprising 299 patients with diabetic foot were included in the qualitative analysis (systematic review) and discussed. The quantitative analysis (meta-analysis) of four selected studies provided the following results on a per patient-based analysis: sensitivity was 74% [95% confidence interval (95%CI): 60-85%], specificity 91% (95%CI: 85-96%), LR+ 5.56 (95%CI: 2.02-15.27), LR- 0.37 (95%CI: 0.10-1.35), and DOR 16.96 (95%CI: 2.06-139.66). The area under the summary ROC curve was 0.874. CONCLUSIONS In patients with suspected osteomyelitis related to diabetic foot (18)F-FDG-PET and PET/CT demonstrated a high specificity, being potentially useful tools if combined with other imaging methods such as MRI. Nevertheless, the literature focusing on the use of (18)F-FDG-PET and PET/CT in this setting remains still limited.
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Affiliation(s)
- Giorgio Treglia
- Department of Nuclear Medicine and PET/CT Center, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.
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Image acquisition and interpretation criteria for 99mTc-HMPAO-labelled white blood cell scintigraphy: results of a multicentre study. Eur J Nucl Med Mol Imaging 2013; 41:615-23. [DOI: 10.1007/s00259-013-2631-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/06/2013] [Indexed: 12/31/2022]
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Palestro CJ, Glaudemans AWJM, Dierckx RAJO. Multiagent imaging of inflammation and infection with radionuclides. Clin Transl Imaging 2013; 1:385-396. [PMID: 32289033 PMCID: PMC7102491 DOI: 10.1007/s40336-013-0041-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Accepted: 11/13/2013] [Indexed: 11/26/2022]
Abstract
Molecular imaging with single photon- and positron-emitting tracers plays an important role in the evaluation of inflammation and infection. Although supplanted by labeled leukocyte imaging for most indications, gallium-67 remains useful for opportunistic infections, pulmonary inflammation and interstitial nephritis and, when [18F]FDG is not available, spinal infection and fever of unknown origin. In vitro labeled leukocyte imaging is the radionuclide procedure of choice for most infections in immunocompetent patients. When performed for musculoskeletal infection, complementary bone marrow imaging usually is necessary. Recent data suggest that dual time point imaging might be an alternative to marrow imaging. Several methods of labeling leukocytes in vivo, with agents including antigranulocyte antibodies and antibody fragments, peptides and cytokines, have been investigated, with variable results. These agents are not widely available and none of them are available in the USA. Radiolabeled antibiotics have been investigated as “infection-specific” tracers, but the results to date have been disappointing. Conversely, radiolabeled antimicrobial peptides do hold promise as infection-specific tracers. The use of positron-emitting tracers for diagnosing inflammation and infection has generated considerable interest. [18F]FDG is useful in fever of unknown origin, spinal osteomyelitis, vasculitis and sarcoidosis. Other positron-emitting tracers that have been investigated include [18F]FDG-labeled leukocytes, copper-64-labeled leukocytes, gallium-68 citrate and iodine-124 FIAU. Although radiolabeled tracers are used primarily for diagnosis, they also offer objective biomarkers for assessing response to therapeutic interventions in inflammatory diseases. They could also potentially be used to target cells and molecules with specific receptor expression for histological characterization, select patients for receptor-targeted therapy and predict response to treatment.
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Affiliation(s)
- Christopher J. Palestro
- Department of Radiology, Hofstra North Shore-LIJ, School of Medicine, Hempstead, NY USA
- Division of Nuclear Medicine and Molecular Imaging, North Shore-Long Island Jewish Health System, Manhasset, NY USA
- Division of Nuclear Medicine and Molecular Imaging, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY 11040 USA
| | - Andor W. J. M. Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rudi A. J. O. Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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The use of (18)F-FDG-PET/CT for diagnosis and treatment monitoring of inflammatory and infectious diseases. Clin Dev Immunol 2013; 2013:623036. [PMID: 24027590 PMCID: PMC3763592 DOI: 10.1155/2013/623036] [Citation(s) in RCA: 163] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 07/20/2013] [Indexed: 02/08/2023]
Abstract
FDG-PET, combined with CT, is nowadays getting more and more relevant for the diagnosis of several infectious and inflammatory diseases and particularly for therapy monitoring. Thus, this paper gives special attention to the role of FDG-PET/CT in the diagnosis and therapy monitoring of infectious and inflammatory diseases. Enough evidence in the literature already exists about the usefulness of FDG-PET/CT in the diagnosis, management, and followup of patients with sarcoidosis, spondylodiscitis, and vasculitis. For other diseases, such as inflammatory bowel diseases, rheumatoid arthritis, autoimmune pancreatitis, and fungal infections, hard evidence is lacking, but studies also point out that FDG-PET/CT could be useful. It is of invaluable importance to have large prospective multicenter studies in this field to provide clear answers, not only for the status of nuclear medicine in general but also to reduce high costs of treatment.
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Glaudemans AWJM, de Vries EFJ, Vermeulen LEM, Slart RHJA, Dierckx RAJO, Signore A. A large retrospective single-centre study to define the best image acquisition protocols and interpretation criteria for white blood cell scintigraphy with 99mTc-HMPAO-labelled leucocytes in musculoskeletal infections. Eur J Nucl Med Mol Imaging 2013; 40:1760-9. [DOI: 10.1007/s00259-013-2481-0] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 06/03/2013] [Indexed: 12/16/2022]
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Guidelines for the use of 18F-FDG in infection and inflammation: a new step in cooperation between the EANM and SNMMI. Eur J Nucl Med Mol Imaging 2013; 40:1120-1. [DOI: 10.1007/s00259-013-2380-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Utility of 99mTc-labelled antimicrobial peptide ubiquicidin (29-41) in the diagnosis of diabetic foot infection. Eur J Nucl Med Mol Imaging 2013; 40:737-43. [DOI: 10.1007/s00259-012-2327-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 12/12/2012] [Indexed: 01/27/2023]
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