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18F-2-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) shows tumor activity in most neuroblastomas, but the role of 18F-FDG PET/CT in neuroblastoma remains to be defined. This study explored the prognostic significance of 18F-FDG PET in newly diagnosed neuroblastic tumors. This retrospective study reviewed all 18F-FDG PET/CT examinations performed for a new diagnosis of suspected neuroblastoma. MYCN amplification status, tumor recurrence and survival were abstracted from the medical record. Primary tumors were manually segmented to measure maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), tumor volume and total lesion glycolysis. Univariate and multivariable analyses using Cox proportional hazards regression testing assessed the predictive performance of PET indices for event-free survival and overall survival with thresholds determined using receiver operating characteristic curve analysis. Fifty-five children were included, with a median age of 2.9 years (interquartile range [IQR] 1.8–3.0 years). SUVmax, tumor volume and total lesion glycolysis were higher in MYCN-amplified tumors (P=0.012, P 4.77) vs. >2,957 days (SUVmax≤4.77). No PET parameters were independently significantly associated with overall survival or event-free survival after controlling for MYCN status, stage or treatment risk stratification. Tumor metabolic activity is higher in higher-stage MYCN-amplified neuroblastic tumors. Higher SUVmax and SUVmean were associated with worse overall survival but were not independent of other prognostic markers.

Background Previous studies suggest that use of artificial intelligence (AI) algorithms as diagnostic aids may improve the quality of skeletal age assessment, though these studies lack evidence from clinical practice. Purpose To compare the accuracy and interpretation time of skeletal age assessment on hand radiograph examinations with and without the use of an AI algorithm as a diagnostic aid. Materials and Methods In this prospective randomized controlled trial, the accuracy of skeletal age assessment on hand radiograph examinations was performed with (

Background Accurate risk stratification of Langerhans cell histiocytosis (LCH) is essential as management can range from conservative in single system, low risk for central nervous system (CNS) involvement lesions to intensive chemotherapy for multisystem or high-risk disease. Additionally, being able to differentiate metabolically active from inactive lesions is essential for both prognostic reasons and to avoid potentially unnecessary treatment. Methods A retrospective review was performed on all patients with histopathology-confirmed LCH at Cincinnati Children's Hospital Medical Center (CCHMC) between 2009 and 2019. Results One hundred seven positron emission tomography (PET)/computerized tomography (CT) images were included in the review. A discrepancy between PET/CT and conventional imaging occurred on 53 occasions. On 13 occasions, increased uptake was observed on PET in an area with no identifiable lesion on conventional imaging. On 40 occasions, lesions were found on conventional imaging where no increased uptake was observed on PET. On eight skeletal surveys, three other radiographs, four diagnostic CTs, five localization CTs, and one bone scan, no lesion was identified in an area with increased fluorodeoxyglucose (FDG) uptake. This occurred exclusively in bone. On nine skeletal surveys, one other radiograph, four diagnostic CTs, six localization CTs, 19 magnetic resonance imaging (MRI) scans, and one bone scan, a lesion was identified in a location without increased FDG uptake. This occurred in bone, CNS, and lungs. Conclusion F-18-FDG PET/CT is vital in the evaluation of LCH lesions given its ability to detect LCH lesions not detectable on conventional imaging modalities, as well as its ability to distinguish metabolically active from inactive disease. MRI and diagnostic CT are still useful adjunctive tests for identification of CNS and lung lesions.

Osteosarcoma is the most common pediatric malignant bone tumor, frequently surgically managed with limb salvage rather than amputation. Local recurrences are seen in up to 9% of osteosarcoma patients, with CT and MRI imaging often limited by metal artifacts. To describe the [F-18]2-fluoro-2-deoxyglucose (FDG) PET/CT appearance of local osteosarcoma recurrences with correlation to findings on other imaging modalities. A retrospective review of pediatric osteosarcoma patients imaged with FDG PET/CT was performed in patients with pathologically proven local recurrences. FDG PET/CT findings were reviewed and correlated with available comparison imaging studies. Ten local osteosarcoma recurrences in eight pediatric osteosarcoma patients were imaged with FDG PET/CT. All eight patients had a local recurrence after limb salvage; two patients had a second local recurrence after amputation. All local recurrences were seen with FDG PET/CT, demonstrating solid (n=5) or peripheral/nodular (n=5) FDG uptake patterns. Maximum standard uptake values (SUVs) ranged from 3.0 to 15.7. In five recurrences imaged with FDG PET/CT and MRI, MRI was limited or nondiagnostic in three. In four recurrences imaged with FDG PET/CT and bone scan, the bone scan was negative in three. Local osteosarcoma recurrences are well visualized by FDG PET/CT, demonstrating either solid or peripheral/nodular FDG uptake with a wide range of maximum SUVs. FDG PET/CT demonstrates the full extent of local recurrences, while MRI can be limited by artifact from metallic hardware. PET/CT appears to be more sensitive than bone scan in detecting local osteosarcoma recurrences.

More older adults suffer from anxiety disorders than any other class of mental health disorders. In general, older adults present with many of the same types of anxiety disorders seen in younger persons, but with some caveats given medical, cognitive, and other contextual issues specific to aging. Subthreshold anxiety symptoms, which do not meet diagnostic criteria but may undermine functioning, are quite common in older adults and may benefit from treatment. The understanding of anxiety disorders in older adults lags behind the rich and extensive empirical work in younger populations with anxiety. However, scientific strides in the assessment and treatment of late-life anxiety over the past two decades have been narrowing this gap. This work has also demonstrated the challenges and limitations of current evidence-based therapies. This chapter summarizes what is known about late-life anxiety disorders and their treatment and offers recommendations for both clinicians and researchers in geriatrics.

Innovative technologies are increasingly used in order to address gaps in access to child behavioral health care. Telemental health is one technological modality in which child behavioral services can be practiced successfully across psychiatry, psychology, and developmental medicine. The authors discuss relevant issues related to delivering telemental health, including why this modality is necessary for delivery, what models and evidence for telemental health exist, when it should be considered across legal/regulatory and ethical considerations, where telemental health services are delivered, who is involved in delivery, and how best telemental health practices may be implemented with diverse youth.

Because of the widening gap between need for child mental health services and availability of child specialists, secure videoconferencing options are more needed than ever to address access challenges across underserved settings. This article reviews real-time videoconferencing evidence across telemental health with children and adolescents. It summarizes emerging guidelines that inform best practices for child telemental health using videoconferencing. It presents a case example of best practices across behavioral health specialties. Videoconferencing is an effective approach to improving access to behavioral health interventions for children and adolescents. Telemental health shows promise for disseminating evidence-based treatments to underserved communities.

BACKGROUND Lymph node metastases are an important cause of treatment failure for pediatric and adolescent/young adult (AYA) sarcoma patients. Nodal sampling is recommended for certain sarcoma subtypes that have a predilection for lymphatic spread. Sentinel lymph node biopsy (SLNB) may improve the diagnostic yield of nodal sampling, particularly when single-photon emission computed tomography/computed tomography (SPECT-CT) is used to facilitate anatomic localization. Functional imaging with positron emission tomography/computed tomography (PET-CT) is increasingly used for sarcoma staging and is a less invasive alternative to SLNB. To assess the utility of these 2 staging methods, this study prospectively compared SLNB plus SPECT-CT with PET-CT for the identification of nodal metastases in pediatric and AYA patients. METHODS Twenty-eight pediatric and AYA sarcoma patients underwent SLNB with SPECT-CT. The histological findings of the excised lymph nodes were then correlated with preoperative PET-CT imaging. RESULTS A median of 2.4 sentinel nodes were sampled per patient. No wound infections or chronic lymphedema occurred. SLNB identified tumors in 7 of the 28 patients (25%), including 3 patients who had normal PET-CT imaging of the nodal basin. In contrast, PET-CT demonstrated hypermetabolic regional nodes in 14 patients, and this resulted in a positive predictive value of only 29%. The sensitivity and specificity of PET-CT for detecting histologically confirmed nodal metastases were only 57% and 52%, respectively. CONCLUSIONS SLNB can safely guide the rational selection of nodes for biopsy in pediatric and AYA sarcoma patients and can identify therapy-changing nodal disease not appreciated with PET-CT. Cancer 2016. © 2016 American Cancer Society.

Metal endoprostheses and internal fixation devices cause significant artifacts on CT after limb salvage surgery; positron emission tomography (PET) images should be evaluated for artifacts. (1) To describe [F-18]2-fluoro-2-deoxyglucose (FDG) PET uptake patterns after limb salvage surgery. (2) To determine whether metal endoprostheses and fixation hardware cause significant artifacts on CT attenuation-corrected PET that interfere with diagnostic use of PET/CT after limb salvage surgery. We reviewed 92 studies from 18 patients ages 5–21 years. Diagnoses were osteogenic sarcoma in 14, Ewing sarcoma in 3, and malignant peripheral nerve sheath tumor originating in bone in 1. Nine patients had distal femur/knee endoprostheses, five had lower-extremity bone allografts secured by large metal plates and four had upper-extremity limb salvage procedures. Maximum standardized uptake value was calculated at lower-extremity soft-tissue–endoprosthesis interfaces. In 15 patients with PET/CT imaging, the first PET/CT scan after limb salvage surgery was reviewed for metal artifacts on CT images and for artifacts at locations on PET corresponding to the CT metal artifacts. Increased FDG uptake was consistently present at soft-tissue interfaces with endoprostheses, allografts and internal fixation devices, with little or no FDG uptake at cemented endoprosthesis–bone interfaces. Maximum standardized uptake value at margins of femur/knee endoprostheses ranged from 1.4 to 5.7. In four patients with distal femur/knee endoprostheses, minimal artifact was noted on attenuation-corrected PET images, but image interpretation was not affected. In the other 11 patients who had CT attenuation correction, we detected no artifacts caused by the attenuation correction. CT attenuation correction did not cause artifacts that affected interpretation of attenuation-corrected PET images.

Granulocyte colony-stimulating factors (G-CSF) speed recovery from chemotherapy-induced myelosuppression but the marrow stimulation they cause can interfere with interpretation of F-18 fluorodeoxyglucose positron emission tomography (F-18 FDG PET) exams. To assess the frequency of interfering G-CSF-induced bone marrow activity on FDG PET imaging in children and young adults with Ewing sarcoma and rhabdomyosarcoma and to define an interval between G-CSF administration and FDG PET imaging that limits marrow interference. Blinded, retrospective review of FDG PET exams performed in patients treated with long-acting G-CSF as part of their chemotherapeutic regimen. Exams were subjectively scored by two reviewers (R1 and R2) who assessed the level of marrow uptake of FDG and measured standardized uptake values in the marrow, liver, spleen and blood pool. FDG PET findings were correlated with time since G-CSF administration and with blood cell counts. Thirty-eight FDG PET exams performed in 17 patients were reviewed with 47.4% (18/38) of exams having marrow uptake of FDG sufficient to interfere with image interpretation. Primary predictors of marrow uptake of FDG were patient age (P = 0.0037) and time since G-CSF exposure (P = 0.0028 for subjective marrow uptake of FDG, P = 0.008 [R1] and P = 0.004 [R2] for measured maximum standardized uptake value (SUVmax)). The median interval between G-CSF administration and PET imaging in cases with marrow activity considered normal or not likely to interfere was 19.5 days (range: 7–55 days). In pediatric and young adult patients with Ewing sarcoma and rhabdomyosarcoma, an interval of 20 days between administration of the long-acting form of G-CSF and FDG PET imaging should limit interference by stimulated marrow.

Advances made in genetic testing and tools applied to pharmacogenetics are increasingly being used to inform clinicians in fields such as oncology, hematology, diabetes (endocrinology), cardiology and expanding into psychiatry by examining the influences of genetics on drug efficacy and metabolism. We present a clinical case example of an adolescent male with anxiety, attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder who did not tolerate numerous medications and dosages over several years in attempts to manage his symptoms. Pharmacogenetics testing was performed and DNA results on this individual elucidated the potential pitfalls in medication use because of specific pharmacodynamic and pharmacokinetic differences specifically involving polymorphisms of genes in the cytochrome p450 enzyme system. Future studies and reports are needed to further illustrate and determine the type of individualized medicine approach required to treat individuals based on their specific gene patterns. Growing evidence supports this biological approach for standard of care in psychiatry.

BACKGROUND Several empirical investigations have attempted to characterize the effect of physical activity on cancer mortality, but these investigations have rarely focused on patients with advanced breast cancer. OBJECTIVE The current study examined the hypothesis that greater physical activity is associated with longer survival among women with advanced breast cancer. METHODS We conducted a secondary data analysis of a prospective study of 103 patients with stage IV (n = 100) or locally recurrent (n = 3) breast cancer involved in a group psychotherapy trial. Physical activity was assessed at baseline using the Seven-Day Physical Activity Recall questionnaire, and patients were followed until April 1, 2016, at which time 93 of 103 had died. RESULTS Greater physical activity level at baseline was significantly associated with longer subsequent survival time in a Cox proportional hazards model (hazard ratio [HR], 0.90; 95% confidence interval [CI], 0.84-0.97; P < .01). Engaging in 1 additional hour per day of moderate activity reduced the hazard of subsequent mortality by 23% (HR, 0.77; 95% CI, 0.65-0.92; P < .01). These results remained significant even after controlling for demographic, medical, cancer, depression, and cortisol variables (HR, 0.91; 95% CI, 0.84-0.99; P < .05). CONCLUSIONS Women with advanced breast cancer who engaged in physical activity for 1 or more hours per day at baseline had an increased likelihood of survival compared with those who exercised less than 1 hour per day. IMPLICATIONS FOR PRACTICE Nurses should consider recommending moderate physical activity for women with advanced breast cancer. Randomized trials of physical activity interventions for this population are needed.

PET/CT, the most common form of hybrid imaging, has transformed oncologic imaging and is increasingly being used for nononcologic applications as well. Performing PET/CT in children poses unique challenges. Not only are children more sensitive to the effects of radiation than adults but, following radiation exposure, children have a longer postexposure life expectancy in which to exhibit adverse radiation effects. Both the PET and CT components of the study contribute to the total patient radiation dose, which is one of the most important risks of the study in this population. Another risk in children, not typically encountered in adults, is potential neurotoxicity related to the frequent need for general anesthesia in this patient population. Optimizing pediatric PET/CT requires making improvements to both the PET and the CT components of the procedure while decreasing the potential for risk. This can be accomplished through judicious performance of imaging, the use of recommended pediatric 18fluorine-2-fluoro-2-deoxy-d-glucose (18F-FDG) administered activities, thoughtful selection of pediatric-specific CT imaging parameters, careful patient preparation, and use of appropriate patient immobilization. In this article, we will review a variety of strategies for radiation dose optimization in pediatric 18F-FDG-PET/CT focusing on these processes. Awareness of and careful selection of pediatric-specific CT imaging parameters designed for appropriate diagnostic, localization, or attenuation correction only CT, in conjunction with the use of recommended radiotracer administered activities, will help to ensure image quality while limiting patient radiation exposure. Patient preparation, an important determinant of image quality, is another focus of this review. Appropriate preparative measures are even more crucial in children in whom there is a higher incidence of brown fat, which can interfere with study interpretation. Finally, we will discuss measures to improve the patient experience, the resource use, the departmental workflow, and the diagnostic performance of the study through the use of appropriate technology, all in the context of minimizing procedure-related risks.

The association of trauma exposure and coping style to sexual risk behavior has yet to be fully examined in the context of primary and casual sexual partnerships. The current study assessed a high risk sexual behavior-unprotected anal intercourse (UAI)-in a high risk population of HIV-positive men who have sex with men (MSM) with a history of trauma. Using audio computer-assisted self-interview technology, 132 HIV-positive MSM completed measures of trauma exposure, trauma symptoms, coping strategies, and sexual risk behavior. Hierarchical logistic regression analyses indicated that completing more years of education and having experienced sexual abuse were positively associated with UAI with casual partners. Additionally, use of active coping was negatively associated with UAI with casual partners and the final model significantly predicted variance in UAI with casual partners. However, no variables were significantly associated with UAI with primary partners, suggesting that sexual risk behavior with primary partners may be associated with factors not commonly assessed in risk prediction or prevention research. We discuss the results in the context of developing new or modifying existing interventions to address rates of sexual risk in the relationships of HIV-positive MSM.

Altered FDG uptake patterns were noted in certain lymphoblastic lymphoma patients during therapy. To describe these altered FDG uptake patterns and their relationship to chemotherapy. Thirty-five FDG PET or PET/CT scans obtained in 11 children with lymphoblastic lymphoma were retrospectively reviewed. FDG uptake patterns were recorded. SUV measurements were performed in liver and facial soft tissues. Results were correlated with induction chemotherapy regimens. Six of the children had transiently altered FDG uptake with increased uptake in the superficial soft tissues, most notably involving the face. Altered uptake was noted approximately 1 month after initiation of chemotherapy and subsequently resolved. Hepatic uptake was transiently reduced on the 1-month scan in all six children with increased facial uptake. No significant FDG uptake in lymphoma was seen on five of six scans with altered uptake; however, two of these five affected children had FDG uptake in lymphoma on the next follow-up examination. Blood glucose levels in the affected children were in the normal range. All six children with altered FDG uptake received the same induction chemotherapy regimen, which included very high doses of corticosteroids. Children with lymphoblastic lymphoma on induction chemotherapy protocols including very high doses of corticosteroids transiently demonstrated altered FDG uptake patterns, including increased superficial facial uptake and reduced hepatic uptake. The facial uptake is probably the FDG PET equivalent of Cushingoid facies. Caution in interpreting scans with this altered FDG uptake pattern is suggested, as uptake at sites of lymphomatous involvement may potentially be affected.

The purpose of this analysis was to evaluate the utility of FDG PET/CT scanning in patients with Wilms' tumors.A total of 58 scans were performed in 27 patients (14 male, 13 female; ages: 1.9-23 years, median: 7 years) with proven Wilms' tumor. Twenty-six patients (56 scans) were studied at the time of suspected relapse, progressive disease, persistent disease, or for monitoring of therapy.In the 27 patients with Wilms' tumor, 34 scans showed areas of abnormal uptake consistent with metabolically active tumors. Of the patients, 8 (24 scans) had pulmonary metastases larger than 10 mm in diameter, 10 (12 scans) had hepatic metastases, 11 (11 scans) had regional nodal involvement, 3 (3 scans) had bone metastases, 1 (1 scan) had chest wall involvement, 2 (2 scans) had pancreatic metastasis, and 5 (5 scans) had abdominal and pelvic soft tissue involvement. Two of eight patients with lung metastases had variable uptakes. Lung lesions 10 mm or smaller were not consistently visualized on PET scans. One patient with a liver metastasis showed no uptake on PET scan after treatment (size decreased from 45 to 15 mm).Most Wilms' tumors concentrate FDG. However, small pulmonary metastases may be better visualized with CT. FDG PET/CT appears useful for defining the extent of involvement and assessing the response to treatment.

Background: Exposure-based therapy for anxiety disorders is believed to operate on the basis of fear extinction. Studies have shown acute administration of D-cycloserine (DCS) enhances fear extinction in animals and facilitates exposure therapy in humans, but the neural mechanisms are not completely understood. To date, no study has examined neural effects of acute DCS in anxiety-disordered populations.Methods: Two hours prior to functional magnetic resonance imaging scanning, 23 spider-phobic and 23 non-phobic participants were randomized to receive DCS 100 mg or placebo. During scanning, participants viewed spider, butterfly, and Gaussian-blurred baseline images in a block-design paradigm. Diagnostic and treatment groups were compared regarding differential activations to spider versus butterfly stimuli.Results: In the phobic group, DCS enhanced prefrontal (PFC), dorsal anterior cingulate (ACC), and insula activations. For controls, DCS enhanced ventral ACC and caudate activations. There was a positive correlation between lateral PFC and amygdala activation for the placebo-phobic group. Reported distress during symptom provocation was correlated with amygdala activation in the placebo-phobic group and orbitofrontal cortex activation in the DCS-phobic group.Conclusions: Results suggest that during initial phobic symptom provocation DCS enhances activation in regions involved in cognitive control and interoceptive integration, including the PFC, ACC, and insular cortices for phobic participants.

Neuroblastoma is a common malignancy observed in infants and young children. It has a varied prognosis, ranging from spontaneous regression to aggressive metastatic tumors with fatal outcomes despite multimodality therapy. Patients are divided into risk groups on the basis of age, stage, and biologic tumor factors. Multiple clinical and imaging tests are needed for accurate patient assessment. Iodine 123 ((123)I) metaiodobenzylguanidine (MIBG) is the first-line functional imaging agent used in neuroblastoma imaging. MIBG uptake is seen in 90% of neuroblastomas, identifying both the primary tumor and sites of metastatic disease. The addition of single photon emission computed tomography (SPECT) and SPECT/computed tomography to (123)I-MIBG planar images can improve identification and characterization of sites of uptake. During scan interpretation, use of MIBG semiquantitative scoring systems improves description of disease extent and distribution and may be helpful in defining prognosis. Therapeutic use of MIBG labeled with iodine 131 ((131)I) is being investigated as part of research trials, both as a single agent and in conjunction with other therapies. (131)I-MIBG therapy has been studied in patients with newly diagnosed neuroblastoma and those with relapsed disease. Development and implementation of an institutional (131)I-MIBG therapy research program requires extensive preparation with a focus on radiation protection.

The purpose of this study is to review and discuss the status of telepsychiatry practice, particularly as applied to treating children and adolescents with psychotropic medications, which is termed "telepharmacotherapy."The literature pertinent to telepsychiatry practice is reviewed, followed by a presentation of the challenges to implementing telepharmacotherapy, potential solutions, current controversies, and future directions, combining insights from the literature with the authors' own experiences.Telepsychiatry services for children and adolescents are expanding, and provide needed pharmacotherapy for patients who are underserved by available resources. The evidence base supporting the effectiveness of telepsychiatry practice and telepharmacotherapy is still emerging, and consists mainly of feasibility and satisfaction studies with limited outcome data. Although a number of challenges to this mode of care delivery currently exist, the authors outline potential solutions for those challenges that are consistent with existing guidelines for clinical practice.Telepsychiatry appears to be a feasible and satisfactory alternative to in-person care, and a valid option for increasing access to psychopharmacotherapy for children and adolescents. Although the evidence base is still emerging, and practitioners may face a number of challenges, solutions are presented that may help to overcome those challenges.

Single photon emission computed tomography (SPECT)/computed tomography (CT) is ideally suited for assessment of low back pain in children and young adults. Spondylolysis is one of the most common structural causes of low back pain and is readily identified and characterized in terms of its chronicity and likelihood to heal. The value of SPECT/CT extends to identification and characterization of other causes of low back pain, including abnormalities of the posterior elements, developing vertebral endplate, transverse processes, and sacrum and sacroiliac joint. Some of the disease processes that are identifiable at SPECT/CT are similar to those that occur in adults (eg, facet hypertrophy) but may be accelerated in young patients by high-level athletic activities. Other processes (eg, limbus vertebrae) are more unique to children, related to injury of the developing spine. The authors review the spectrum of pars interarticularis abnormalities with emphasis on the imaging features of causes of pediatric low back pain other than spondylolysis.

Positron emission tomography (PET) has transformed nuclear medicine imaging technology. PET is an inherently tomographic technique that utilizes the simultaneous detection of 180-degree opposed 511 keV photons emitted by positron annihilation. Collimation can be eliminated, greatly improving sensitivity and spatial resolution. By placing PET and CT scanners on the same gantry, co-registered PET/CT images can be obtained, allowing normal and abnormal physiology to be accurately depicted in a high-resolution spatial context. The CT part of the PET/CTscanner can be used in any of three modes: as a diagnostic CT scanner at appropriate diagnostic settings for pediatric CT, at reduced non-diagnostic localization settings, and at extremely low non-imaging settings for attenuation correction only. PET/CT has improved the accuracy of PET imaging in 10–30% of patients in adult and pediatric studies. With precise localization of PET abnormalities on PET/CT images and the anatomical information obtained from the co-registered diagnostic or localization CT, interpretative errors are reduced in frequency.

Society for Pediatric Radiology, Research and Education Foundation (Dorst-Fleischer Grant) OBJECTIVE. the purpose of this article is to assess the feasibility and utility of PET/CT in distinguishing benign from malignant pulmonary nodules in patients with solid childhood malignancies.SUBJECTS and METHODS. This prospective study was conducted between March 2008 and August 2010. We enrolled 25 subjects 21 years old or younger with solid childhood malignancies and at least one pulmonary nodule measuring 0.5-3.0 cm. PET/CT was performed within 3 weeks of diagnostic chest CT. Three panels of three reviewers each reviewed diagnostic CT only (panel 1), PET/CT only (panel 2), or diagnostic CT and PET/CT concurrently (panel 3) and predicted each nodule's histologic diagnosis as benign, malignant, or indeterminate. Interreviewer agreement was assessed with the kappa statistic. Using nodule biopsy or clinical follow-up as reference standards, the sensitivity, specificity, and accuracy for each panel was assessed. Logistic regression was used to assess the nodule's maximum standardized uptake value (SUVmax) association with its histologic diagnosis.RESULTS. There were 75 nodules with a median size of 0.74 cm (range, 0.18-2.38 cm); 48 nodules were malignant. Sensitivity was 85% (41/48) for panel 1, 60% (29/48) for panel 2, and 67% (32/48) for panel 3. All panels had poor specificities. Interreviewer agreement was moderate for panel 1 (0.43) and poor for panels 2 (0.22) and 3 (0.33). SUVmax was a significant predictor of histologic diagnosis (p = 0.004).CONCLUSION. PET/CT assessment of pulmonary nodules is feasible in children with solid malignancies but may not reliably improve our ability to predict a nodule's histologic diagnosis. the SUVmax may improve the performance of PET/CT in this setting. St Jude Childrens Res Hosp, Div Diagnost Imaging, Memphis, TN 38105 USA St Jude Childrens Res Hosp, Dept Biostat, Memphis, TN 38105 USA Cincinnati Childrens Hosp Med Ctr, Dept Radiol, Cincinnati, OH 45229 USA British Columbia Childrens Hosp, Dept Radiol, Vancouver, BC V6H 3V4, Canada Hosp Sick Children, Dept Radiol, Toronto, ON M5G 1X8, Canada Universidade Federal de São Paulo, Paulista Sch Med, GRAACC, Pediat Oncol Inst, São Paulo, Brazil St Louis Childrens Hosp, Dept Radiol, St Louis, MO 63178 USA St Jude Childrens Res Hosp, Dept Surg, Memphis, TN 38105 USA St Jude Childrens Res Hosp, Dept Oncol, Memphis, TN 38105 USA Universidade Federal de São Paulo, Paulista Sch Med, GRAACC, Pediat Oncol Inst, São Paulo, Brazil Web of Science

In Langerhans cell histiocytosis (LCH), FDG PET demonstrates active disease in bone. Other imaging modalities show the effects of bone destruction by LCH.To evaluate a selective CT method for reducing effective dose from FDG PET/CT in LCH, using whole-body modified attenuation correction CT at extremely low exposure settings, with repeat selective limited-volume CT at typical localization settings.Fifty-one PET/CT scans were performed in 23 LCH patients, median patient age 8.5 years (range: 1-25 years). Thirty-four were performed with modified attenuation correction CT settings, with bed positions (excluding head and neck) repeated at localization CT settings in regions with abnormal or difficult to interpret PET findings.Of 34 modified attenuation correction PET/CT scans, 10 required repeat localization CT of 1 to 3 bed positions (total: 17 bed positions). Lytic bone lesions were easily recognized at modified attenuation correction settings. Calculated average effective dose for the 34 whole-body CT scans at modified attenuation correction settings was 1.65 mSv. Average effective dose per patient for repeat imaging of 17 bed positions at localization settings was 1.19 mSv. Average total effective dose from CT for all 34 scans performed at the modified attenuation correction CT settings, including the 10 repeat localization CT scans, was 2.0 mSv. High-quality PET scans were consistently obtained with reduced FDG-administered activities of 3.7 MBq/kg (0.10 mCi/kg). In active LCH, abnormal FDG uptake was seen in all lytic bone lesions ≥9 mm, including cranial vault lesions.Substantial reduction in effective dose is possible using selective CT techniques for FDG PET/CT.

Neuroblastoma is the most common pediatric extracranial soft-tissue tumor, accounting for approximately 8% of childhood malignancies. Its prognosis is widely variable, ranging from spontaneous regression to fatal disease despite multimodality therapy. Multiple imaging and clinical tests are needed to accurately assess patient risk with risk groups based on disease stage, patient age, and biological tumor factors. Approximately 60% of patients with neuroblastoma have metastatic disease, most commonly involving bone marrow or cortical bone. Metaiodobenzylguanidine (mIBG) scintigraphy plays an important role in the assessment of neuroblastoma, allowing whole-body disease assessment. mIBG is used to define extent of disease at diagnosis, assess disease response during therapy, and detect residual and recurrent disease during follow-up. mIBG is highly sensitive and specific for neuroblastoma, concentrating in >90% of tumors. mIBG was initially labeled with 131 I, but 123 I-mIBG yields higher quality images at a lower patient radiation dose. 123 I-mIBG (AdreView; GE Healthcare, Arlington Heights, IL) was approved for clinical use in children by the Food and Drug Administration in 2008 and is now commercially available throughout the United States. The use of single-photon emission computed tomography and single-photon emission computed tomography/computed tomography in 123 I-mIBG imaging has improved certainty of lesion detection and localization. Fluorodeoxyglucose positron-emission tomography has recently been compared with mIBG and found to be most useful in neuroblastomas which fail to or weakly accumulate mIBG.

Psychology as a field continues to move toward competencies across all levels of training (Fouad et al., Training and Education in Professional Psychology 3(4):S5–S26, 2009). New technologies bring the opportunity and responsibility to consider new training competencies for psychologists. This holds true with telemental health, or delivery of mental health services using real-time videoconferencing. While psychiatry has been the most common telemedicine service, psychology services are becoming more common over televideo and warrant consideration of training competencies for the next generation of psychologists.

SPECT/CT improves localization of single photon-emitting radiopharmaceuticals. To determine the utility of SPECT/CT in children with papillary thyroid carcinoma. 20 SPECT/CT and planar studies were reviewed in 13 children with papillary thyroid carcinoma after total thyroidectomy. Seven studies used I-123 and 13 used I-131, after elevating TSH by T4 deprivation or intramuscular thyrotropin alfa. Eight children had one study and five children had two to four studies. Studies were performed at initial post-total thyroidectomy evaluation, follow-up and after I-131 treatment doses. SPECT/CT was performed with a diagnostic-quality CT unit in 13 studies and a localization-only CT unit in 7. Stimulated thyroglobulin was measured (except in 2 cases with anti-thyroglobulin antibodies). In 13 studies, neck activity was present but poorly localized on planar imaging; all foci of uptake were precisely localized by SPECT/CT. Two additional foci of neck uptake were found on SPECT/CT. SPECT/CT differentiated high neck uptake from facial activity. In six studies (four children), neck uptake was identified as benign by SPECT/CT (three thyroglossal duct remnants, one skin contamination, two by precise anatomical CT localization). In two children, SPECT/CT supported a decision not to treat with I-131. When SPECT/CT was unable to identify focal uptake as benign, stimulated thyroglobulin measurements were valuable. In three of 13 studies with neck uptake, SPECT/CT provided no useful additional information. SPECT/CT precisely localizes neck iodine uptake. In small numbers of patients, treatment is affected. SPECT/CT should be used when available in thyroid carcinoma patients.

The purpose of this study was to compare the diagnostic utility of (123)I-metaiodobenzylguanidine ((123)I-MIBG) scintigraphy and (18)F-FDG PET in neuroblastoma.A total of 113 paired (123)I-MIBG and (18)F-FDG PET scans in 60 patients with neuroblastoma were retrospectively reviewed. Paired scans were acquired within 14 days of each other.For stage 1 and 2 neuroblastoma (13 scans, 10 patients), (18)F-FDG depicted more extensive primary or residual neuroblastoma in 9 of 13 scans. (123)I-MIBG and (18)F-FDG showed equal numbers of lesions in 1 of 13 scans, and 3 of 13 scan results were normal. For stage 3 neuroblastoma (15 scans, 10 patients), (123)I-MIBG depicted more extensive primary neuroblastoma or local or regional metastases in 5 of 15 scans. (18)F-FDG depicted more extensive primary neuroblastoma or local or regional metastases in 4 of 15 scans. (123)I-MIBG and (18)F-FDG were equal in 2 of 15 scans, and 4 of 15 scan results were normal. For stage 4 neuroblastoma (85 scans, 40 patients), (123)I-MIBG depicted more neuroblastoma sites in 44 of 85 scans. (18)F-FDG depicted more neuroblastoma sites in 11 of 85 scans. (123)I-MIBG and (18)F-FDG were equivalent or complementary in 13 of 85 scans, and 17 of 85 scan results were normal.(18)F-FDG is superior in depicting stage 1 and 2 neuroblastoma, although (123)I-MIBG may be needed to exclude higher-stage disease. (18)F-FDG also provides important information for patients with tumors that weakly accumulate (123)I-MIBG and at major decision points during therapy (i.e., before stem cell transplantation or before surgery). (18)F-FDG can also better delineate disease extent in the chest, abdomen, and pelvis. (123)I-MIBG is overall superior in the evaluation of stage 4 neuroblastoma, especially during initial chemotherapy, primarily because of the better detection of bone or marrow metastases.

Background: For quality assurance reasons, it is important to monitor the services provided over time for infants and their families through both hospital and community-based early hearing detection and intervention programs (EHDIPs) and to compare results for local programs to national benchmarks. This two-part study is an update to earlier reports published for a particular EHDIP. Purpose: To evaluate a maturing, diverse community-based EHDIP partially managed through a private practice in Santa Barbara, California, and to compare results to earlier reports for this program and to national data. Research Design: A parent questionnaire and a retrospective case-report chart review process was used. Study Sample: Charts were reviewed for 150 babies that were referred to the practice from two hospitals and were seen for screenings and follow-up. Also, parents of 34 infants seen beyond their initial or secondary screenings were surveyed about their experiences with and impressions of the program. Data Collection And Analysis: Babies seen by the practice between May 2003 and November 2006 were tracked across five levels (from hospital screening through intervention) to determine if parents complied with professionals' recommendations, time taken to comply, and highest level reached and whether it was an appropriate termination point. Also, parents' responses to an 11-item questionnaire assessing their impressions about their participation in the program were analyzed and compared to the compliance data. Results: Of the 150 babies, 116 passed initial or secondary screenings; compliance details at the subsequent levels of follow-up are provided for the remaining 34 infants. Seven of the 34 families completed the questionnaire. Compliance at early levels was excellent, meeting EHDIP benchmarks and previous results for this program; that for subsequent levels was poorer, possibly due to the diverse population. Parents' impressions of this program ranged from neutral to generally positive. Conclusions: This maturing EHDIP generally met national benchmarks and continued to serve the infants and families well. However, parents' compliance with physician visits and audiologic follow-up for habilitation including hearing aids in a timely manner could still be improved.

Background: Given the widespread reports involving the use of selective serotonin reuptake inhibitors (SSRIs) in children, the present paper reviews and discusses published double-blind, placebo-controlled studies assessing the safety and efficacy of SSRIs in children and adolescents with major depressive disorder. Methods: Published and unpublished double-blind, placebo-controlled studies of SSRIs in children and adolescents with depression during the years 1990-2004 were reviewed. A MEDLINE search was performed using the words ‘depression’, ‘randomised controlled trial’, ‘SSRIs’, ‘children’ and ‘adolescents’. The GlaxoSmithKline website was also searched for relevant studies on paroxetine. Outcome measures were the Clinical Global Impressions scale, the Children’s Depression Rating Scale-Revised, the Hamilton Rating Scale for Depression, the depression subscales of the Kiddie Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version, and the Montgomery and Asberg Depression Rating Scale. Adverse effects and withdrawal rates are reported. Results: There were seven randomised, placebo-controlled trials involving 1619 children and adolescents aged 6–18 years in total. The SSRIs fluoxetine, paroxetine, sertraline and citalopram were reported to exhibit safety and efficacy for treatment of depression in children and adolescents. Reanalysis of published and unpublished studies by the US FDA and the UK’s Medicines and Healthcare products Regulatory Agency (MHRA) raised alerts regarding higher suicidal ideation rates from SSRIs in this population. Present guidelines are discussed. Conclusions: SSRIs remain a first-line pharmacological treatment for depression in children and adolescents for whom psychotherapy has failed or is unavailable. Suicidal ideation and behaviours merit close monitoring. More studies are needed.

Sir, The article by Chawla et al. [1] calculates effective doses for [F-18]FDG PET/CT studies performed at their hospital. This paper provides interesting data with respect to the numbers of PET/CT scans performed in their patients and an estimate of the resulting cumulative dose. However, a careful reading discloses that the effective dose from the PET radiopharmaceutical does not represent optimal clinical practice in 2010 and that it also no longer represents clinical practice at the authors’ hospital. The CT doses attributed to PET/CT represent the full diagnostic CT doses in use at their hospital. The authors state that it was their practice to perform the diagnostic CT required by the patient as part of the PET/CT scan. Therefore, the only added effective dose from the PET/CT scan is due to the addition of PET imaging. The amount of [F-18]FDG (administered activity) that a pediatric patient receives is usually calculated from a reference adult administered activity. The authors’ administered activity of 0.21 mCi/kg (7.8 MBq/kg) indicates that they used a reference activity of 15 mCi (555 MBq), which is commonly used at adult hospitals. However, a survey of North American children’s hospitals in 2008 indicated the median administered activity at these specialty hospitals surveyed was 0.145 mCi/kg (5.4 MBq/kg), corresponding to a reference activity of 10.1 mCi (373 MBq). An FDG administered activity of 0.14 mCi/kg (5.2 MBq/kg) has been used or recommended by other authors [2–5]. The authors indicate in a single sentence in the Discussion section that, after completion of PET/CT studies in this study’s patient cohort, they reduced the administered activity at their hospital to 0.14 mCi/kg. At an administered activity of 0.14 mCi/kg, the effective dose attributable to [F-18]FDG is reduced by 33%. Recent studies indicate that administered activities can be reduced further in pediatric patients younger than 5 to 10 years of age and for brain imaging [6, 7]. In the authors’ estimation of an average effective dose of 24.8 mSv per PET/CT, 80% of this dose is due to the CT acquisition. In general, the CT acquisition was performed with a rather high technique over the entire body. In contrast to the presented cohort, the CT component of the PET/CT study can be performed using any of three approaches. One approach is to perform a full diagnostic CT scan, usually with intravenous contrast agent, integrated into the PET/CT protocol. The authors appear to have used this approach. In a patient with neoplasm, this diagnosticquality CT scan would typically be the only diagnostic CT scan performed at this time point in the patient’s care. The added effective dose for the CT part of the PET/CT study at this time point is, therefore, zero. A second approach to the use of CT during PET/CT is to perform a reduced dose localization CT scan during free breathing as part of the PET/CT scan. This scan is typically performed at less than half of the exposure settings used for a diagnostic CT scan. This results in an effective dose attributable to CT of about 4–6 mSv. M. J. Gelfand (*) : S. E. Sharp Department of Radiology, Cincinnati Children’s Medical Center, 3333 Burnet Ave., Cincinnati, OH 45215-3039, USA e-mail: Michael.gelfand@cchmc.org

Introduction: During embryogenesis, developing organs are in direct apposition to one another. The coelomic epithelium (peritoneal anlage) has barrier properties and its removal adversely affects development. We hypothesize that coelomic epithelium contains signals within a developing organ to prevent inappropriate attenuation of signals. Methods: Pancreas was harvested from day 11 mouse embryos. Several experimental systems were used: apposition of organs with and without enveloping coelomic epithelium; transfilter experiments; cultures to allow regrowth of coelomic epithelium in the absence of underlying mesenchyme. Results: Differentiation of embryonic pancreas in the presence of mesenchyme, but absence of coelomic epithelium, led to decreased acinar tissue and overabundance of endocrine differentiation. These results suggest a loss of acinar-specific mesenchymal factors, and support coelomic epithelium as a barrier that contains signals. Isolated pancreatic epithelium was unable to differentiate significantly if coelomic epithelium-enveloped mesenchyme on the opposite side of a filter. Importantly, however, endocrine differentiation occurred if the coelomic epithelium had been removed from the mesenchyme on the opposite side of the filter, confirming a role for coelomic epithelium in containing signals. An instructive role for coelomic epithelium was ruled out using a culture system in which coelomic epithelium regrows over epithelium in the absence of mesenchyme. Here, no differentiation of the underlying epithelium was seen. Conclusions: These results support a novel concept in developmental biology, wherein coelomic epithelium serves to compartmentalize organs during growth, preventing diffusion out of critical morphogenic signals.

The aim of this evaluation was to examine how specialist portals within the UK’s National electronic Library for Health were developing as communities of practice to support continuing professional development. Objectives included a literature review, to inform the development of an appraisal framework for the individual portals, and interviews with portal development teams and stakeholder groups. Appraisals of the websites and the data from the interviews showed that most of the specialist portals had evolved beyond the initial stages of community of practice development. Further planning of outsourcing would require a balance between maintaining a recognizable identity for the portals and not stifling the creativity of the development tea