Radiosynovectomy of the hip joint - preliminary experience.

Introduction: Radiosynovectomy (RSV) is a minimally invasive method of treating and controlling joint inflammation refractory to conventional pharmacotherapy. It consist in intraarticular injection of radioactive colloids which irradiate the inflamed synovial membrane to cause its subsequent involution. Despite the fact that hip joint involvement is quite common in systemic inflammatory arthropathies, hip joint RSVs are rarely performed. The aim of this paper is to assess to safety and efficacy of hip joint radioisotope treatment. Material and methods: We retrospectively analyzed the effects of 21 hip joint RSVs performed in 14 patients (10 female, 4 male; aged 8 to 79; mean age 48 years). Before the RSV, all the patients underwent clinical and ultrasound examination. The radiosynovectomies were performed using rhenium-186 sulfide under ultrasound guidance. Each patient underwent post-therapeutic scintigraphy to assess intraarticular distribution of the radiopharmaceutical. The effects of the treatment were assessed clinically and ultrasonographically during at least 2 follow-up visits 3 and 6 months after the RSV. Results: In 9 cases, we observed complete resolution of symptoms 3 and 6 months after the RSV. Four patients had only a partial response and required repeated treatment, and all responded well to the second RSV. In 4 patients the treatment had no significant effect, and no repeated treatment attempt was made. All the responders suffered from inflammatory arthropathies; the non-responders had osteoarthritis, with no history of systemic diseases. In all the patients, no significant adverse effects were observed; in particular there were no radiation burns or infections. All post-therapeutic scintigrams showed proper, intraarticular distribution of the radiopharmaceutical. Conclusions: Radiosynovectomy of the hip joint in systemic joint diseases, especially performed using ultrasound-guidance, is a safe and effective treatment modality.

Serum microRNAs in Systemic Sclerosis, Associations with Digital Vasculopathy and Lung Involvement.

Background and aims: Systemic sclerosis (SSc) is an autoimmune, rare multisystem chronic disease that is still not well-understood aetiologically and is challenging diagnostically. In the literature, there are ever-increasing assumptions regarding the epigenetic mechanisms involved in SSc development; one of them is circulating microRNAs. Many of them regulate TLR pathways and are significant in autoimmune balance. The aim of this study was to determine profile expression of selected microRNAs in SSc patients, including miR-126, -132, -143, -145, -155, -181a, -29a and -3148, in comparison to healthy controls. Methods: Serum microRNAs were isolated from 45 patients with SSc and 57 healthy donors (HC). Additionally, SSc patients were considered in the aspect of disease subtype, including diffuse systemic sclerosis (dcSSc) and limited systemic sclerosis (lcSSc). Results: miR-3148 was detected neither in the serum of HC nor in SSc patients. All of the rest of the analyzed microRNAs, excluding miR-126, miR-29a and miR-181a, were significantly upregulated in SSc patients in comparison to HC. However, miR-181a has been revealed only in the serum of patients with lcSSc but not dcSSc. Moderate positive correlations between the transfer factor of the lung for carbon monoxide (TLCO) and miR-126 and miR-145 were observed. A significant correlation has been found between serum miR-143 level and forced vital capacity (FVC). SSc patients with FVC ≤ 70% were characterized by significantly lower levels of miR-143 compared to patients with normal FVC. Additionally, the expression of miR-132 was significantly higher in dcSSc subgroup with detected active lung lesions compared to dcSSc patients with fibrotic lesions. Patients with an early scleroderma pattern of microangiopathy seen on nailfold video-capillaroscopy (NVC) revealed higher expression of miR-155 in serum than those with a late pattern. Conclusions: The expression profile of circulating cell-free miRNAs is significantly changed in the serum of SSc patients compared to healthy individuals. Downregulation of miRNA-181a and overexpression of miR-132, miR-143, miR-145 and miR-155 in serum may be significant in SSc in the context of biomarkers.

Is intra-articular infliximab therapy a good alternative to radionuclide synovectomy for a patient with refractory pigmented villonodular synovitis?

Pigmented villonodular synovitis (PVNS) is a rare disease that has clinical and histopathological characteristics of both benign proliferative disorder and a chronic inflammatory process of the synovial tissue. The primary mode of treatment is surgery followed by an adjuvant radiotherapy; however, the risk of recurrence is a significant (40-70%). Several publications suggest that the TNF-α inhibitors might be a treatment option. We present a case of a 29-year-old female diagnosed with PVNS of the knee joint, refractory to surgery and 3 radionuclide synovectomies. Because the possibilities of conventional therapy were exhausted, treatment with an intra-articular anti-TNF-α monoclonal antibody (infliximab) was performed. Despite a high safety profile and a good tolerance of that therapy we did not observe significant clinical and radiological improvement. To assess the effectiveness of intra-articular TNF-α inhibitors as an adjuvant treatment in PVNS, prospective studies are needed.

Microvascular damage - a marker of specific organ involvement in mixed connective tissue disease?

Mixed connective tissue disease (MCTD) is a complex entity, which incorporates features of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), systemic sclerosis (SSc) and polymyositis/dermatomyositis (PM/DM). Nailfold videocapillaroscopy (NVC) is a simple, safe and non-invasive technique of capillary vessel assessment, allowing for qualitative and quantitative assessment of microcirculation. NVC plays a pivotal role in the diagnostic algorithm of connective tissue diseases, especially in systemic sclerosis (SSc). Numerous studies have shown a correlation between organ involvement and disease progression in SSc. In the current literature, there are limited data on relationship between NVC and organ involvement in MCTD patients. In the present article the relevant literature describing NVC examination in patients with MCTD and comparisons with some clinical situations are discussed.

Diagnostic utility of hybrid single photon emission computed tomography/computed tomography imaging in patients with Takotsubo syndrome.

PURPOSE: Clinical symptoms and electrocardiographic changes in patients with Takotsubo syndrome can be similar to patients with myocardial infarction. The aim of the study was to assess the impact of SPECT/CT imaging on the diagnosis and management of Takotsubo syndrome (TTS). METHODS: Gated single photon emission computed tomography (SPECT)/CT after injection 99Tc-MIBI in resting conditions was performed in 27 patients with TTS using dual-head Symbia T6SPECT/CT hybrid device. CT data were used for attenuation correction of SPECT images and to assess the risk of coronary artery disease on the basis of coronary artery calcium score. RESULTS: Abnormal myocardial perfusion was found in 20/27 patients. The mean defect size was 9.8 cm, the extent 11.7%, mean total perfusion defect was 10.36%, mean summed rest score (SRS) 6.71.Left ventricle ejection fraction was lower in patients with SRS at least 4 than in patients with SRS less than 4. Perfusion defect size, total perfusion defect, number of akinetic segments in echocardiography and number of segments with perfusion defect in SPECT were higher in the group with SRS at least 4. The applied attenuation correction algorithms did not change the result of our SPECT study. CONCLUSION: In the majority of patients with TTS perfusion in SPECT was normal or only minor perfusion defect was observed. Application of CT attenuation correction did not change the final result of myocardial perfusion imaging; therefore, the CT component of the SPECT/CT study performed for attenuation correction is not useful for TTS diagnosis.

Beta burns following radionuclide synovectomy.

Radionuclide synovectomy (RSV) is a form of minimally invasive treatment of persistent joint inflammation. The procedure has a high safety profile and the occurrence of serious adverse events, such as full-thickness skin radiation necrosis, is rare. Less severe radiation events, while more common, are usually benign and self-limiting. We present two cases of low-grade beta burns that developed after RSV, despite proper injection technique. The potential long-term risk of such exposure is also discussed, with reference to historical radiation incidents. While low-grade beta burns after RSV usually pose little danger to the patient, any clinician involved in radionuclide treatment of arthritis should be aware of their existence and management.

Takotsubo cardiomyopathy: FDG myocardial uptake pattern in fasting patients. Comparison of PET/CT, SPECT, and ECHO results.

BACKGROUND: The aim of this study was to assess the accumulation pattern of 18F-FDG in fasting patients with takotsubo cardiomyopathy (TTC) and to correlate the results with perfusion scintigraphy and echocardiography. METHODS: 18 consecutive patients with TTC were identified by clinical symptoms, cardiac catheterization, and echocardiography. Coronary angiography (CA) and transthoracic echocardiography (TTE) were performed on the day of the onset of symptoms. An assessment of myocardial perfusion (99mTc-MIBI) and glucose metabolism (18F-FDG) was performed within 18 days. RESULTS: SPECT showed no regional perfusion abnormalities in 10/18 patients, and a mild perfusion defect was found in 8/18 patients. Perfusion abnormalities were limited to apical and para-apical regions. In 8/18 cases, there was an increased selective apical 18F-FDG accumulation. In 10/18 cases, in spite of the fastened 18F-FDG protocol, slightly inhomogeneous 18F-FDG uptake was present in the entire myocardium: with relatively reduced uptake of 18F-FDG in the apical region and LV mid-segments. CONCLUSION: This study demonstrated the heterogeneous nature of myocardial 18F-FDG accumulation in patients with TTC. Selective, preferential apical 18F-FDG uptake in almost half of the patients confirms an existing disorder of glucose metabolism, similar to that observed in stunned or hibernated myocardium.

Assessment of the myocardial FDG-PET image quality with the use of maximal Standardized Uptake Value myocardial to background index. Application of the results in regard to semiquantitative assessment of myocardial viability with cardiac dedicated softwar.

BACKGROUND: The objective of this study was to semiquantitatively assess the degree of myocardial fluorodeoxyglucose (FDG) uptake in glucose-loaded myocardial viability positron emission tomography/computed tomography (PET/CT) scans, to calculate the myocardial to background index, and correlate the index with image quality assessed on the basis of visual qualitative assessment. MATERIAL AND METHODS: The myocardial FDG-PET/CT study was carried out in 69 non-diabetic patients, who had known coronary artery disease, by intravenous injection of 250 ± 70 MBq (range: 180-320 MBq) FDG. Images were interpreted visually and patients were divided into three groups according to the grade of myocardial uptake: optimal, suboptimal, and uninterpretable. Semiquantitative analysis was performed by calculating the standardized uptake value (SUVmax) for myocardium and background (blood pool) activity, and expressed as the myocardial to background (M/B) activity ratio. RESULTS: On the basis of visual (qualitative) analysis, 60/69 (86.96%) patients showed optimal quality of FDG cardiac uptake, 3/69 (4.35%) were suboptimal, and uninterpretable FDG PET scan results were found in 6/69 (8.70%) patients. The M/B index was found to be significantly higher in images of optimal vs. suboptimal quality (6.87 ± 3.99 vs. 1.65 ± 0.78 respectively; p < 0.0001). CONCLUSIONS: The index ratio of 2.2, which is consistent with the upper borderline value for visually uninterpretable images, was considered the cut-off value for scans of optimal and non-optimal quality.

Infrared thermal imaging in connective tissue diseases.

Infrared thermal imaging (IRT) is a non-invasive, non-contact technique which allows one to measure and visualize infrared radiation. In medicine, thermal imaging has been used for more than 50 years in various clinical settings, including Raynaud's phenomenon and systemic sclerosis. Imaging and quantification of surface body temperature provides an indirect measure of the microcirculation's overall performance. As such, IRT is capable of confirming the diagnosis of Raynaud's phenomenon, and, with additional cold or heat challenge, of differentiating between the primary and secondary condition. In systemic sclerosis IRT has a potential role in assessing disease activity and monitoring treatment response. Despite certain limitations, thermal imaging can find a place in clinical practice, and with the introduction of small, low-cost infrared cameras, possibly become a part of routine rheumatological evaluation.

Radionuclide imaging and therapy in a patient with coexistent diabetic foot syndrome and psoriatic arthritis.

We report a case of 67-year-old man suffering from psoriatic arthritis, type 2 diabetes and diabetic foot syndrome. The patient presented symptoms of inflammation of the right ankle joint. Scintigraphic imaging with radiolabeled white blood cells was performed to differentiate whether the inflammation was related to psoriatic arthritis or diabetic foot syndrome. After revealing that, the inflammatory process was restricted only to the articular space of subtalar joint, the patient was diagnosed with exacerbation of psoriatic arthritis and qualified for radionuclide synovectomy. In patients with coexistent diabetic foot syndrome and inflammatory arthritis of the foot it is of vital importance to accurately differentiate these two conditions. We conclude that this can be potentially achieved with radiolabeled white blood cells scintigraphic imaging.

Esophageal transit scintigraphy in systemic sclerosis.

Systemic sclerosis is a rare connective tissue disease, distinctive features of which are fibrosis and microangiopathy. The esophagus is one of the most commonly involved internal organs. Most patients experience dysphagia, difficulties in swallowing and gastro-esophageal reflux. However, in up to one third of cases, the initial onset of esophageal disease may be clinically silent. There are several diagnostic modalities available for assessing both morphological and functional abnormalities of the esophagus. If structural abnormalities are suspected, endoscopy is the method of choice. Functional evaluation is best achieved with manometry. Both endoscopy and manometry are invasive techniques, with low patient acceptance. Barium-contrast study is well tolerated, but qualitative assessment of functional abnormalities is imprecise. Esophageal scintigraphy is an easy, non-invasive, sensitive and specific diagnostic modality. It can detect esophageal dysfunction even in asymptomatic patients. In patients already diagnosed with systemic sclerosis, scintigraphy is useful in evaluating severity and progression of the disease.

Radionuclide synovectomy - essentials for rheumatologists.

Radionuclide synovectomy is a minimally invasive method of treating persistent joint inflammation. It involves intra-articular injection of radioactive colloids which induce necrosis and fibrosis of hypertrophic synovial membrane. The most common indication for radiosynovectomy is rheumatoid arthritis, although patients with seronegative spondyloarthropathies, unclassified arthritis, haemophilic arthropathy and other less common arthropathies can also benefit from this method. Radiosynovectomy is safe, well tolerated and efficacious. About 70-80% of patients respond well to the therapy. However, the therapeutic effects are considerably worse in patients with co-existent osteoarthritis and advanced joint degeneration. Despite its advantages, radionuclide synovectomy is not performed as often as it could be, so greater knowledge and understanding of this method are needed. The authors present the most important facts about radiosynovectomy that may help rheumatologists in their daily clinical practice.

Capillaroscopy - a role in modern rheumatology.

Capillaroscopy is a non-invasive, easy and safe diagnostic technique designed to evaluate small vessels of the microcirculation in the nailfold. It can reveal both the general architecture of capillary rows and fine details of particular vessels. The most important indications for performing capillaroscopy include differential diagnosis of primary and secondary Raynaud's phenomenon, as well as assessment of scleroderma spectrum disorders. In systemic sclerosis capillary abnormalities appear and evolve in a clearly defined sequence called the scleroderma pattern, which correlates with internal organ involvement. Capillaroscopy is also listed as a systemic sclerosis classification criterion recognized by the European League Against Rheumatism (EULAR). With digitized equipment, capillaroscopy allows for precise qualitative and quantitative evaluation of the microcirculation and is a valuable tool in the rheumatologists' daily practice.

Charcot arthropathy in ultrasound examination - a case report.

This article presents a patient with a long history of type 1 diabetes mellitus complicated with neuropathy and Charcot disease. The most common cause of neuropathic osteoarthropathy, called Charcot osteoarthropathy, is poorly controlled diabetes. The clinical picture is characterized by considerable edema, redness and increased skin temperature with relatively slight pain due to injury to nerve fibers responsible for pain sensation. The differential diagnosis should include bacterial or autoimmune arthritis, arthritis associated with gout as well as venous thrombosis and injury. The contribution of a local inflammatory reaction and abnormal bone turnover with excessive osteoclast activity might play a role in the etiopathogenesis of this disease. As a result, osseous and articular destruction progresses rapidly leading to irreversible deformity of the foot. Avoiding weight-bearing and resting the foot in a specially selected plaster cast is the most important part of treatment. Patients with the aforementioned complaints are referred to radiologists for imaging examinations. An ultrasonographer should pay attention to changes typical of Charcot arthropathy, such as: inflammatory and destructive changes in joints of the foot, uneven contour of bones with thickening and periosteal hyperemia as well as soft tissue swelling.

Evaluation of T-wave alternans in high-resolution ECG maps recorded during the stress test in patients after myocardial infarction.

INTRODUCTION: Recent studies point to analysis of T-wave alternans as a promising indicator of an increased risk of life-threatening ventricular arrhythmias. In this study the occurrence of T-wave alternans in the high-resolution ECGs recorded during the exercise stress test and scintigraphic tests (SPECT) in patients with ischemic heart disease was examined. MATERIAL AND METHODS: The study group consisted of 33 patients after myocardial infarction. In the group of patients after myocardial infarction and with low left ventricular ejection fraction correlations of 70% between the test results of T-wave alternans and SPECT and 60% between the test results of T-wave alternans and stress test were found. RESULTS: In the group of patients after myocardial infarction but with high left ventricular ejection fraction correlations were respectively 39% and 48%. The analysis of the electrocardiographic maps showed a strong dependence of this correlation on the T-wave alternans amplitude and location of the ECG measuring electrode on the chest. The results might suggest that in patients after myocardial infarction and at increased risk for sudden cardiac death T-wave alternans may also provide information about cardiac electrical instability associated with ischemia. CONCLUSIONS: It can also be assumed that the position of the electrode where the highest level of the T-wave alternans was detected can indicate the location of the ischemic region of the heart.

Simplified protocol of cardiac 18F-fluorodeoxyglucose positron emission tomography viability study in normoglycemic patients with known coronary artery disease.

PURPOSE: The purpose was to evaluate quality of 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) myocardial scans and its correlation with background glucose (BG) after simplified 5% intravenous glucose load protocol. METHODS: An intravenous glucose load protocol was applied in 69 normoglycemic patients with confirmed coronary artery disease. The blood glucose level was measured every 15 min. RESULTS: Eighty-four percent of images were optimal, 8.7% suboptimal, and 7.3% uninterpretable. The quality of 18F-FDG-PET was BG independent and body mass index dependent (P=.0007). CONCLUSIONS: Simplified glucose load protocol is a safe and efficient method of preparation for FDG cardiac viability study in patients with normoglycemia.