[Sacroiliitis:the key symptom of spondylarthropathies. 2: morphological aspects]. / Die Sakroiliitis: Das Schlüsselsymptom der Spondylarthropathien. Teil 2: Morphologische Aspekte.

Because of their curved course and segmental convolution of articular surfaces, the anatomy of the sacroiliac joints is complex. An important part of the diagnosis of sacroiliitis of spondyloarthropathy patients relies on radiographic imaging techniques: x-ray, conventional tomography, computed tomography (CT) and scintigraphy. Diagnosis can be difficult in early and acute stages of sacroiliitis because radiographic findings may be normal, although dynamic magnetic resonance imaging (MRI) of the sacroiliac joints certainly enables to detect chronic as well as acute inflammatory changes. In spondyloarthropathy patients with acute sacroiliitis or acute exacerbation of chronic sacroiliitis who do not respond to or do not tolerate non-steroidal antiinflammatory drugs, CT-guided corticosteroid injection into the sacroiliac joints has proved to be an effective therapy.

[Pneumocysts juxta-articular to the ilial bone and the sacral bone]. / Juxtaartikuläre Pneumatozysten im Os ilium und Os sacrum.

PURPOSE: The purpose of the study was to detect and safely diagnose pneumatocysts by means of computed tomography. METHODS: From September 1995 to May 1996 computed tomography of the pelvis was performed in six patients for various indications. A slice thickness of 8 mm was employed for all studies. One patient had undergone surgery for hyperparathyroidism nine years previously. Attenuation values within the coincidentally diagnosed pneumatocysts were obtained. RESULTS: We found a total of 14 pneumatocysts juxtaarticular to the sacroiliac joint. Three patients demonstrated a bilateral intraarticular vacuum phenomenon, yet a joint communication was not found. The lesions did not coincide with inflammation, tumour or trauma. CONCLUSION: Pneumatocysts are benign bone lesions associated with arthrotic changes of the sacroiliac joint. Computed tomography is the modality of choice for the diagnosis of pneumatocysts.

[Roentgen diagnostic studies of peripheral joints, sacroiliac joints and the spine in psoriasis arthropathy]. / Röntgendiagnostische Untersuchungen an peripheren Gelenken, an den Sakroiliakalgelenken und an der Wirbelsäule bei der Psoriasis arthropathica.

The secure diagnosis "psoriasis arthropathica" must always be the result of a clinical examination, paraclinical and radiological findings. In 150 patients with arthropathic psoriasis X-ray examinations of peripheral joints, of the sacroiliac joints and of the spine were performed. As a result of subtle evaluations of the findings X-ray-morphological criteria on the skeleton of hand and foot, on the sacroiliac joints and on the spine may be derived. On the basis of the experiences gathered recommendations for the practice in form of radiographic objects of an X-ray-diagnostic basic programme in primary diagnostics and in repeated examinations are proposed. An optimum diagnostics of the arthropathic psoriasis can be achieved only ba close co-operation and by constant mutual informations between rheumatologists, dermatologists and radiologists.

[Psoriatic arthritis with synchondrosis sternal superior manifestation]. / Arthritis psoriatica mit Manifestation an der Synchondrosis sternalis superior.

We describe the imaging procedures for the diagnosis of manubriosternal joint arthritis in a 64 years old man with psoriatic arthritis. Involvement of the manubriosternal joint (synchondrosis sternalis) in psoriatic arthritis is a rare manifestation. The findings of bone-scintigraphy, conventional radiography and arthrosonography of the manubriosternal joint arthritis are compared and discussed.

[Organ manifestations, immunologic findings and roentgen morphologic changes in the bones of the hand in progressive scleroderma]. / Organmanifestationen, immunologische Befunde und röntgenmorphologische Veränderungen am Handskelett bei progressiver Sklerodermie.

In 60 patients with progressive sclerodermia apart from investigations of clinical and paraclinical parameters detailed evaluations of the X-ray-morphological findings at the skeleton of the hand were performed. Possible connections between the proof of pathological immunophenomena, the frequency of visceral manifestations at other organs, the duration of the disease and pathological X-ray-morphological changes at the skeleton of the hand are discussed and own conclusions are drawn.

[The manifestation of psoriasis arthropathica in later life]. / Uber die Manifestation der Psoriasis arthropathica im höheren Lebensalter.

The article deals with a group of 12 patients (8 females and 4 males), who generally first developed arthralgia as a feature of psoriasis beyond the age of 60. In all cases psoriasis arthropatica was diagnosed on the basis of physical, laboratory and X-ray examinations. Radiomorphological changes in the skeletal system are described in detail. The article also contains information on the treatment given, which in later life should be chiefly symptomatic on account of the increased risk of side-effects.

Sacroiliitis - it's not all B 27.

We describe an HLA-B27 positive patient in whom posttraumatic pyogenic sacroiliitis led to complete unilateral sacroiliac joint ankylosis in the absence of any signs indicative of HLA-B27 associated spondyloarthropathy. Sacroiliitis is the pathologic hallmark - and usually one of the earliest pathologic manifestations - of ankylosing spondylitis (AS). Bilateral sacroiliitis is typical for ankylosing spondylitis. The frequency of asymmetric sacroiliitis may be higher in other inflammatory disorders, e.g., reactive arthritis, Reiters syndrome, spondylitis associated with psoriasis, or inflammatory bowel disease. Most but not all of these disorders show an increased prevalence among individuals who have inherited the HLA-B27 gene. In the context of this case, we discuss the differential diagnosis of unilateral sacroiliitis.

[Diagnosis and clinical relevance of microcirculation disorders in progressive scleroderma]. / Diagnostik und klinische Relevanz von Mikrozirkulationsstörungen bei der progressiven Sklerodermie.

Microcirculation in the hands of patients with progressive systemic sclerosis shows some peculiarities. For diagnostic purposes functional thermography and the acrale rewarming test may be used. Typical features of progressive systemic sclerosis are a general hypothermia of the hands and localized hypothermic areas and refractory hyperthermic areas. In the acrale rewarming test reactive vasodilatation after cold stimuli is often not inducible and the significantly retarded rewarming shows a marked local restrict dependence. The significance of these facts for a more intensive physical therapy is discussed.

[Combination of rare anomalies of the cervical spine and peripheral skeleton]. / Kombination seltener Anomalien der Halswirbelsäule und des peripheren Skeletts.

This paper presents a case report on a 59-year old patient of small stature with moderate mental retardation, strabismus and several rare skeletal anomalies. We found an os odontoideum, a dysontogenetic 3fold fusion of cervical vertebrae, multiple double-sided wrist bone dysplasias and brachytelephalangical digiti pedis I, but no anomalies of the heart or genitals. Clinical signs, biochemical parameters and results of x-ray and ultrasonic examination are demonstrated in this complex malformation syndrome that combines different anomalies known from other syndromes.

A new scale for comprehensive assessment of psychopathology in Alzheimer's disease.

The Dementia Signs and Symptoms (DSS) Scale documents non-cognitive signs and symptoms (e.g., delusions, hallucinations, anxiety, depression, mania, and behavioral disturbances) in dementia. Patients, informants, and a clinical examiner rated signs and symptoms over the preceding month. Fifty-six Alzheimer's disease patients were administered the DSS, the BEHAVE-AD, the Cornell Scale for Depression in Dementia, the Young Mania Rating Scales, the Hamilton Depression Scale, the Hamilton Anxiety Scale, and the Psychogeriatric Dependency Rating Scale. DSS subscale scores correlated with corresponding scale scores, confirming construct validity. The DSS subscales were internally consistent (Cronbach's alpha, 0.3 7-0.75) and interrater reliability was high (ICC, 0.92-0.99).

[Psoriasis arthropathica and seronegative rheumatoid arthritis--differential diagnostic considerations]. / Die Psoriasis arthropathica und die seronegative Rheumatoid-Arthritis--Differentialdiagnostische Erwägungen.

For differential-diagnostic considerations concerning seronegative arthritides two groups of patients with 25 patients each of the disease groups psoriasis arthropathica and serologically negative rheumatoid arthritis were selected. The differentiation of the two diseases was performed by clinical, paraclinical and radiological findings. When there are no typical psoriatic changes of skin and/or nails and there is an empty family anamnesis concerning this dermatosis, respectively, the coordination of seronegative arthritides is considerably rendered more difficult. Here the radiomorphological investigations particularly of the sacroiliacal joint and/or of the spine essentially contribute, since the arthritis of the sacroiliacal joint is to seen in high incidence in psoriasis arthropathica. Out of the number of the paraclinical values the determination of the complement factor C 4 and of immunoglobulin M gets the importance of a sign of differentiation, in which case C 4 in the psoriasis arthropathica and the immunoglobulin M in the seronegative rheumatoid arthritis are statistically significantly increased. The problems of the often difficult differential diagnosis between the two groups of disease can be clarified only by complex clinical examinations, paraclinical parameters and subtile radiodiagnosis. A close interdisciplinary cooperation between experienced dermatologists, rheumatologists and radiologists seems reasonable.

[Multicenter reticulohistiocytosis. A contribution to clinical aspects and therapy]. / Multizentrische Retikulohistiozytose. Ein Beitrag zur Klinik und Therapie.

It is reported on a 48-year-old woman suffering from a multicentric reticulohistiocytosis. Most trouble in this case is caused by severe arthritis, which could not be stopped by various therapy schedules. The actual treatment is the combination of Prednisolone, Chloroquine, Ibuprofen and roentgenotherapy of the hands.

Effects of ethnicity on skeletal maturation: consequences for forensic age estimations.

An X-ray of the hand is an important method in forensic science for estimation of the age of juvenile suspects with uncertain date of birth. Relevant X-ray standards for evaluation of skeletal maturity are available for white US Americans as well as for North and Central Europeans. The applicability of these standards to members of ethnic groups different from the reference population has been the subject of controversial discussion. More than 80 publications were analysed with the view to finding out whether skeletal maturation is affected by ethnic identity. It was concluded that skeletal maturation takes place in phases which are identically defined for all ethnic groups. Time-related differences in passing those stages of skeletal maturation within the relevant age group appear to be unaffected by ethnic identity. It is the socioeconomic status of a given population which is of decisive importance to the rate of ossification. The application of X-ray standards to individuals of a socio-economic status lower than that of the reference population usually leads to underestimation of that person's age. In terms of criminal responsibility, this is of no adverse effect on the person concerned.

Regulation of the pentose phosphate pathway in human astrocytes and gliomas.

Several aspects of the regulation of the pentose phosphate pathway were examined in cultured normal human cortical astrocytes and gliomas of pathological grades I-IV. The generation of radiolabeled CO2 from [1-14C]glucose by the oxidative arm of the pentose phosphate pathway is a saturable process and has a maximum flux rate of 8-9 nmol/hr/mg cell protein. The flux can be blocked by the glycolytic inhibitor iodoacetamide but is unaffected by agents which inhibit oxidative phosphorylation. The magnitude of the pentose phosphate flux is directly related to the glioma grade. Grade IV gliomas (glioblastoma) show a pentose phosphate flux rate of approximately 4% of the total glucose flux. The flux rate can be increased by pharmacological agents which decrease the NADPH/NADP+ ratio. Both the activity and the regulation of glioma glucose-6-phosphate dehydrogenase (G6PDH) are altered in high-grade gliomas. While the affinity constants for cofactors in whole homogenates were not significantly different in glioma or normal astrocyte homogenates, normal astrocytes have a lower Km for glucose-6-phosphate and a G6PDH activity which is 10-fold greater than that of gliomas. NADPH is a powerful regulator of G6PDH activity in the normal astrocytes and in gliomas. At a NADPH/NADP+ ratio of 7:1 the normal astrocyte G6PDH is entirely inhibited, while the glioma enzyme is only 70% inhibited even at a ratio of 20:1. Increased metabolic flux through the oxidative arm of the pentose phosphate pathway is apparently due to an altered form of G6PDH.

Glucose metabolism in human gliomas: correspondence of in situ and in vitro metabolic rates and altered energy metabolism.

The rates of disappearance of glucose from the medium of 13 human glioma-derived cell lines and one cultured of normal human cortical astrocytes were determined by fluorometric techniques. High-grade glioma-derived cultures showed a range of glucose consumption between 1 and 5 nmol/min/mg protein. Normal astrocyte cultures and cultures derived from grades I-III gliomas had a glucose consumption rate of 2-3 nmol/min/mg protein. Seven high-grade glioma lines were derived from surgical samples taken from patients who had been scanned by 18F-2-deoxy-d-glucose positron computed tomography. The rate of glucose consumption in these high-grade glioma-derived lines was close to the maximum local cerebral metabolic rate for glucose (LCMRglc) measured in situ in the tumors from which the cultures were derived. In cultured glioma-derived lines, approximately one-half of the glucose consumed was recovered as lactate and pyruvate, suggesting a reliance of glioma cells on aerobic glycolysis. ATP and phosphocreatine (PCr) levels were variable in the glioma-derived lines, and ATP was lower in the glioma-derived lines than in the normal astrocytes. Levels and regulation of glycogen differed significantly among the various glioma-derived cell lines. Glycogen content did not diminish as glucose was consumed, suggesting that glycogen utilization is not tightly regulated by the glucose metabolic rate. These results suggest that human glioma-derived cell cultures (1) adequately reflect the metabolic capacity of gliomas in situ and (2) are significantly altered in several aspects of their glycolytic metabolism.

Enzymes of glucose metabolism in cultured human gliomas: neoplasia is accompanied by altered hexokinase, phosphofructokinase, and glucose-6-phosphate dehydrogenase levels.

The enzymes of glycolysis and selected enzymes of the pentose phosphate pathways were measured by fluorometric methods in extracts prepared from cultures of normal cortical human astrocytes and from cultures derived from low-grade (II) or high-grade (IV) gliomas. The hexokinase and phosphofructokinase levels of the low-grade glioma-derived line were not significantly different from those of the normal astrocyte cultures. However, the activities of hexokinase and phosphofructokinase were consistently and significantly increased in the high-grade glioma-derived lines. The activity of glucose-6-phosphate dehydrogenase was significantly decreased in all glioma-derived lines and by more than 90% in the high-grade-derived lines. Other enzymes of the glycolytic pathway were not significantly different from those of normal astrocytes, or they showed a variation inconsistently related to the neoplastic state. Glucose flux is not apparently regulated to a significant degree of hexokinase in glioma-derived lines, since the measured Vmax values are in substantial excess over the measured flux rates. Reversible binding of hexokinase to the particulate fraction was observed in both the normal astrocytes cultures and the high-grade glioma-derived lines. A twofold displacement of particulate hexokinase by ATP, ADP, 1-O-methylglucose, sorbitol-6-phosphate, and dibutyryl cyclic AMP was observed in the high-grade glioma-derived lines. The degree of displacement by various agents and the basal ratio of free/bound was not significantly different between the transformers and the nontransformants. The hexokinase from both the gliomas and the normal astrocytes was noncompetitively inhibited by the glucose analogue 2-deoxy-d-glucose. Phosphofructokinase activity is close to the observed glucose flux rates in both the normal astrocyte and the glioma-derived cultures. The phosphofructokinase activity of normal astrocytes is activated twofold or more by ADP, AMP, fructose-2,6-diphosphate, and Pi. However, these same ligands activate phosphofructokinase by less than twofold in a typical high-grade glioma-derived line. ATP, dibutyryl cyclic AMP, and citrate inhibit glioma and normal astrocytic phosphofructokinase, but the magnitude of the inhibition is much less than in the glioma-derived lines.

Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging.

OBJECTIVE: A prospective study was performed comparing conventional radiography, 3-phase bone scintigraphy, ultrasound, and magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examinations in 60 patients with various forms of arthritis including rheumatoid arthritis (RA), spondyl-arthropathy, and arthritis associated with connective tissue disease. METHODS: A total of 840 finger joints were examined clinically and by all 4 imaging methods. Experienced investigators blinded to the clinical findings and diagnoses analyzed all methods independently of each other. The patients were divided into 2 groups. Group 1 included 32 patients (448 finger joints) without radiologic signs of destructive arthritis (Larsen grades 0-1) of the evaluated hand and wrist and group 2 included 28 patients (392 finger joints) with radiographs revealing erosions (Larsen grade 2) of the evaluated hand and/or wrist. RESULTS: Clinical evaluation, scintigraphy, MRI, and ultrasound were each more sensitive than conventional radiography in detecting inflammatory soft tissue lesions as well as destructive joint processes in arthritis patients in group 1. All differences were statistically significant. We found ultrasound to be even more sensitive than MRI in the detection of synovitis. MRI detected erosions in 92 finger joints (20%; 26 patients) in group 1 that had not been detected by conventional radiography. CONCLUSION: Our data indicate that MRI and ultrasound are valuable diagnostic methods in patients with arthritis who have normal findings on radiologic evaluation.

Relationship between aggressive behaviors and depression among nursing home residents with dementia.

BACKGROUND: Verbal and physical aggression are common behavior problems among nursing home residents with dementia. Depression among nursing home residents is also a common but underdiagnosed disorder. METHOD: Data collected on 1101 residents with dementia, newly admitted to a sample of 59 nursing homes across Maryland, were analyzed to determine if there was a relationship between depression and physical and verbal aggression. RESULTS: Residents with dementia who manifested physical or verbal aggression had a higher prevalence of depression than those without such behaviors (p<0.05). CONCLUSIONS: Our findings suggest that nursing home residents with aggressive behaviors should be screened for depression and treated.

Prospective two year follow up study comparing novel and conventional imaging procedures in patients with arthritic finger joints.

OBJECTIVE: To carry out a prospective two year follow up study comparing conventional radiography, three-phase bone scintigraphy, ultrasonography (US), and three dimensional (3D) magnetic resonance imaging (MRI) with precontrast and dynamic postcontrast examination in detecting early arthritis. The aim of the follow up study was to monitor the course of erosions during treatment with disease modifying antirheumatic drugs by different modalities and to determine whether the radiographically occult changes like erosive bone lesions of the finger joints detected by MRI and US in the initial study would show up on conventional radiographs two years later. Additionally, to study the course of soft tissue lesions depicted in the initial study in comparison with the clinical findings. METHODS: The metacarpophalangeal, proximal interphalangeal, and distal interphalangeal joints (14 joints) of the clinically more severely affected hand (soft tissue swelling and joint tenderness) as determined in the initial study of 49 patients with various forms of arthritis were examined twice. The patients had initially been divided into two groups. The follow up group I included 28 subjects (392 joints) without radiographic signs of destructive arthritis (Larsen grades 0-1) of the investigated hand and wrist, and group II (control group) included 21 patients (294 joints) with radiographs showing erosions (Larsen grade 2) of the investigated hand or wrist, or both, at the initial examination. RESULTS: (1) Radiography at the two year follow up detected only two erosions (two patients) in group I and 10 (nine patients) additional erosions in group II. Initial MRI had already detected both erosions in group I and seven (seven patients) of the 10 erosions in group II. Initial US had depicted one erosion in group I and four of the 10 erosions in group II. (2) In contrast with conventional radiography, 3D MRI and US demonstrated an increase in erosions in comparison with the initial investigation. (3) The abnormal findings detected by scintigraphy were decreased at the two year follow up. (4) Both groups showed a marked clinical improvement of synovitis and tenosynovitis, as also shown by MRI and US. (5) There was a striking discrepancy between the decrease in the soft tissue lesions as demonstrated by clinical findings, MRI, and US, and the significant increase in erosive bone lesions, which were primarily evident at MRI and US. CONCLUSIONS: Despite clinical improvement and a regression of inflammatory soft tissue lesions, erosive bone lesions were increased at the two year follow up, which were more pronounced with 3D MRI and less pronounced with US. The results of our study suggest that owing to the inadequate depiction of erosions and soft tissue lesions, conventional radiography alone has limitations in the intermediate term follow up of treatment. US has a high sensitivity for depicting inflammatory soft tissue lesions, but dynamic 3D MRI is more sensitive in differentiating minute erosions.

[Imaging diagnosis in suspected inflammatory rheumatoid axial skeleton diseases (sacroilitis)]. / Bildgebende Diagnostik bei Verdacht auf entzündlich rheumatische Achsenskeletterkrankungen (Sakroiliitis).

Involvement of the sacroiliac joints is a hallmark of the spondyloarthropathies, especially in ankylosing spondylitis. The conventional diagnostic imaging of sacroiliitis in early stages might cause problems, because sensitivity of conventional radiographic methods is known to be too low in early stages of the disease. Magnetic resonance imaging of the sacroiliac joints certainly enables one to detect acute as well as chronic inflammatory changes in all stages of the disease. The potential disadvantages of this method are the dependency on the examiner, the lack of standardization, and the relatively high costs. Therefore, the "Workgroup of Diagnostic Imaging in Rheumatology of the Regional Center of Rheumatology of Berlin" including experienced rheumatologists, skeletal radiologists, and orthopedists acquired an imaging graduation for detection of sacroiliitis in consideration of the clinical background, the technical details of the methods, questions of ionizing radiation exposure, and cost effectiveness.