Preoperative imaging of Charcot neuroarthropathy

With about 4 million diabetics in germany and presumed inclination over the following years the treatment of diabetic complications like diabetic foot will become an even more important point. The management of Charcot’s foot has undergone fundamental change in the last few years. Formerly, treatment was almost exclusively limited to non surgical measures; since the late 1990’s, however, current practice has shifted to early, stage-appropriate surgical therapy. The aim of the present prospective study was to investigate the value of positron emission tomography (PET) in the pre-operative work-up of Charcot’s foot. PET were compared to magnetic resonance tomography (MRI). Patients, methods: MRI and PET imaging were used as part of the preoperative work-up in 18 patients with Type II diabetes mellitus. The diagnosis of Charcot’s foot requiring surgical treatment were made on the basis of clinical and radiologic criteria. Results: Of 46 Charcot’s lesions confirmed at surgery, 44 and 35 were detected by means of PET and MRI, respectively. PET can be used in the work-up of patients with metal implants where the MRI does not show adequate findings. PET shows the areas of detritus formation exhibit only moderately increased glucose metabolism and at visual interpretation do not usually impress as typical for acute osteomyelitis. Average SUV values stood at 1.2 (range: 0.5–2.9). Conclusions: The differentiation between Charcot’s lesions and florid osteomyelitis provides the surgeon with important additional information, which is often unavailable from MRI. Because of this important additional data, PET could be considered preferable to morphologic imaging (CT, projection radiography) in the preoperative work-up of Charcot’s foot.

Efficacy of a new tonic containing urea, lactate, polidocanol, and glycyrrhiza inflata root extract in the treatment of a dry, itchy, and subclinically inflamed scalp

BACKGROUND/AIMS

Dry, itchy and inflamed scalp conditions are common and often associated with diseases such as atopic dermatitis or psoriasis. To improve these symptoms, we investigated the efficacy of a new tonic containing the active ingredients urea, lactate, polidocanol, and Glycyrrhiza inflata root extract, containing licochalcone A.

STUDY DESIGN/METHODS

30 subjects with dry and itchy scalp conditions underwent a randomized half-head study for 4 weeks, applying the leave-on tonic three times a week on one side of the scalp. Tonic effects on skin hydration, itching, lipids, microinflammation, and substantivity of tonic compounds were determined using corneometry, middle-infrared spectroscopy, direct analysis in real-time mass spectrometry, and enzyme-linked immunosorbent assay. Volunteers performed a self-assessment; changes in scalp condition were documented by in vivo microscopy.

RESULTS

After tonic treatment, scalp moisture was significantly increased, whereas scalp itching and tautness were significantly reduced. Results also demonstrated a high substantivity of urea and lactate on the scalp, an increase in triglyceride, and a decrease in free fatty acid levels. The amount of total lipids was unchanged. Analyses of scalp wash-ups verified a significant reduction in important pro-inflammatory markers.

CONCLUSION

Due to the actives urea, lactate, polidocanol, and the anti-inflammatory licochalcone A, the new scalp tonic exhibited excellent performance in alleviating scalp dryness, itching, microinflammation, and in normalizing disturbances of scalp lipids.

Bildgebende Verfahren in der Frühdiagnostik rheumatischer Veränderungen der Hände

PURPOSE

Besides the use of conventional x-rays in the diagnostic work-up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of ultrasound of the hands with proven methods such as conventional x-rays, low-field MRI and 3P-Sz.

METHODS

A total of 30 patients were studied using a 1 day protocol with ultrasound, 3P-Sz, MRI and x-ray of the hands. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA typical and non-RA typical changes. All methods were compared to the summarized findings interpreted by a rheumatologist after 2 years.

RESULTS

Of the 30 patients, 19 presented with clinical symptoms of initial changes due to rheumatoid arthritis. Ultrasound revealed 14/19 patients with the correct diagnosis. Conventional x-rays indicated 11/19 patients, while 3P-Sz (100%) and low-field MRI (95%) showed high sensitivity. It was possible to differentiate between inflammation and inconspicuous findings.

CONCLUSIONS

An experienced examiner can use ultrasound effectively for the initial diagnosis of RA. Based on its low cost, ultrasound is a valid alternative to conventional x-rays.

[Neonatal screening for congenital hypothyreoidism in Germany. The development of concerned children in retrospect analysis using the federal state "Hessen"]

BACKGROUND

Since widespread screenings for hypothyreosis were started in 1981 in Germany, the numbers of mental and physical handicaps due to hypothyroidism are reduced markedly. The aim of this study is to evaluate the actual efficiency of the newborn screenings in Germany using in the federal state "Hessen".

METHODS/SUBJECTS

All children born between 1988 and 1992 with suspicions laboratory results in the screening examination were contacted personally and statements concerning the screening itself and the physical and mental development were gathered from their parents, doctors and teachers.

RESULTS

99.1% of all hessian newborns born between 1988 and 1992 were included into the screening for hypothyreosis. The incidence of congenital hypothyreosis in general was 1:3 313. An etiological classification was possible in 77% of the patients which is divided as follows: 40% athyreosis, 24% hypoplasia of the thyroid, 8% dyshormonogenesis, 5% ektopia of the thyroid. In 67% of the cases hormone substitution was initiated during the first 14 days of life. In 23.9% it was started in the third week, in 6.8% in the fourth week and only in 2.3% of the patients treatment was started later on. The physical development of the children with congenital hypothyreosis can be regarded as widely normal. The school achievement was moderately retarded even when treatment was started in the early neonatal period.

CONCLUSIONS

The screening for hypothyreosis is well established in Hessen concerning tracking, organisation and analysis. There are short comings concerning the follow ups of children with suspicions findings, which shall be overcome by creating a new position. The long-term-follow-up according to the guidelines of the "Arbeitsgemeinschaft Pädiatrische Endokrinologie" is of central interest. Furthermore compliance is improved by regular personal counselling with the parents.

[Preoperative imaging of Charcot neuroarthropathy: Does the additional application of (18)F-FDG-PET make sense?]

With about 4 million diabetics in germany and presumed inclination over the following years the treatment of diabetic complications like diabetic foot will become an even more important point. The management of Charcot's foot has undergone fundamental change in the last few years. Formerly, treatment was almost exclusively limited to non surgical measures; since the late 1990's, however, current practice has shifted to early, stage-appropriate surgical therapy. The aim of the present prospective study was to investigate the value of positron emission tomography (PET) in the pre-operative work-up of Charcot's foot. PET were compared to magnetic resonance tomography (MRI).

PATIENTS, METHODS

MRI and PET imaging were used as part of the preoperative work-up in 18 patients with Type II diabetes mellitus. The diagnosis of Charcot's foot requiring surgical treatment were made on the basis of clinical and radiologic criteria.

RESULTS

Of 46 Charcot's lesions confirmed at surgery, 44 and 35 were detected by means of PET and MRI, respectively. PET can be used in the work-up of patients with metal implants where the MRI does not show adequate findings. PET shows the areas of detritus formation exhibit only moderately increased glucose metabolism and at visual interpretation do not usually impression as typical for acute osteomyelitis. Average SUV values stood at 1.2 (range: 0.5-2.9).

CONCLUSIONS

The differentiation between Charcot's lesions and florid osteomyelitis provides the surgeon with important additional information, which is often unavailable from MRI. Because of this important additional data, PET could be considered preferable to morphologic imaging (CT, projection radiography) in the preoperative work-up of Charcot's foot.

[Diagnosis of initial changes in patients suffering from rheumatoid arthritis. Two years follow up control with a low-field magnetic resonance scanner, 3-phase bone scintigraphy and conventional x-ray]

Besides conventional x-ray, in the diagnostic work up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The AIM of this study was to compare the diagnostic value of a newly developed low field MRI with proven methods such as conventional x-ray and 3P-Sz.

PATIENTS, METHODS

42 patients were studied using a one days protocol with 3P-Sz, MRI, and x-ray of the hands with yearly follow up examinations. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA-typical and non-RA-typical changes. All methods were compared to the summarised findings interpreted by a rheumatologist in consideration of the Ritchie articular index as gold-standard.

RESULTS

24/42 patients presented with clinical symptoms of initial changes by rheumatoid arthritis. Conventional x-ray revealed in 20/24 patients within the correct diagnosis in the study period. On the other hand 3P-Sz and low field MRI concordantly showed all 24 patients with initial changes due to RA. Time of detection showed variations with a tendency to later findings by conventional x-ray.

CONCLUSIONS

In the diagnostic work up of initial changes conventional x-ray should be the first choice in imaging. Our findings suggest that MRI represents an equally sensitive method for the diagnosis of initial changes due to RA in the region of the hands as compared to the 3P-Sz. The limitation of the low field MRI is the small field of view, so we prefer 3P-Sz or high field MRI in the diagnosis of patients with suspected RA.

Diagnosis of initial changes in patients suffering from rheumatoid arthritis

In der Initialdiagnostik bei rheumatoider Arthritis (RA) werden neben der Projektionsradiographie (PR) auch die Magnetresonanztomographie (MRT) und die 3-PhasenSkelettszintigraphie (3P-SZ) eingesetzt. Ziel dieser Studie war es, bei Patienten mit Verdacht auf RA die Wertigkeit der PR, der 3P-SZ und der MRT anhand von Verlaufsbeobachtungen über 2 Jahre zu beurteilen. Patienten, Methoden: Bei 42 Patienten wurden am selben Tag je eine 3P-SZ, Niederfeld-MRT und PR der Hände im dorsovolaren Strahlengang durchgeführt. Verlaufskontrollen erfolgten im jährlichen Abstand. Alle Bilder wurden von jeweils zwei erfahrenen Radiologen/ Nuklearmedizinern befundet und in rheumatypisch und nicht rheumatypisch unterteilt. Als Goldstandard diente die abschließende klinische Diagnose des Rheumatologen unter Berücksichtigung des Ritchie-articular-Index. Ergebnisse: Bei 24/42 Patienten wurde die Diagnose einer initialen RA gestellt. In der PR konnte bei 20/ 24 Patienten im zeitlichen Verlauf die richtige Diagnose gestellt werden. Demgegenüber wurde sowohl in der 3P-SZ als auch in der MRT bei allen 24 Patienten eine beginnende RA erkannt. Lediglich im Detektionszeitpunkt gab es Variationen mit insgesamt tendenziell späterer Diagnosestellung in der PR. Schlussfolgerung: In der bildgebenden Initialdiagnostik der RA ist die PR weiterhin als Verfahren der ersten Wahl anzusehen. In der weiterführenden Diagnostik von unklaren Befunden stellt die Niederfeld-MRT ein der 3P-SZ annähernd vergleichbar sensitives Verfahren dar. Trotzdem sollten – wenn möglich – aufgrund des geringen Field-of-view neben der 3P-SZ zur weiteren Abklärung unklarer Befunde Hochfeldtomographen bevorzugt werden.

[Imaging of neuroendocrine tumors of the pancreas]

OBJECTIVE

To compare the value of the various imaging modalities in the detection of pancreatic islet cell tumors.

METHODS

Analysis of the literature to compare the value of ultrasound, CT, MRI, angiography, venous sampling, scintigraphy and PET in the detection of neuroendocrine tumors of the pancreas.

RESULTS

For transabdominal ultrasound a sensitivity of 60% has been reported; for endoscopic ultrasound a sensitivity of more than 90%. MRI with a sensitivity of 75-100% is more sensitive compared to CT with a sensitivity of 64-82%. Angiography and venous sampling have a reported sensitivity of 66% and 76%. Somatostatin receptor scintigraphy has a sensitivity of 81-88% with significant differences between the various histological subtypes of the pancreatic islet cell tumors. PET does not play an important role in the detection of neuroendocrine tumors of the pancreas.

CONCLUSION

None of the various modalities is superior alone, so that it is often necessary to combine them for diagnostic imaging of pancreatic islet cell tumors.

[Diagnosis of initial changes in the hand of patients with rheumatoid arthritis--comparison between low-field magnetic resonance imaging, 3-phase bone scintigraphy and conventional x-ray]

Besides conventional X-rays, in the diagnostic work up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of the newly developed low field MRI with the proven methods X-rays and 3P-Sz.

METHODS

65 patients (47f, 18m; 20-86 yrs) were studied on a one day protocol with 3P-Sz (550 MBq Tc-99m DPD), MRI and X-rays of the hands. Images were visually analysed by two blinded nuclear medicine physicians and radiologists and classified as a) RA-typical, b) inflammatory, non-RA-typical and c) non inflammatory changes. All methods were compared to 3P-Sz as golden standard.

RESULTS

In comparison to 3P-Sz, low field MRI presents with almost equal sensitivity and specificity in rheumatoid-typical and inflammatory changes. Conventional X-rays revealed in arthritis-typical changes as well as in inflammatory changes a significantly lower sensitivity and also a lower negative predictive value while specificity equals the one of MRI. Quantitative analysis of 3P-Sz using ROI-technique unveiled significantly higher values in patients with rheumatoid arthritis than in those with no inflammatory changes.

CONCLUSION

MRI represents an equally sensitive method in the initial diagnosis of rheumatoid-typical and inflammatory changes in the region of the hands as compared to the 3P-Sz. Besides the basic diagnosis with conventional X-rays, 3P-Sz is still the recommended method of choice to evaluate the whole body when RA is suspected. Additionally, quantitative analysis of the 3P-Sz using the ROI technique in the region of the hands reveals statistically significant results and should therefore be taken into account in the assessment of inflammatory changes.

Diagnosis of initial changes in patients suffering from rheumatoid arthritis

Zur Diagnostik initialer Veränderungen bei rheumatoider Arthritis (RA) werden neben der Projektionsradiographie (PR) im bilddiagnostischen Stufenkonzept die 3-Phasen- Skelettszintigraphie (3P-Sz) und die Magnetresonanz- Tomographie (MRT) eingesetzt. Ziel dieser Studie war es, die neu entwickelte Niederfeld-MRT mit den etablierten Verfahren (PR, 3P-Sz) in der Initialdiagnostik der RA an der Hand zu vergleichen. Methode: Bei 65 Patienten (47 w, 18 m; 20-86 Jahre) wurden an einem Tag 3P-Sz (550 MBq Tc-99m DPD), Niederfeld-MRT und PR der Hände durchgeführt. Alle Bilder wurden von zwei erfahrenen Nuklearmedizinern/Radiologen geblindet befundet und unterteilt in a) rheumatypische, b) entzündliche, nicht rheumatypische und c) nicht entzündliche Veränderungen sowie der 3P-Sz als Goldstandard gegenüber gestellt. Ergebnisse: Im Vergleich zur 3P-Sz zeigt die Niederfeld-MRT bei nahezu gleicher Sensitivität gegenüber rheumatypischen und entzündlichen Veränderungen nur eine gering niedrigere Spezifität. Bei der PR war sowohl bei rheumatypischen als auch bei entzündlichen Veränderungen die Sensitivität vermindert bei gleicher Spezifität wie die Niederfeld-MRT. Die quantitative Auswertung der 3P-Sz mittels ROI-Technik ergab signifikant höhere Werte bei rheumatypischen Veränderungen. Schlussfolgerung: Die Niederfeld-MRT stellt ein der 3PSz vergleichbar sensitives Verfahren in der Initialdiagnostik zum Nachweis rheumatypischer und entzündlicher Veränderungen im Bereich der Hände dar. Neben der Basisuntersuchung der PR empfiehlt sich die 3P-Sz durch Erhebung eines Ganzkörperstatus sowie quantitativer ROI-Technik für die weiterführende Diagnostik bei Verdacht auf RA.

The distribution of aminoacylase I among mammalian species and localization of the enzyme in porcine kidney

Aminoacylase I (Acy-1, EC 3.5.1.14) is found in many mammalian tissues, with highest activities occurring in kidney. The enzyme hydrolyzes a variety of N-acylated amino acids; however, the physiological role and the exact cellular localization of Acy-1 are still a matter of debate. The comparison of Acy-1 activities in kidney and liver homogenates of 11 mammalian species showed that the enzyme is most abundant in true herbivores such as sheep and cattle as well as in omnivores, while activities were very low in both rodents and the cat. Acy-1 activity was not detected in livers of dogs of five different breeds. Using in situ hybridization of porcine kidney sections with DIG-labeled RNA probes, Acy-1 mRNA was shown to be evenly distributed throughout the tubular system, while glomeruli and the interstitium were free of stain. During subcellular fractionation, porcine Acy-1 behaved like a typical cytosolic enzyme. Commonly, Acy-1 is thought to catalyze hydrolytic reactions, i.e., the formation of free amino acids from acylated derivatives. Based on the present results and literature data, we propose a novel hypothesis, i.e., that Acy-1 catalyzes the synthesis (rather than the hydrolysis) of hippurate that is formed as a detoxification product of aromatic compounds.