PURPOSE:Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain. METHODS:The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed. CONCLUSION:These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

Background:Intra-articular therapies (IAT) are widely used in clinical practice to treat patients with rheumatic and musculoskeletal diseases (RMDs). Many factors influence their efficacy and safety. There is a wide variation in the way IATs are delivered by health professionals. In an attempt to standardise these procedures, evidence-based recommendations are the right way forward.Objectives:To establish evidence-based recommendations to guide health professionals using IAT in adult patients with peripheral arthropathies.Methods:At a first face-to-face meeting, the results of an overview of systematic reviews were presented to the multidisciplinary task force of members from 8 countries. The aim, scope and outline of the taskforce were also established at this meeting. Thirty-two clinical questions ranked for priority (relevance for practice plus feasibility) drove the systematic reviews performed by two fellows. In addition, two surveys addressed to physicians, health professionals and patients throughout Europe were agreed to acquire more background information. At the second face-to-face meeting, the evidence for each research question was discussed, and each recommendation shaped and voted in a first Delphi round. Level of agreement was numerically scored 0 to 10 (0 completely disagree, 10 completely agree). All panellists voted anonymously using a sli.do app. Agreement needed to be greater than 80% to be included in a second Delphi round, which also allowed reformulation of statements. Finally, a third Delphi round was sent to the taskforce. The level of evidence was assigned to each recommendation according to the EULAR SOP for establishing recommendations.Results:Recommendations focus on practical aspects for daily practice to guide health professionals before, during and after IAT in adult patients with peripheral arthropathies. Five overarching principles were established, together with 11 recommendations that address the following issues: (1) patient information; (2) procedure and setting; (3) accuracy issues; (3) routine and special antiseptic care; (4) safety issues and precautions to be addressed in special populations; (5) efficacy and safety of repeated joint injections; (6) the usage of local anaesthetics; and (7) aftercare. The document includes the supporting evidence and results from the surveys, level of evidence and agreement.Conclusion:We have developed the first evidence and expert opinion based recommendations to guide health professionals using IAT.Acknowledgments:Eular Taskforce grant CL109Disclosure of Interests:Jacqueline Uson Jaeger: None declared, Esperanza Naredo: None declared, Sebastian C Rodriguez-García Speakers bureau: Novartis Farmaceutica, S.A., Merck Sharp & Dohme España, S.A., Sanofi Aventis, UCB Pharma, Raul Castellanos-Moreira: None declared, Terence O’Neill: None declared, Hemant Pandit Grant/research support from: Glaxo Smith Kline (GSK) for work on Diclofenac Gel, Speakers bureau: Bristol Myers Squibb for teaching their employees about hip and knee replacement, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Ingrid Möller: None declared, Valentina Vardanyan: None declared, Jenny de la Torre-Aboki: None declared, Lene Terslev: None declared, Francis Berenbaum Grant/research support from: TRB Chemedica (through institution), MSD (through institution), Pfizer (through institution), Consultant of: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Bone Therapeutics, Regulaxis, Peptinov, 4P Pharma, Paid instructor for: Sandoz, Speakers bureau: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Sandoz, Maria Antonietta D’Agostino Consultant of: AbbVie, BMS, Novartis, and Roche, Speakers bureau: AbbVie, BMS, Novartis, and Roche, Willm Uwe Kampen: None declared, Elena Nikiphorou: None declared, IRENE Pitsillidou: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

Background:Intra-articular therapy (IAT) is routinely used in rheumatic and musculoskeletal diseases (RMDs). In order to improve the effectiveness and safety of IAT, it is essential to understand patients’ perceptions and needs.Objectives:To assess the perspective of persons who have experienced IAT, including perceptions on benefits and safety.Methods:A steering committee (including a patient research partner) prepared a 44-item questionnaire based on the information needs of a Taskforce on IAT in adult patients with RMDs. The questionnaire was translated into 11 languages and disseminated via EULAR PARE associations and social media. Persons who had experienced at least two IAT procedures were eligible for the survey. Descriptive statistics were used to summarise results as well as inductive codification of open-ended questions.Results:The survey was answered by 200 individuals diagnosed with rheumatoid arthritis (66%), osteoarthritis (21%), spondyloarthritis (10%), psoriatic arthritis (9%), and others (16%). The mean number of IATs received was 7 (SD 8), mainly in the knee (66%), shoulder (42%), and wrist (28%), and primarily with corticosteroids (83%) or hyaluronic acid (16%). Twenty-seven percent had not been informed about benefits or potential complications of IAT, and 73% had not been asked whether they wanted local anaesthetic. Consent was deemed necessary by 82 (41%). Most (65%) had never received an ultrasound (US)-guided injection, and of those who had experienced blinded and guided injections, 42 (63%) preferred US-guided because of increased perceived accuracy and confidence in the procedure. Only 50% reported a clear benefit of IAT, mainly in terms of reduced pain and increased joint mobility, but also perceived reduced inflammation, with effect from immediate to 36 hours or even 3 weeks post-injection, and that lasted from as little as less than one week to years. Regarding safety, 40 (20%) had experienced some complications from IAT, including but not limited to increased pain, impaired mobility, rashes, or swelling.Finally, the respondents suggested improvements in the procedure, including: (1) wider availability; (2) less painful procedures; (3) greater efficacy, faster and longer-lasting; (4) fewer side effects; (5) a clear diagnosis beforehand; (6) better shared decision-making, including better information; (7) follow-up, (8) better accuracy; and (9) more expertise.Conclusion:The survey has identified gaps in the IAT procedures, such as a need for clearer information. Patients perceive IAT as relatively safe, though painful, and with varying effect. Suggestions for improving the procedure, including more expertise, should be relayed to professionals and relevant organisations.Acknowledgments:Eular Taskforce grant CL109Disclosure of Interests:IRENE Pitsillidou: None declared, Jenny de la Torre-Aboki: None declared, Jacqueline Uson Jaeger: None declared, Esperanza Naredo: None declared, Lene Terslev: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Hemant Pandit Grant/research support from: Glaxo Smith Kline (GSK) for work on Diclofenac Gel, Speakers bureau: Bristol Myers Squibb for teaching their employees about hip and knee replacement, Ingrid Möller: None declared, Maria Antonietta D’Agostino Consultant of: AbbVie, BMS, Novartis, and Roche, Speakers bureau: AbbVie, BMS, Novartis, and Roche, Willm Uwe Kampen: None declared, Terence O’Neill: None declared, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Francis Berenbaum Grant/research support from: TRB Chemedica (through institution), MSD (through institution), Pfizer (through institution), Consultant of: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Bone Therapeutics, Regulaxis, Peptinov, 4P Pharma, Paid instructor for: Sandoz, Speakers bureau: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Sandoz, Valentina Vardanyan: None declared, Elena Nikiphorou: None declared, Sebastian C Rodriguez-García Speakers bureau: Novartis Farmaceutica, S.A., Merck Sharp & Dohme España, S.A., Sanofi Aventis, UCB Pharma, Raul Castellanos-Moreira: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

Background: Intra-articular therapies (IAT) are routinely used in rheumatic and musculoskeletal diseases (RMDs); however large variability exists regarding current practice of delivery amongst health professionals. Objectives: To inquire about common practice aspects to inform the EULAR Taskforce for the IAT of arthropathies. Methods: A steering committee prepared a 160-item questionnaire based on the information needs of the Taskforce. The survey was disseminated via EULAR professional associations and social media and it was open to any health professional treating persons with RMDs, regardless of using IAT personally. Results: The survey was answered by 186 health professionals from 26 countries, the large majority of whom (77%) were rheumatologists, followed by nurses (12%), general practitioners (2%) and orthopaedic surgeons (2%). The two collectives that perform IAT routinely are rheumatologists (97%) and orthopaedic surgeons (89%), with other professionals <50%. Specific training was compulsory for 32%. The most frequent indication for IAT is inflammatory arthritis (76%), followed by osteoarthritis (74%), crystal arthritis (71%) and bursitis (70%); and all joints are injected, with knee (78%) and shoulder (70%) being the most frequent. When questioned about specific contexts, such as pre-surgical, diabetic or hypertensive patients, variability among respondents was evident, with around 30 to 69% of professionals considering it acceptable to inject glucocorticoids (GC), while in others there was less variability (prosthetic or septic joints, <1%). GCs are the most used compounds, followed by hyaluronic acid and saline/dry puncture. Only 66 (36%) use ultrasound to guide IAT. In their opinion, to be accurately in the joint is moderately to largely important for large joints (80%) and very important in small joints. The maximum number of injections to perform safely in the same joint within one year was “2 to 3” for 65% (2% thought there is “No limit”). The majority reported that they informed patients about side-effects (73%), benefits (72%), and the nature of the procedure (72%), and less frequently about other aspects; with 10% obtaining written consent and 56% oral consent (mandatory only for 32%). Other questions help to understand the setting and procedures followed, including use of local anaesthetics and care after injection. Conclusion: Although often performed in clinical practice for RMDs, there is apparent variability in several elements related to delivery of this treatment. This information, together with patient input, will help design current recommendations where research evidence is not available. Acknowledgments: Eular Taskforce grant CL109 Disclosure of Interests: Jenny de la Torre-Aboki: None declared, IRENE Pitsillidou: None declared, Jacqueline Uson Jaeger: None declared, Esperanza Naredo: None declared, Lene Terslev: None declared, Mikael Boesen Consultant of: AbbVie, AstraZeneca, Eli Lilly, Esaote, Glenmark, Novartis, Pfizer, UCB, Paid instructor for: IAG, Image Analysis Group, AbbVie, Eli Lilly, AstraZeneca, esaote, Glenmark, Novartis, Pfizer, UCB (scientific advisor)., Speakers bureau: Eli Lilly, Esaote, Novartis, Pfizer, UCB, Hemant Pandit Grant/research support from: Glaxo Smith Kline (GSK) for work on Diclofenac Gel, Speakers bureau: Bristol Myers Squibb for teaching their employees about hip and knee replacement, Ingrid Möller: None declared, Maria Antonietta D’Agostino Consultant of: AbbVie, BMS, Novartis, and Roche, Speakers bureau: AbbVie, BMS, Novartis, and Roche, Willm Uwe Kampen: None declared, Terence O’Neill: None declared, Michael Doherty Grant/research support from: AstraZeneca funded the Nottingham Sons of Gout study, Consultant of: Advisory borads on gout for Grunenthal and Mallinckrodt, Francis Berenbaum Grant/research support from: TRB Chemedica (through institution), MSD (through institution), Pfizer (through institution), Consultant of: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Bone Therapeutics, Regulaxis, Peptinov, 4P Pharma, Paid instructor for: Sandoz, Speakers bureau: Novartis, MSD, Pfizer, Lilly, UCB, Abbvie, Roche, Servier, Sanofi-Aventis, Flexion Therapeutics, Expanscience, GSK, Biogen, Nordic, Sandoz, Regeneron, Gilead, Sandoz, Valentina Vardanyan: None declared, Elena Nikiphorou: None declared, Sebastian C Rodriguez-García Speakers bureau: Novartis Farmaceutica, S.A., Merck Sharp & Dohme España, S.A., Sanofi Aventis, UCB Pharma, Raul Castellanos-Moreira: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution)

A vast spectrum of lower limb bone and joint disorders (hip, knee, ankle, foot) present with a common clinical presentation: limping. Too often this symptom generates an inefficient cascade of imaging studies. This review attempts to optimise the diagnostic effectiveness of bone scintigraphy using the hybrid SPECT/CT technique in relation to the diagnostic clues provided by other imaging modalities, discusses the appropriate clinical indications, optimal scintigraphic procedures and illustrates updated image pattern-oriented reporting. Frequent lower limb bone and joint pathologies that can now be reliably diagnosed using hybrid bone SPECT/CT imaging will be reviewed. Bone SPECT/CT can be an effective problem-solving tool in patients with persistent limping when careful history taking, clinical examination, and first-line imaging modalities fail to identify the underlying cause.

Since its first description in 1952, radiosynoviorthesis (RSO) is performed as a local treatment of synovitis in patients with inflammatory joint disease by intraarticular injection of beta-emitting radiocolloides. The radioactive particles are phagocytized by the superficial type-A synoviocytes and the local high-energy beta radiation with a therapeutic range of only a few millimetres results in a coagulation necrosis of the superficial synovial layers. The necrotic tissue is then repelled, the respective area is demarcated by a pronounced inflammatory reaction and finally a new synovial membrane is regenerated. Clinically, a significant reduction of both joint effusion and articular pain is noted with a consecutive improved mobility. Apart from its classical indication Rheumatoid Arthritis, RSO can be used to treat each kind of synovitis, regardless of the underlying pathology. The indication for RSO should be discussed in line with an interdisciplinary treatment regimen in cooperation between the nuclear medicine physician and a clinician experienced in rheumatology or orthopaedics, dependant on the respective patient. Clinical results with significant pain reduction and improved joint motion are achieved in approx. 60–80% of all joints treated are published in several randomized, controlled studies on evidence level Ib in patients with rheumatoid Arthritis. The treatment is cost-effective and safe, assuming a proper patient selection and a skilful injection technique. Local complications are very rare with an overall rate of 1‰ and less. This presentation will give an overview of the different indications for RSO, the pretherapeutic examinations and prerequisites necessary for patient selection, the procedure of the treatment itself with special aspects of radiation protection and imaging. Finally, possible side effects and complications with treatment strategies will be discussed. Disclosure of Interest None declared

Zusammenfassung Die intraartikuläre Applikation kolloidaler Betastrahler zur Lokaltherapie entzündlicher Gelenkerkrankungen wurde 1952 erstmals beschrieben, der Begriff „Radiosynoviorthese“ (RSO) als Wiederherstellung der entzündeten Synovialmembran in 1968 in die Literatur eingeführt. Die Phagozytose der hochenergetischen Partikel durch die oberflächlichen Makrophagen der Synovialmembran führt zu einer oberflächennahen Bestrahlung der entzündeten Schleimhaut. Eine dadurch induzierte Sklerose und Fibrose der Synovialmembran reduziert die entzündliche Ergussneigung und die Schmerzen. Klinisch zeigt sich beim Patienten dadurch eine vermehrte Gelenkmobilität. Bei korrekter Indikationsstellung und sachgerechter Durchführung ist die RSO eine sichere und kosteneffektive Methode mit sehr niedrigen Komplikationsraten. Insbesondere lokale Komplikationen an den behandelten Gelenken sind sehr selten. Nichtsdestotrotz können radiogene Gewebsnekrosen durch eine paraartikuläre Fehlapplikation des Radiopharmakons oder als kleine Stichkanalnekrosen durch Kontaminationen beim Herausziehen der Injektionskanüle auftreten. Auch eine iatrogene Gelenkinfektion, wie sie im Rahmen jeder Gelenkpunktion passieren kann, ist bei der RSO nicht auszuschließen. Thrombembolische Ereignisse aufgrund der posttherapeutischen Immobilisation, insbesondere nach RSO an der unteren Extremität, sind die dritte Gruppe möglicher Komplikationen im Rahmen der nuklearmedizinischen Gelenktherapie. Aufgrund der geringen Häufigkeit publizierter Fälle sind die klinischen Erfahrungen im Umgang mit den genannten Komplikationen nur sehr gering, entsprechende Empfehlungen sind nicht verfügbar. Diese Übersichtsarbeit gibt einen Überblick über die in der Literatur dokumentierten Fälle und entsprechende Therapieansätze.

PURPOSE:The radionuclide bone scan is the cornerstone of skeletal nuclear medicine imaging. Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign disease, as well as physiological processes.METHODS:The European Association of Nuclear Medicine (EANM) has written and approved these guidelines to promote the use of nuclear medicine procedures of high quality.CONCLUSION:The present guidelines offer assistance to nuclear medicine practitioners in optimizing the diagnostic procedure and interpreting bone scintigraphy. These guidelines describe the protocols that are currently accepted and used routinely, but do not include all existing procedures. They should therefore not be taken as exclusive of other nuclear medicine modalities that can be used to obtain comparable results. It is important to remember that the resources and facilities available for patient care may vary.

The trouble with the world is that the stupid are cocksure and the intelligent are full of doubt.(Bertrand Arthur William Russell, britischer Philosoph und Mathematiker, 1872–1970) Wir alle, die wir in der klinischen Nuklearmedizin täglich auf der Suche nach dem pathologischen Befund sind, werden eine multilokuläre ossäre Metastasierung im Skelettszintigramm ebenso leicht und sicher erkennen wie eine ausgedehnte Hinterwandnarbe in der Myokardszintigrafie. Auch die multiplen, keilförmigen Ausfälle in der Lungenperfusions-SPECT bei erhaltener Ventilation werden uns nicht vor ein diagnostisches Problem stellen.

Die nuklearmedizinische palliative Schmerztherapie stellt eine nebenwirkungsarme, ergänzende Behandlungsoption im Gesamtspektrum der Schmerztherapie bei Patienten mit einer multilokulär osteoblastischen Metastasierung vieler Primärtumoren dar. Sie zeichnet sich durch einen raschen Einsatz der Schmerzlinderung und durch lang anhaltende Wirkung aus. Vorläufige Berechnungen weisen auf eine günstige Kosten-Nutzen-Relation hin. Durch die nuklearmedizinische palliative Schmerztherapie bessert sich bei Patienten mit metastasiertem Mamma- oder Prostatakarzinom die Schmerzsymptomatik in 70–80%, bei anderen Primärtumoren weniger häufig 7 10. Völlig schmerzfrei werden nur wenige Patienten. Eine medikamentöse Basistherapie ist bei den meisten Tumorpatienten weiterhin erforderlich. Insgesamt zeichnet sich die Therapie durch eine hohe Akzeptanz bei den Patienten aus, da es sich bei der Verwendung von 89Strontium oder 153Samarium um eine einmalige intravenöse Applikation handelt. Aktuelle Studien zum kombinierten Einsatz von Radionukliden und Chemotherapie bzw. die klinischen Daten der Anwendung von 223Radium belegen weitere Entwicklungsmöglichkeiten der systemischen Radionuklidtherapie von einer rein palliativen Behandlung hin zu tumoriziden Effekten mit signifikanter Lebensverlängerung der betroffenen Patienten.

Zusammenfassung Die Radiosynoviorthese (RSO) mittels intraartikulärer Injektion kolloidaler Betastrahler wird als Lokaltherapie der Synovialitis seit vielen Jahren in Europa angewandt. Schwere Komplikationen wie Weichteilnekrosen, Infekte oder Thrombosen sind im klinischen Alltag sehr selten, deshalb sind Erfahrungen bei der Behandlung kaum verfügbar. Die vorliegende Arbeit beinhaltet neben einer allgemeinen Darstellung von Indikationen und Anwendungen der intraartikulären Gelenktherapie insbesondere eine kritische Wertung der publizierten Studien zu eventuellen Komplikationen sowie erstmals eine Auswertung der „Periodic-Safety-Update-Reports“ (PSURs) der Jahre von 1990–2011, die alle dem Hersteller der betreffenden (Radio-)Pharmaka gemeldeten Nebenwirkungen dokumentieren und bezüglich ihres Schweregrades bewerten. Auch diese Auswertungen belegen, dass die Rate schwerer Komplikationen nach der RSO in der Tat äußerst selten, allenfalls im Promillebereich zu beobachten sind. Im zweiten Teil der Arbeit werden dem Leser und Anwender dieses etablierten Behandlungsverfahrens praktische Hinweise zu hygienischen Aspekten bei der Durchführung der Radiosynoviorthese an die Hand gegeben.

Diese Arbeit beschreibt die Rahmenbedingungen, Inhalte, Vor- und Nachteile sowie die Umsetzung eines QM-Systems in einer nuklearmedizinischen Praxis. Ziel ist es, dem Leser die Implementierung und den täglichen Umgang mit einem routinefähigen Qualitätsmanagement zu erleichtern. Konkrete Beispiele aus der Praxis sollen helfen, die Vorgaben eines solchen Sys­tems mit Leben zu füllen und auf diese Weise seine Anwendung und ständige Verbesserung in der täglichen Routine zu sichern. Einzelne Maßnahmen der Qualitätssicherung werden ebenso angesprochen wie der Umgang mit Fehlern und Beschwerden sowie Vor- und Nachteile der offiziellen Zertifizierung.

The diagnostic accuracy of infection scintigraphy with 99mTc-labelled monoclonal antibody Fab' fragments (sulesomab) was studied in patients with suspected total knee arthroplasty (TKA) infection. Images from 26 patients were evaluated by two independent readers and compared with a quantitative interpretation of time-activity courses. Microbiological examinations and joint aspiration results were used as reference standards. Histologically, aseptic TKA loosening occurred in two patients and severe, moderate or mild septic loosening in four, nine and 11 patients, respectively. Diagnostic accuracy for severe infection was 100% for both readers, whereas for moderate infection accuracy decreased by 12% and 12% for readers one and two, respectively. For mild infection a further decrease of approximately 61% and 52% occurred for readers one and two, respectively. Quantitative evaluation gave significantly better results over visual interpretation with a diagnostic accuracy of 100% for severe infection and decreased by only 10% and 15% in patients with moderate and mild infection, respectively. Quantitative evaluation of 99mTc-Fab' fragments is highly sensitive and specific for diagnostic imaging of infection in patients with septically-loosened TKA.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Radiosynoviorthesis (RSO) with an yttrium-90 colloid offers a local and minimally invasive therapy for treating inflammatory hypertrophy of the synovial membrane of the knee that has arisen from numerous kinds of disorder: these include rheumatoid arthritis (RA), osteoarthritis (OA), spondyloarthropathy, villonodular synovitis and others. There is substantial evidence that this treatment is efficacious and that, in view of the benefits that it offers, its tolerability and safety are very good. Administration should be restricted to patients in whom other therapies (including locally injected corticoids) have failed, and proper attention must be paid to correct administration, including post-treatment immobilization and the co-administration of corticoids, to minimize the risk of leakage and of efflux through the puncture channel.

Die vorliegende Arbeit fasst die verfügbare Literatur zur Wirksamkeit der Radiosynoviorthese nach Gesichtspunkten der Evidenz-basierten Medizin zusammen. Gerade in Zeiten zunehmender Verknappung finanzieller Mittel im Gesundheitssystem muss sich jede Therapie dem Vergleich mit anderen Methoden stellen. Hier erscheint vielen die Evidenz-basierte Medizin, d. h. die Gewichtung publizierter klinischer Studien nach bestimmten Kriterien wie der Randomisierung, Verblindung oder Kontrolle durch Vergleich mit einem Plazebo gewissermaßen als „Stein der Weisen”. Für die Radiosynoviorthese wird die Existenz qualitativ hochwertiger Studien häufig verneint - eine Aussage, die jedoch nach genauem Studium der verfügbaren Literatur nicht zu halten ist. Dem in der RSO tätigen Nuklearmediziner sollen durch die Auflistung und kurze inhaltliche Beschreibung einer Reihe von Studien der Evidenzgrade I b und II a wichtige Argumente an die Hand gegeben werden, die die eigene klinische Erfahrung mit dieser nuklearmedizinischen Therapie wissenschaftlich stützen und als Rüstzeug in der Diskussion mit Kollegen anderer Fachdisziplinen dienen sollen. Eine kritische Betrachtung der Evidenz-basierten Medizin als alleinige Grundlage des therapeutischen Handelns rundet die Arbeit ab.

Aim: Radiosynoviorthesis using intraarticular injection of beta-emitting radiocolloids is increasingly performed throughout Europe in patients with inflammatory joint disease. It is a cost-effective and safe treatment, local complications are very rare with only eight cases mentioned in the literature so far. No recommendations for therapy of tissue necrosis, infection or thromboembolism after radiosynoviorthesis are available. Methods: Using a standardized questionary, 260 nuclear medicine physicians and 20 medical liability insurances were asked for the kind and frequency of complications after radiosynoviorthesis between 1998 and 2003. The survey was terminated after nine months with a response of only 25.7 /0. Results: A total of 53 severe complications were documented (28 necroses, 12 thromboses, 13 joint infections). Eight other complications were seen but difficult to correlate directly with radiosynoviorthesis. Tissue necroses from yttrium-90 were successfully treated by surgical excision and closure of the defect. Rhenium-186-induced ulcers healed by hyperbaric oxygen therapy in two cases. Lesions from erbium-169 showed restoration by conservative treatment. Thramboembolic events happened after radiosynoviorthesis in joints of the lower limb only, mostly treated by conventional anticoagulation. Intraarticular infections showed restoration after intraarticular antibiotics in the majority of cases. Conclusion: Severe complications after radiosynoviorthesis seem to be rare. However, because of the low return rate, a reliable frequency cannot be calculated. Nevertheless, important advices regarding treatment concepts can be taken from our data.