Literature DB >> 25207401

Bremsstrahlung dose of 165Dy in radiosynovectomy.

H C Manjunatha1.   

Abstract

There has been an increased interest in 165Dy radiossynovectomy, which emits relatively high-energy (> 1 MeV) beta rays. The production of in vivo bremsstrachlung radiation hazards warrants evaluation. The bremsstrahlung component of the decay scheme of 165Dy has been traditionally ignored in internal dosimetry calculations. We have estimated the bremsstrahlung dose of 165Dy distributed in muscle and bone to body by various internal organs (adrenals, brain, breasts, gallbladder wall, LLI wall, small intestine, stomach, ULI wall, heart wall, kidneys, liver, lungs, muscle, ovaries, pancreas, red marrow, bone surfaces, skin, spleen, testes, thymus, thyroid, urine bladder wall, uterus, fetus, placenta, and total body) during radiosynovictomy. In the present study, muscle and bone are considered to be source organs. These estimated values show that the bremsstrahlung radiation absorbed dose contribution from an organ to itself is very small compared to that originating from the beta source. However, contribution to other organs is not always negligible, especially when large amounts of 165Dy may be involved, such as in therapy applications. Hence the component of the total dose due to bremsstrahlung dose should be considered in radiosynovictomy or other therapy applications.

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Year:  2014        PMID: 25207401      PMCID: PMC5875505          DOI: 10.1120/jacmp.v15i4.4746

Source DB:  PubMed          Journal:  J Appl Clin Med Phys        ISSN: 1526-9914            Impact factor:   2.102


INTRODUCTION

Rheumatoid arthritis (RA), a systemic disease of the connective tissue, whose alterations occur in the areas of articular, periarticular, and tendinous structures, manifests itself through local inflammation, predominantly in the synovial membrane. Almost half of the patients diagnosed with RA have problems with the knee joint. In the treatment of rheumatoid arthritis, a surgical, chemical, or radiation synovectomy (RSV) may be applied. The first treatment used is the prescription of anti‐inflammatory drugs, steroids, and others. In some cases, this treatment may not be effective, and may cause the formation of pannus and the destruction of the articular cartilage, requiring surgical treatment, arthrodesis, or even total knee replacement. Surgical synovectomy is expensive and may have side effects, such as the possibility of a local infection and loss of joint mobility. Arthroscopic synovectomy of the knee may be less invasive, but the results are limited. When conventional treatment fails or surgery is impossible, radiation synovectomy (RS) may be applied. This technique consists of an intraarticular injection of colloids or macroaggregates bound to radionuclide beta‐emitters. The objective is to destroy the diseased pannus and inflamed synovium by direct and highly selective irradiation, with the expectation that following synovium destruction, the regenerated synovium will be free of disease. It is necessary that the colloidal particle be large enough to remain intraarticular for at least a half‐life of the beta nuclide and avoid irradiation of remote organs. The radiation synovectomy (RS) has the merits of a simple operation and no postoperative complications. In the treatment of arthritis by radiation from radioactive materials in the lesions, the material administered to the lesion should be retained only in the lesion, with no leakage. Since the introduction of RS in 1952, a large number of radionuclides have been studied, and their usefulness and clinical efficacy were analyzed in several clinical trials. The first beta‐emitting radionuclide for RS was colloidal gold, Au‐198. Though it was clinically effective, it did not gain widespread use because of an unacceptable whole‐body radiation load due to its additional gamma‐emission and a high extraarticular leakage into regional lymph nodes. Thus, as early as 1963, yttrium‐90 was recommended, instead, and is still in use for RS of the knee joint. It is a pure with a physical half‐life of 2.7 days and a high energy of 2.26 MeV. Due to its maximum tissue penetration of approximately 11 mm, yttrium‐90 cannot be used to treat joints smaller than the knee because this could lead to damage to articular cartilage or overlying skin. Due to these disadvantages, dysprosium‐165 was recommended as an alternative radionuclide for knee joint RS. The radionuclides available to RS have a short physical half‐life and emit ionizing particles with an average affective tissue penetration (the maximum penetration is less than 10 mm). The objective is to reach the inflamed synovia, producing an absorbed dose sufficient to eliminate the disease. Another desirable feature is the existence of a combined emission of low‐energy gamma rays that can generate a scintigraphy image to evaluate the quality of the injection and to monitor the migration of radio nuclides in the lymphatic system. It is important that the radioisotope be available, nontoxic, and chemically pure. Thus, dysprosium‐165 () and samarium‐153 () present features suitable for use in RS treatment. These radionuclides have a short physical half‐life, emit beta and gamma rays of low energy, and can bind themselves to macroaggregates (particles of an adequate size) so that there is no radioactive spreading in the lymphatic system. Their use is expected to reduce inflammation and pain and improve the articular mobility. Radiation synovectomy (RS) using Ferric‐hydroxide causes no significant radiation burden to most patients as indicated by the absence of adverse changes in levels of biomarkers of cytogenetic damage and a low incidence of leakage. The incorporated/injected during radiosynovectomy produces bremsstrahlung radiation and could have different energies and intensities. The bremsstrahlung yield is a function of two components, namely internal bremsstrahlung and external bremsstrahlung. The intensity of external bremsstrahlung (EB) largely depends on the energy of the emitted beta particles and atomic number of the surrounding matrix material. On the other hand, internal bremsstrahlung component inherently depends on the interaction of the emitted beta particle with the nucleus of the source radionuclide itself. It can, therefore, be stated that the photon characteristics of external bremsstrahlung depend on the surrounding matrix material (tissue), whereas those of internal bremsstrahlung would depend on the emission characteristics of radionuclide. The bremsstrahlung component of beta emitters has been traditionally ignored in internal dosimetry calculations. This may be due to a lack of available methods for including this component in the calculations or to the belief that the contribution of this component is negligible compared to that of other emissions. The phenomenon of bremsstrahlung production is most important at high energies and high medium atomic numbers. In patients with chronic synivitis to rheumatoid arthritis (RA), the results of RSV are favorable. Local instillation of radiopharmaceuticals can reduce effusion. In our previous work, we have formulated a general method to evaluate the EB spectrum and hence the bremsstrahlung dose of therapeutic beta nuclides in bone and muscle only. Radiation therapy needs experimental studies on the exposure due to bremsstrahlung in tissues. But these experiments are very difficult to undertake and analyze, since many biochemical processes are taking place at the same time, competing with radiation effects. The resulting hazard of bremsstrahlung radiation released during beta therapy may, therefore, be some of concern, at least theoretically, and should be systematically evaluated. The injected beta nuclide interacts with surrounding bone and muscle and produce bremsstrahlung radiation. In the present study, we have formulated the method to estimate the radiation dose from the bremsstrahlung component of distributed in the muscle and bone to body for various body organs during radiosynovectomy.

MATERIALS AND METHODS

The computations of bremsstrahlung radiation dose have been divided into three parts, which are as follows:

Estimation of bremsstrahlung cross section

Markowicz et al. proposed an expression for modified atomic number () of compound target defined for bremsstrahlung process to take into account the self absorption of bremsstrahlung and electron back scattering: Here, , and are atomic weight, weight fraction, and atomic number of ith element, respectively. is evaluated using Eq. (1) and their composition. The evaluated values of for muscle and bone are 6.481 and 10.991, respectively. The bremsstrahlung cross section is evaluated using Lagrange's interpolation technique, Seltzer‐Berger theoretical bremsstrahlung cross section data given for elements using the following expression where lower case z is the atomic number of the element of known bremsstrahlung cross section adjacent to the modified atomic number () of the compound whose bremsstrahlung cross section is desired, and upper case Z are atomic numbers of other elements of known bremsstrahlung cross section adjacent to . The estimated (milli barn/MeV) is used for evaluation of spectrum.

Evaluation of Bremsstrahlung spectrum

The number n(T,k) of bremsstrahlung photons of energy k when all of the incident electron energy T completely absorbed in thick target is given by Bethe and Heitler is where is bremsstrahlung cross section at photon energy k and electron energy E, N is the number of atoms per unit volume of target, and E is the energy of an electron available for an interaction with nucleus of the thick target after it undergoes a loss of energy per unit length . For a beta emitter with end point energy , spectral distribution of bremsstrahlung photons (S (k)) is given by where P(T) is the beta spectrum. Evaluated results of of Eq. (2) and tabulated values of of Seltzer‐Berger data are used to get S(k) for the target compounds.

Evaluation of Bremsstrahlung dose

We used the following expression for the calculation of specific absorbed fraction of energy at distance x from the point source monoenergetic photon emitter: Here is linear absorption coefficient of photons of given energy, μ is linear attenuation coefficient of photons of given energy, is energy absorption buildup factor, ρ is density of the medium. The energy absorption buildup factors have been computed using geometric progression (GP) fitting method. The values of and photons have been taken from Hubbel. The specific absorbed fraction for a given beta source was estimated by integrating over the entire bremsstrahlung spectrum. where is the maximum energy of beta. Estimation of the value of Φ allows calculation of the absorbed dose at fixed distances from the point source in the infinite, homogeneous medium where D(x) is the absorbed dose at distance x per unit initial activity (), τ is the residence time of activity, and Δ is the energy emitted per unit cumulated activity and it is numerically equal to (2.13 ), where is the frequency of occurrence of emissions with energy ; the quantities and are provided by the calculated bremsstrahlung spectrum using Eq. (4). We have estimated D(x) between and , through complete decay of a beta source. After obtaining the absorbed dose at a number of chosen distances from the source, we have also plotted the calculated estimates of absorbed dose per unit initial activity as a function of distance from the point source. We then developed S‐values for bemsstrahlung emissions for activity uniformly distributed throughout the muscle and cortical bone of the standard reference male phantom by folding the bremsstrahlung spectrum over the specific absorbed fractions as a function of energy for these source regions.

RESULTS & DISCUSSION

The calculations employed the accurate energy absorption buildup factors and the bremsstrahlung photon spectrum. This estimated spectrum is accurate because it is based on more accurate , Seltzer‐Berger data where an electron–electron interaction is also included. The variation of specific absorbed fractions of energy (Φ) with photon energy in cortical bone and muscle are as shown in Figs. 1 and 2. For the purpose of comparison, we have simulated the bremsstrahlung cross sections in bone and muscle using a GEANT4. The cross sections calculated in the present method agrees with that of Geant4 and it is shown in Table 1. The specific absorbed fraction of energy (Φ) increases up to 0.1 MeV and then decreases. The variation of Φ with energy is due to dominance of photoelectric absorption in the lower end and dominance of pair production in the higher photon energy region. During the calculation of Φ values, thickness of penetration depth is considered up to 40 mean free paths. The estimated beta induced bremsstrahlung dose per unit activity (in ) of a point source in a muscle and cartical bone medium, through complete decay is as shown in Fig. 3. We find that the bremsstrahlung dose at about 0.01 mm from source in a muscle would be 1.08 and that of bone is 23.2 .
Table 1

Comparision of bremsstrahlung cross sections (milli barn/MeV) calculated using present method with that of Geant4

Bone Muscle
EnEnergy (MeV) Present Work Using Geant4 Present Work Using Geant4
0.10185.00191.00170.20176.30
0.504.485.104.134.45
1.001.321.381.241.25
1.500.930.970.870.89
2.000.530.580.500.53
2.500.430.480.410.41
3.000.340.390.320.32
Figure 3

The evaluated bremsstrahlung spectra (S(k)) of expressed as number of photons per per beta.

Variation of bremsstrahlung cross section with photon energy in muscle (k and T are photon and electron energies, respectively). Variation of bremsstrahlung cross section with photon energy in cortical bone (k and T are photon and electron energies, respectively). The bremsstrahlung dose of sauraj source in a muscle is less than that of cortical bone because it depends on modified atomic number () of the target medium () of muscle is less than that of cortical bone). In both muscle and bone medium, bremsstrahlung dose decreases with distance (Table 2). Bremsstrahlung dose depends on the specific absorbed fraction of energy (Φ) of the target medium. The variation of specific fraction of absorbed energy (Φ) with incident photon energy in bone and muscle are shown in Figs. 4 and 5. The specific absorbed fraction of energy (Φ) also increases up to the and then decreases. Here is the energy value at which the photo electric interaction coefficients match with Compton interaction coefficients for a given material. For a bone and muscle, is almost equal to 0.1 MeV. The variation of Φ with energy is due to dominance of photoelectric absorption in the lower end and dominance of pair production in the higher photon energy region. In the lower energy end, photoelectric absorption is dominant photon interaction process; hence Φ values are minimum. As the energy of incident photon increases, Compton scattering overtakes the photoelectric absorption. It results in multiple Compton scattering events which increases the value of Φ up to the and becomes maximum at . Thereafter (above ), pair production starts dominating (absorption process), which reduces the value of Φ to minimum. emits relatively high energy (1.286 MeV) beta particles, so that it produces high energy photons (), hence dose of ‐induced bremsstrahlung dose decreases with distance (Fig. 6).
Table 2

Bremsstrahlung absorbed dose (in ) near a point source of

Distance (in mm) Source Medium
Muscle Cortical Bone
0.01 1.08×10+0 2.32×10+1
0.05 4.31×102 9.27×101
0.1 1.08×102 2.31×101
0.5 4.25×104 9.19×103
1 1.05×104 2.28×103
5 3.70×106 8.50×105
10 7.96×107 1.95×105
Figure 6

Bremsstrahlunag beta dose per unit activity (in ) of a point source in a muscle and cartical bone medium, through complete decay.

Comparision of bremsstrahlung cross sections (milli barn/MeV) calculated using present method with that of Geant4 The evaluated bremsstrahlung spectra (S(k)) of expressed as number of photons per per beta. Bremsstrahlung absorbed dose (in ) near a point source of The variation of specific fraction of absorbed energy (Φ) with incident photon energy in bone at penetration . The variation of specific fraction of absorbed energy (Φ) with incident photon energy in muscle at penetration . The estimated S‐values for bremsstrahlung dose () to various target organs from a uniform source of in the muscle and cortical bone are given in Table 3. We have also computed the total equivalent dose due to sum of all other decays of using radiation tool box and compared this with the equivalent dose due to bremsstrahlung radiation (it is given in Table 4). These estimated values show that the bremsstrahlung dose contribution from an organ to itself is very small, but contribution to other organs is not always negligible, especially when large amounts of may be involved as in therapy applications. When using for the radiosynovictomy, the administrated activity varies from 10 to 200 MBq. The estimated component of bremsstrahlung dose compared with overall dose due to injection of beta source is presented in Tables 5 to 7. The component of bremsstrahlung dose is not negligible for higher administrated activities. Bremsstrahlung dose depends on the radionuclide kinetics in a given situation; however, all contributions to total dose should be considered in therapy applications.
Table 3

S‐values for bremsstrahlung dose () to various target organs from a uniform source of in the muscle and cortical bone

Target Organ Muscle Cortical Bone
Adrenals 1.119×105 1.134×105
Brain 1.451×107 2.708×108
Breasts 1.662×107 2.095×107
Gallbladder Wall 7.193×106 1.818×105
LLI Wall 7.470×107 1.281×106
Small Intestine 8.735×108 1.633×107
Stomach 2.614×107 6.740×107
ULI Wall 3.855×107 8.003×107
Heart Wall 3.109×107 4.697×107
Kidneys 3.610×107 5.357×107
Liver 4.385×108 6.439×108
Lungs 1.156×107 1.496×107
Ovaries 1.256×105 2.633×105
Pancreas 1.188×106 2.105×106
Red Marrow 3.039×107 1.356×107
Bone Surfaces 1.537×107 5.816×108
Skin 2.991×108 3.316×108
Spleen 4.640×107 9.158×107
Testes 1.860×106 4.225×106
Thymus 4.019×106 8.241×106
Thyroid 6.420×106 9.064×106
Urine Bladder Wall 1.442×106 4.707×106
Uterus 1.056×106 2.890×106
Table 4

Comparison of the total equivalent dose (Sv/MBq) due to sum of all other decays of 165Dy using radiation tool box with the dose due to bremsstrahlung radiation

Overall Dose Due Administrated 165Dy Source (from primary and secondary radiation) Bremsstrahlung Dose Due Administrated 165Dy Source (from secondary radiations)
Target Organ Muscle Muscle Cortical Bone
Adrenals 2.900×107 1.119×1011 1.134×1011
Brain 2.700×109 1.451×1013 2.708×1014
Breast 5.500×107 1.662×1013 2.095×1013
LLI 2.000×104 7.470×1013 1.281×1012
Small Intestine 4.600×104 8.735×1014 1.633×1013
Stomach 4.000×104 2.614×1013 6.740×1013
ULI 5.600×104 3.855×1013 8.003×1013
Kidneys 5.000×107 3.610×1013 5.357×1013
Liver 3.300×107 4.385×1014 6.439×1014
Lungs 9.500×108 1.156×1013 1.496×1013
Ovaries 1.700×106 1.256×1011 2.633×1011
Pancreas 9.500×107 1.188×1012 2.105×1012
Red Marrow 3.500×107 3.039×1013 1.356×1013
Skin 8.700×108 2.991×1014 3.316×1014
Spleen 6.000×107 4.640×1013 9.158×1013
Testes 7.300×108 1.860×1012 4.225×1012
Thymus 3.700×108 4.019×1012 8.241×1012
Thyroid 7.000×109 6.420×1012 9.064×1012
Urinary Bladder 4.000×107 1.442×1012 4.707×1012
Uterus 1.200×106 1.056×1012 2.890×1012
Table 5

Comparison bremsstrahlung dose (Sv) with overall dose due to sum of all other decays of (source organ for all doses is the knee)

Estimated Dose for Injection of 10 MBq of 165Dy Beta Source Estimated Dose for Injection of 50 MBq of 165Dy Beta Source
Organs Overall Dose (Sv) Bremsstrahlung Dose (Sv) Overall Dose (Sv) Bremsstrahlung Dose (Sv)
Adrenals 2.900×106 1.119×1010 1.450×105 5.595×1010
Brain 2.700×108 1.451×1012 1.350×107 7.255×1012
Breast 5.500×107 1.662×1012 2.750×106 8.310×1012
LLI 2.000×103 7.470×1012 1.000×102 3.735×1011
Small Intestine 4.600×103 8.735×1013 2.300×102 4.368×1012
Stomach 4.000×103 2.614×1012 2.000×102 1.307×1011
ULI 5.600×103 3.855×1012 2.800×102 1.928×1011
Kidneys 5.000×106 3.610×1012 2.500×105 1.805×1011
Liver 3.300×106 4.385×1013 1.650×105 2.193×1011
Lungs 9.500×107 1.156×1012 4.750×106 5.780×1012
Ovaries 1.700×105 1.256×1010 8.500×105 6.280×1010
Pancreas 9.500×106 1.188×1011 4.750×105 5.940×1011
Red Marrow 3.500×106 3.039×1012 1.750×105 1.520×1011
Skin 8.700×107 2.991×1013 4.350×106 1.496×1012
Spleen 6.000×106 4.640×1012 3.000×105 2.320×1011
Testes 7.300×107 1.860×1011 3.650×106 9.300×1011
Thymus 3.700×107 4.019×1011 1.850×106 2.010×1010
Thyroid 7.000×108 6.420×1011 3.500×107 3.210×1010
Urinary Bladder 4.000×106 1.442×1011 2.000×105 7.210×1011
Uterus 1.200×105 1.056×1011 6.000×105 5.280×1011
Table 7

Comparison of bremsstrahlung dose (Sv) to overall dose due to sum of all other decays of (source organ for all doses is the knee)

Estimated Dose for Injection of 10000 MBq of 165Dy Beta Source
Organs Overall Dose (Sv) Bremsstrahlung Dose (Sv)
Adrenals 2.90×103 3.20×107
Brain 2.70×102 4.10×106
Breast 5.50×104 3.50×108
LLI 2.00×$$100 1.80×104
Small Intestine 4.60×100 5.10×103
Stomach 4.00×100 3.80×103
ULI 5.60×100 5.10×103
Kidneys 5.00×103 4.60×106
Liver 3.30×103 4.70×107
Lungs 9.50×104 9.80×108
Ovaries 1.70×102 2.30×105
Pancreas 9.50×103 8.20×107
Red Marrow 3.50×103 4.10×104
Skin 8.70×104 8.10×107
Spleen 6.00×103 7.30×107
Testes 7.30×104 6.90×107
Thymus 3.70×104 1.90×108
Thyroid 7.00×105 6.50×109
Uterus 1.20×102 2.30×107
Bremsstrahlunag beta dose per unit activity (in ) of a point source in a muscle and cartical bone medium, through complete decay. S‐values for bremsstrahlung dose () to various target organs from a uniform source of in the muscle and cortical bone Comparison of the total equivalent dose (Sv/MBq) due to sum of all other decays of 165Dy using radiation tool box with the dose due to bremsstrahlung radiation Comparison bremsstrahlung dose (Sv) with overall dose due to sum of all other decays of (source organ for all doses is the knee) Comparison of bremsstrahlung dose (Sv) to overall dose due to sum of all other decays of (source organ for all doses is the knee) Comparison of bremsstrahlung dose (Sv) to overall dose due to sum of all other decays of (source organ for all doses is the knee)

CONCLUSIONS

Calculated S‐values of bremsstrahlung radiation from have been compared with S‐values of beta and all other radiations of same source. These estimated values show that the bremsstrahlung radiation absorbed dose contribution from an organ to itself is very small. But contribution to other organs is not always negligible, especially when large amounts of may be involved as in therapy applications. Hence the component of bremsstrahlung dose to total dose should be considered in radiosynovictomy or other therapy applications.

ACKNOWLEDGMENTS

The author would like to thank Vision Group on Science and Technology (VGST), Government of Karnataka, India, for providing financial grants in the scheme “Seed Money to Young Scientist Research”.
Table 6

Comparison of bremsstrahlung dose (Sv) to overall dose due to sum of all other decays of (source organ for all doses is the knee)

Estimated Dose for Injection of 100MBq of 165Dy Beta Source Estimated Dose for Injection of 200MBq of 165Dy Beta Source
Organs Overall Dose (Sv) Bremsstrahlung Dose (Sv) Overall Dose (Sv) Bremsstrahlung Dose (Sv)
Adrenals 2.900×105 1.119E×109 5.800×105 2.238×109
Brain 2.700×107 1.451×1011 5.400×107 2.902×1011
Breast 5.500×106 1.662×1011 1.100×105 3.324×1011
LLI 2.000×102 7.470×1011 4.000×102 1.494×1010
Small Intestine 4.600×102 8.735×1012 9.200×102 1.747×1011
Stomach 4.000×102 2.614×1011 8.000×102 5.228×1011
ULI 5.600×102 3.855×1011 1.120×101 7.710×1011
Kidneys 5.000×105 3.610×1011 1.000×104 7.220×1011
Liver 3.300×105 4.385×1011 6.600×105 8.770×1011
Lungs 9.500×106 1.156×1011 1.900×105 2.312×1011
Ovaries 1.700×104 1.256×109 3.400×104 2.512×109
Pancreas 9.500×105 1.188×1010 1.900×104 2.376×1010
Red Marrow 3.500×105 3.039×1011 7.000×105 6.078×1011
Skin 8.700×106 2.991×1012 1.740×105 5.982×1012
Spleen 6.000×105 4.640×1011 1.200×104 9.280×1011
Testes 7.300×106 1.860×1010 1.460×105 3.720×1010
Thymus 3.700×106 4.019×1010 7.400×106 8.038×1010
Thyroid 7.000×107 6.420×1010 1.400×106 1.284×109
Urinary Bladder 4.000×105 1.442×1010 8.000×105 2.884×1010
Uterus 1.200×104 1.056×1010 2.400×104 2.112×1010
  9 in total

1.  Radiation synovectomy using 165Dy ferric-hydroxide and oxidative DNA damage in patients with different types of arthritis.

Authors:  C Pirich; A Pilger; E Schwameis; D Germadnik; U Prüfert; E Havlik; S Lang; H Kvaternik; J A Flores; P Angelberger; A Wanivenhaus; H W Rüdiger; H Sinzinger
Journal:  J Nucl Med       Date:  2000-02       Impact factor: 10.057

2.  Decay data for internal and external dose assessment.

Authors:  Michael G Stabin; Lydia C Q P da Luz
Journal:  Health Phys       Date:  2002-10       Impact factor: 1.316

3.  Intra-articular injection of Y-90 resin colloid in the treatment of rheumatoid knee joint effusions.

Authors:  M Oka; A Rekonen; A Ruotsi; O Seppälä
Journal:  Acta Rheumatol Scand       Date:  1971

Review 4.  Radiosynovectomy in rheumatology, orthopedics, and hemophilia.

Authors:  Peter Schneider; Jamshid Farahati; Christoph Reiners
Journal:  J Nucl Med       Date:  2005-01       Impact factor: 10.057

Review 5.  Arthroscopy of the ankle and foot.

Authors:  R D Ferkel; P E Scranton
Journal:  J Bone Joint Surg Am       Date:  1993-08       Impact factor: 5.284

6.  Experiences of intra-articular administration of radioactive gold.

Authors:  M Virkkunen; F E Krusius; T Heiskanen
Journal:  Acta Rheumatol Scand       Date:  1967

7.  The foot in chronic rheumatoid arthritis.

Authors:  E Vidigal; R K Jacoby; A S Dixon; A H Ratliff; J Kirkup
Journal:  Ann Rheum Dis       Date:  1975-08       Impact factor: 19.103

Review 8.  Innovative treatment approaches for rheumatoid arthritis. Non-surgical synovectomy.

Authors:  C Cruz-Esteban; W S Wilke
Journal:  Baillieres Clin Rheumatol       Date:  1995-11

9.  Bremsstrahlung dose of therapeutic beta nuclides in bone and muscle.

Authors:  H C Manjunatha
Journal:  Indian J Nucl Med       Date:  2013-01
  9 in total

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