Magnetic Resonance Imaging and 99Tc WBC-SPECT/CT Scanning in Differential Diagnosis between Osteomyelitis and Charcot Neuroarthropathy: A Case Series
, Cinzia Romagnolo 4, Elena Tortato 2, Anna Rita Bonfigli 5, Roberta Galeazzi 6, Fabiola Olivieri 5,7, Giuseppe Bronte 6,7,*,†and Enrico Paci 1
Round 1
Reviewer 1 Report (Previous Reviewer 1)
Comments and Suggestions for AuthorsThis study assessing a limited number of cases cold be of potential interest if appropriately designed and presented. It has multiple flaws that make the message difficult to understand to say the least. It needs to be rewritten:
1. Parts of the M&M belong to introduction or discussion
2. The Discussion should be shortend by at least 50%
3. The gold standard and criteria for final diagnosis need to be clearly presented.
4. The aim of the study needs to be clearly presented - if understood correctly the case series includes patients who all have Charcot and a suspicion of additional osteomyelitis and the aim would be the final diagnosis of absence or presence of OM as diagnosed by MRI or WBC. If this is indeed the case then this is what has to be presented.
Many more minor issues that will need o be addresed.
Comments on the Quality of English Languagemediocre
Author Response
This study assessing a limited number of cases cold be of potential interest if appropriately designed and presented. It has multiple flaws that make the message difficult to understand to say the least. It needs to be rewritten:
- Parts of the M&M belong to introduction or discussion
REPLY: We thank the reviewer for further comments, useful to improve our paper.
A part of M&M section was moved to the Introduction section (lines 73-91), not in the discussion section, because we tried to shorten this section.
- The Discussion should be shortend by at least 50%
REPLY: We shortened the Discussion section by almost 50%.
- The gold standard and criteria for final diagnosis need to be clearly presented.
REPLY: A paragraph was added (lines 179-189) to address this point.
- The aim of the study needs to be clearly presented - if understood correctly the case series includes patients who all have Charcot and a suspicion of additional osteomyelitis and the aim would be the final diagnosis of absence or presence of OM as diagnosed by MRI or WBC. If this is indeed the case then this is what has to be presented.
REPLY: The aim was stated at the beginning of M&M section, but we explained better (lines 96-98) as suggested by the reviewer.
Many more minor issues that will need o be addresed.
REPLY: English language was edited.
Reviewer 2 Report (Previous Reviewer 2)
Comments and Suggestions for AuthorsThe authors have sufficiently addressed my concerns.
Comments on the Quality of English Languageminor editing is recommended.
Author Response
The authors have sufficiently addressed my concerns.
REPLY: We thank the reviewer for the evaluation.
Reviewer 3 Report (Previous Reviewer 3)
Comments and Suggestions for AuthorsThis manuscript has gone through the revision requested by the reviewer.
Comments on the Quality of English Language-
Author Response
This manuscript has gone through the revision requested by the reviewer.
REPLY: We thank the reviewer for the evaluation.
This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsInteresting study, not easy to perform but needs clarifications and more details.
Major comment: what are the imaging studies included in the CC-DFO? If they include MRI and/or WBC scans this gold diagnostic standard needs to be clearly explained and justified.
Additional comments:
1. Introduction: SPECT/CT started in 1999 - it is not an "emerging" technique
2. M&M: with a single woman 44 years old was pregnancy and breastfeeding really an exclusion criterion? The other two female patients were 76y and 83 y old.
3. M&M: explain and detail "challenging" and "uncertain" MRI cases
Comments on the Quality of English Language
None
Reviewer 2 Report
Comments and Suggestions for AuthorsComments
The authors report a small case series of patients with Charcot neuropathy complicated with osteomyelitis. They are combining clinical and imaging criteria to establish the diagnosis of infection.
The main methodological problems are the lack of quantitative evaluation of the findings and the lack of statistical comparison due to the limited number of patients. A positive and negative predictive value could be more useful.
The figures and table should be designated only with their respective number, without the number S.
Specific comments:
Line 17 for the treatment
Line 19 99mTc-HMPAO–WBC SPECT/CT .
Line 20 the challenges in distinguishing these forms. Is not clear. Please improve.
Line 21 for the diagnosis.
Line 24. SPECT-CT and CC-DFO, provide explanation of terms.
Line 28. Surgery in diabetic feet is not tissue sparing. The limits of the disease should be delineated by the imaging.
Line 37. Please provide references throughout the abstract on the prevalence and the clinical presentation of CN.
Line 48. Can be complicated.
Line 51. Tissue culture, despite its limitations is preferable over bone biopsy. Please elaborate.
Line 54 C-reactive protein is probably more useful than the erythrocyte sedimentation rate.
Line 58 Among these. Please delete
Line 69. studies to produce a probability. The meaning is not clear.
Line 79. The primary object of the study should be placed in the last paragraph of the abstract.
Line 87. 30 mmhg. Please correct.
Line 90 endocorporeal. Intracorporeal
Line 109-110 should be deleted.
Discussion
Should start with the main findings of your study (Lines 167-173).
Line 190 was represented by bone. Please improve
Several significant references have not been included in the discussion:
La Fontaine J, Bhavan K, Lam K, Van Asten S, Erdman W, Lavery LA, Öz OK. Comparison Between Tc-99m WBC SPECT/CT and MRI for the Diagnosis of Biopsy-proven Diabetic Foot Osteomyelitis. Wounds. 2016 Aug;28(8):271-8.
Llewellyn A, Kraft J, Holton C, Harden M, Simmonds M. Imaging for detection of osteomyelitis in people with diabetic foot ulcers: A systematic review and meta-analysis. Eur J Radiol. 2020 Oct;131:109215. doi: 10.1016/j.ejrad.2020.109215
Comments on the Quality of English Language
The quality of written English is not satisfactory and should be significantly improved.
Reviewer 3 Report
Comments and Suggestions for AuthorsThis manuscript presents a diagnosis of CN and OM using MRI and SPECT/CT scan of diabetic feet.
1. The authors should present the MRI and SPECT/CT scan images that fall into the classification in Figure 1.
Comments on the Quality of English Language-
