The "Balgrist Score" for evaluation of Charcot foot: a predictive value for duration of off-loading treatment

OBJECTIVE To develop a new magnetic resonance imaging(MRI) scoring system for evaluation of active Charcot foot and to correlate the score with a duration of off-loading treatment ≥ 90 days. METHODS An outpatient clinic database was searched retrospectively for MRIs of patients with active Charcot foot who completed off-loading treatment. Images were assessed by two radiologists (readers 1 and 2) and an orthopedic surgeon (reader 3). Sanders/Frykberg regions I-V were evaluated for soft tissue edema, bone marrow edema, erosions, subchondral cysts, joint destruction, fractures, and overall regional manifestation using a score according to degree of severity (0-3 points). Intraclass correlations (ICC) for interreader agreement and receiver operating characteristic analysis between MR findings and duration of off-loading-treatment were calculated. RESULTS Sixty-five feet in 56 patients (34 men) with a mean age of 62.4 years (range: 44.5-85.5) were included. Region III (reader 1/reader 2: 93.6/90.8%) and region II (92.3/90.8%) were most affected. The most common findings in all regions were soft tissue edema and bone marrow edema. Mean time between MRI and cessation of off-loading-treatment was 150 days (range: 21-405). The Balgrist Score was defined in regions II and III using soft tissue edema, bone marrow edema, joint destruction, and fracture. Interreader agreement for Balgrist Score was excellent: readers 1/2: ICC 0.968 (95% CI: 0.948, 0.980); readers 1/2/3: ICC 0.856 (0.742, 0.917). A cutoff of ≥ 9.0 points in Balgrist Score (specificity 72%, sensitivity 66%) indicated a duration of off-loading treatment ≥ 90 days. CONCLUSION The Balgrist Score is a new MR scoring system for assessment of active Charcot foot with excellent interreader agreement. The Balgrist Score can help to identify patients with off-loading treatment ≥ 90 days

The “Balgrist Score” for evaluation of Charcot foot: a predictive value for duration of off-loading treatment

Objective To develop a new magnetic resonance imaging(MRI) scoring system for evaluation of active Charcot foot and to correlate the score with a duration of off-loading treatment ≥ 90 days. Methods An outpatient clinic database was searched retrospectively for MRIs of patients with active Charcot foot who completed off-loading treatment. Images were assessed by two radiologists (readers 1 and 2) and an orthopedic surgeon (reader 3). Sanders/Frykberg regions I–V were evaluated for soft tissue edema, bone marrow edema, erosions, subchondral cysts, joint destruction, fractures, and overall regional manifestation using a score according to degree of severity (0–3 points). Intraclass correlations (ICC) for interreader agreement and receiver operating characteristic analysis between MR findings and duration of off-loading-treatment were calculated. Results Sixty-five feet in 56 patients (34 men) with a mean age of 62.4 years (range: 44.5–85.5) were included. Region III (reader 1/reader 2: 93.6/90.8%) and region II (92.3/90.8%) were most affected. The most common findings in all regions were soft tissue edema and bone marrow edema. Mean time between MRI and cessation of off-loading-treatment was 150 days (range: 21–405). The Balgrist Score was defined in regions II and III using soft tissue edema, bone marrow edema, joint destruction, and fracture. Interreader agreement for Balgrist Score was excellent: readers 1/2: ICC 0.968 (95% CI: 0.948, 0.980); readers 1/2/3: ICC 0.856 (0.742, 0.917). A cutoff of ≥ 9.0 points in Balgrist Score (specificity 72%, sensitivity 66%) indicated a duration of off-loading treatment ≥ 90 days. Conclusion The Balgrist Score is a new MR scoring system for assessment of active Charcot foot with excellent interreader agreement. The Balgrist Score can help to identify patients with off-loading treatment ≥ 90 days.ISSN:0364-2348ISSN:1432-216

Muscle atrophy in diabetic patients with Charcot foot: a case-control study

PurposeTo evaluate the distribution and severity of muscle atrophy in diabetic patients with active Charcot foot (CF) compared to diabetic patients without CF. Furthermore, to correlate the muscle atrophy with severity of CF disease.Material/methodsIn this retrospective study, MR images of 35 diabetic patients (21 male, median:62.1 years +/- 9.9SD) with active CF were compared with an age- and gender-matched control group of diabetic patients without CF. Two readers evaluated fatty muscle infiltration (Goutallier-classification) in the mid- and hindfoot. Furthermore, muscle trophic (cross-sectional muscle area (CSA)), intramuscular edema (none/mild versus moderate/severe), and the severity of CF disease (Balgrist Score) were assessed.ResultsInterreader correlation for fatty infiltration was substantial to almost perfect (kappa-values:0.73-1.0). Frequency of fatty muscle infiltration was high in both groups (CF:97.1-100%; control:77.1-91.4%), but severe infiltration was significantly more frequent in CF patients (p-values: < 0.001-0.043). Muscle edema was also frequently seen in both groups, but significantly more often in the CF group (p-values: < 0.001-0.003). CSAs of hindfoot muscles were significantly smaller in the CF group. For the flexor digitorum brevis muscle, a cutoff value of 139 mm(2) (sensitivity:62.9%; specificity:82.9%) in the hindfoot was found to differentiate between CF disease and the control group. No correlation was seen between fatty muscle infiltration and the Balgrist Score.ConclusionMuscle atrophy and muscle edema are significantly more severe in diabetic patients with CF disease. Muscle atrophy does not correlate with the severity of active CF disease. A CSA < 139 mm(2) of the flexor digitorum brevis muscle in the hindfoot may indicate CF disease.ISSN:0364-2348ISSN:1432-216

Statins and the risk of cancer after heart transplantation

BACKGROUND: Although newer immunosuppressive agents, such as mTOR (mammalian target of rapamycin) inhibitors, have lowered the occurrence of malignancies after transplantation, cancer is still a leading cause of death late after heart transplantation. Statins may have an impact on clinical outcomes beyond their lipid-lowering effects. The aim of the present study was to delineate whether statin therapy has an impact on cancer risk and total mortality after heart transplantation. METHODS AND RESULTS: A total of 255 patients who underwent heart transplantation at the University Hospital Zurich between 1985 and 2007 and survived the first year were included in the present study. The primary outcome measure was the occurrence of any malignancy; the secondary end point was overall survival. During follow-up, a malignancy was diagnosed in 108 patients (42%). The cumulative incidence of tumors 8 years after transplantation was reduced in patients receiving a statin (34% versus 13%; 95% confidence interval, 0.25-0.43 versus 0.07-0.18; P<0.003). Statin use was associated with improved cancer-free and overall survival (both P<0.0001). A Cox regression model that analyzed the time to tumor formation with or without statin therapy, adjusted for age, male sex, type of cardiomyopathy, and immunosuppressive therapy (including switch to mTOR inhibitors or tacrolimus), demonstrated a superior survival in the statin group. Statins reduced the hazard of occurrence of any malignancy by 67% (hazard ratio, 0.33; 95% confidence interval, 0.21-0.51; P<0.0001). CONCLUSIONS: Although it is not possible to adjust for all potential confounders because of the very long follow-up period, this registry suggests that statin use is associated with improved cancer-free and overall survival after cardiac transplantation. These data will need to be confirmed in a prospective trial

36-month clinical outcomes of patients with venous thromboembolism: GARFIELD-VTE

Background: Venous thromboembolism (VTE), encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of morbidity and mortality worldwide.Methods: GARFIELD-VTE is a prospective, non-interventional observational study of real-world treatment practices. We aimed to capture the 36-month clinical outcomes of 10,679 patients with objectively confirmed VTE enrolled between May 2014 and January 2017 from 415 sites in 28 countries.Findings: A total of 6582 (61.6 %) patients had DVT alone, 4097 (38.4 %) had PE +/- DVT. At baseline, 98.1 % of patients received anticoagulation (AC) with or without other modalities of therapy. The proportion of patients on AC therapy decreased over time: 87.6 % at 3 months, 73.0 % at 6 months, 54.2 % at 12 months and 42.0 % at 36 months. At 12-months follow-up, the incidences (95 % confidence interval [CI]) of all-cause mortality, recurrent VTE and major bleeding were 6.5 (7.0-8.1), 5.4 (4.9-5.9) and 2.7 (2.4-3.0) per 100 person-years, respectively. At 36-months, these decreased to 4.4 (4.2-4.7), 3.5 (3.2-2.7) and 1.4 (1.3-1.6) per 100 person-years, respectively. Over 36-months, the rate of all-cause mortality and major bleeds were highest in patients treated with parenteral therapy (PAR) versus oral anti-coagulants (OAC) and no OAC, and the rate of recurrent VTE was highest in patients on no OAC versus those on PAR and OAC. The most frequent cause of death after 36-month follow-up was cancer (n = 565, 48.6 %), followed by cardiac (n = 94, 8.1 %), and VTE (n = 38, 3.2 %). Most recurrent VTE events were DVT alone (n = 564, 63.3 %), with the remainder PE, (n = 236, 27.3 %), or PE in combination with DVT (n = 63, 7.3 %).Interpretation: GARFIELD-VTE provides a global perspective of anticoagulation patterns and highlights the accumulation of events within the first 12 months after diagnosis. These findings may help identify treatment gaps for subsequent interventions to improve patient outcomes in this patient population