Akinci B, Yener S, Yesil S, Yapar N, Kucukyavas Y, Bayraktar F. Acute phase reactants predict the risk of amputation in diabetic foot infection. J Am Podiatr Med Assoc.  2011 Jan-Feb; 101(1): 1-6. (PubMed ID: 21242464)

WHY did the authors undertake this study?
Both diabetic foot infection and osteomyelitis are by in large clinical diagnoses, although we utilize many objective laboratory and radiographic tools to help us reach these diagnoses. Acute phase reactants, such as the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and white blood cell (WBC) count, generally increase in the setting of infection and inflammation. The aim of this study was to determine whether any of these acute phase reactants are predictive in determining the outcome of diabetic foot infections.  

HOW did they attempt to answer this question?
The primary outcome measure of the study was whether or not a cohort of diabetic patients presenting with an infected diabetic foot ulceration eventually underwent an amputation (both minor or major). Comparative statistics were performed on a host of variables to determine any differences between those patients who eventually had an amputation versus those who did not require amputation. 

WHAT were the specific results?
Statistically significant differences were found with respect to several factors between the two groups.  Patients requiring amputation were more likely to have limb ischemia, osteomyelitis, and deeper ulcerations.  They also had statistically significant higher baseline CRP, post-treatment CRP, baseline ESR, post-treatment ESR, baseline WBC, and post-treatment WBC, as well as lower post-treatment albumin values.  The value with the strongest association with amputation was post-treatment CRP.

HOW did the authors interpret these results?
From these results, the authors concluded that pre- and post-treatment elevation of acute phase reactants may be used to help predict the risk of amputation in patients presenting with infected diabetic foot ulcerations.

Collinge C, Reddix R. The incidence of wound complications related to negative pressure wound therapy power outage and interruption of treatment in orthopaedic trauma patients. Journal of Orthopedic Trauma. 2011 Feb; 25(2): 96-100.

WHY did the authors undertake this study?
In many ways negative pressure wound therapy (NPWT) has revolutionized wound care, but it does not come without its own set of potential intrinsic complications and pitfalls. One of these potential problems is unexpected loss of power to the device resulting in a wound left under an unrecognized occlusive dressing. The authors of this study aimed to examine if unexpected interruption of NPWT would result in greater wound complications when used for orthopedic indications.

HOW did they attempt to answer this question?
The primary outcome measure of this study was incidence of development of a wound complication (defined as superficial infection, deep infection, loss of graft requiring debridement, need for regrafting) in a cohort of patients. One hundred twenty three consecutive orthopedic trauma patients were identified at two trauma centers that underwent NPWT treatment. Of these, 12 experienced an unexpected failure of treatment when the device had an unrecognized loss of power.

WHAT were the specific results?
Patients who experienced an unrecognized loss of NPWT had a statistically significant greater incidence of development of wound complications.

HOW did the authors interpret these results?
Based on these results, the authors concluded that interruption of NPWT may lead to increased patient complications. Although it should remain a valuable asset in the treatment of wounds, patients and staff should be educated on the consequences of this potential problem.

Let’s take a closer look at the topic of “scientific” advertising as it applies to these two journals.  I became (probably unnecessarily) enraged when flipping through this edition of JAPMA (2011 Jan-Feb) and came across the full-page advertisement for Arthrex on the back cover. By itself, an advertisement shouldn’t be particularly enraging of course! All scientific journals have advertisements scattered throughout their editions, as do the online versions of these publications. Although this “eZine” that you are reading right now only has one “primary sponsor” at the top and bottom of the page, most of the eZines you receive from PRESENT have a long list of “sponsors” at the end of the editions. There’s nothing particularly enraging about Arthrex of course either. It is certainly a reputable company that has been good to our profession over the years with a lot of effective products.

What was enraging, however, was that the advertisement declared that the Arthrex TightRope® device was, and this is a direct quotation, the “gold standard for syndesmotic fixation”. The advertisement also declared that the TightRope® device was “3.5 times stronger than the competition” in no uncertain terms. What we don’t have is any data to back up these declarations that were posted in large font and bold print on the back of what is supposed to be one of our profession’s leading scientific publications.

If TightRope® is in fact the “gold standard” for syndesmotic fixation, then I certainly didn’t get the memo, read that article, or hear that lecture. I think that most people would argue that there is actually not a gold standard for syndesmotic fixation, and although different surgeons certainly have differing opinions and preferences, this would represent Level V evidence at best. 

We are also told that TightRope® is “three times stronger” than the competition, but we are not told what that competition is, how it was measured, or who measured it. We are instead presented with a primarily unlabeled graph in support of this declaration, but no actual statistics or direct references to peer-reviewed publications. 

My point is that this particular advertisement really went against the very principles of evidence-based medicine that JAPMA (and our other peer-reviewed scientific publications) should stand for! In theory, the editor of a journal would never allow the “gold standard” or “three times stronger” statements to be published within the journal without backing up these declarations with appropriate references and an actual study with statistical analysis. It’s a little ironic that the advertisements printed on either side of the evidence-based articles don’t have to live up to the same editorial standards. 

Again, I’m not intending to pick on JAPMA or Arthrex specifically, more so making a general statement about the product infusion into our profession’s continuing education. At the recent ACFAS conference, for example, the organization appropriately proudly toted that there were 200 scientific poster abstracts on display demonstrating the cutting edge of foot and ankle surgery science. What wasn’t mentioned was that you had to walk through over 100 booths/exhibitions in order to get to these posters!  While typing this “critical analysis” section, I pulled up the JAMA website and had to scroll through an advertisement for Aricept before getting to any of the articles. And just for fun, I counted 16 pages of advertisements in a recent edition of JFAS before I actually got to the first article.

All of our national organizations and publications are appropriately moving towards an evidence-based approach to continuing education, but it does come at a certain cost. lthough unfortunately unrealistic, it would be nice to hold everyone to the same standards when they are purporting “science”.  I would simply like to remind readers that your critical analysis can’t end on the last page of a journal article, but instead has to continue into all portions of your professional lives.