Where Art Thou Diabetic Limb Salvage Data?:A Literature Review and Subsequent Challenge to the Diabetic Limb Salvage Community

Christine K. Nolan, DPMa, KeriAnne Spiess, DPMa, and Andrew J. Meyr, DPMb

aResident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PennsylvaniabAssociate Professor, Department of Podiatric Surgery, Temple University School of Podiatric Medicine, Philadelphia, Pennsylvania (AJMeyr@gmail.com)

Conclusions and Take Home Points

ResultsMethodsPurposeA multidisciplinary team approach to the diabetic foot has been established to lead towards improved overall patient care, decreased rates of major limb amputation and increased rates of wound healing. When communicating efficiently as a team, each individual specialty can bring to the patient unique and individual perspective, education, training and experience. This is generally a good thing, but could potentially lead to fragmentation of the medical literature specific to the diabetic foot if each member of the team looks to publish within their own specialty. The objective of this observational investigation was to examine the diabetic foot medical literature with a specific aim to assess (1) the quantity that is published on the diabetic foot, and (2) the location of the published articles.

A literature search was performed on 3/1/13 via PubMed with the search terms (“diabetes” or “diabetic”) and (“toe” or “foot” or “ankle” or “leg” or “limb” or “infection” or “ulcer” or “wound” or “osteomyelitis” or “salvage” or “amputation”) with a publication date range between 1/1/2012 and 12/31/2012.

Returned article abstracts were then reviewed and judged by a two-person panel as to whether or not the article was “relevant to a medical professional working within the field of diabetic foot disease.”

Those articles deemed to be “relevant” were then classified by which specific journal the article was published in, as well as the general medical specialty/primary readership of that journal.

A total of 2616 articles were returned within the inclusion criteria of the search. These included 303 review articles, 131 clinical trials, 149 comparative studies, 57 randomized controlled trials, 7 practice guidelines, 27 meta-analyses (including 3 Cochrane reviews), 157 foreign language articles, and 441 articles that were available free through Pubmed.

Of these, 1286 were judged by our panel to be “relevant to a medical professional working within the field of diabetic foot disease”. These articles were published in a

total of 659 different journals (range 1-41 relevant publications/journal/year).

• As with any scientific investigation, readers are encouraged to review and critically assess the study design and specific results in order to reach their own independent conclusions, while the following represents our conclusions based on the preceding data. It is also important to note that as scientists we never consider data to be definitive, but we do think there are some interesting findings presented here worthy of attention and future investigation:

• We think these results highlight both the incredible quantity, as well as the surprising variety of published data within the diabetic limb salvage community. To put these results in a more applicable light, medical professionals working with the diabetic foot would have to read an average 3.5 articles/day and review nearly 13 journals/week to get through what we have defined as “relevant” new published literature. We were also surprised at the quantity of published data within what we defined as “general medicine/endocrinology” and “basic science/research” publications (over 350 different journals within these two designations alone!).

• We also think these results represent a challenge to the diabetic limb salvage community in terms of organization of our data. We think it is reasonable to conclude that we need (1) some way of controlling this data expansion, and (2) an effective means to disseminate newly published relevant information to the average practitioner working with the diabetic foot.

• And on a more individual level, we personally changed our practice based on these results by now holding monthly multispecialty journal clubs, where the different medical specialties that comprise our Limb Salvage Center present recent data published within their respective fields.

Categories of Journal Medical Specialty/Readership

Number of Different Journals(n=659)

“Podiatric/Orthopedic” 26 (3.9%; 26/659)

“Plastic Surgery” 11 (1.7%; 26/659)

“Vascular Medicine/Surgery” 33 (5.0%; 26/659)

“Other Surgical” 58 (8.8%; 26/659)

“General Medicine/Endocrinology” 250 (37.9%; 26/659)

“Diabetes-specific” 23 (3.5%; 26/659)

“Infectious Disease” 37 (5.6%; 26/659)

“Wound-specific” 12 (1.8%; 26/659)

“Radiology” 11 (1.7%; 26/659)

“Basic Science/Research” 114 (17.3%; 26/659)

“Other/Misc” 105 (15.9%; 26/659)

Internationally Published 31.9% (210/659)

Specific Journal Titles Publishing >10 “Relevant” Articles During the 2012 Data

Collection Period (n=26; Listed Alphabetically)*

Advances in Clinical and Experimental Medicine (0.293)

Angiology (1.647)

Atherosclerosis (3.706)

Diabetic Foot and Ankle (N/A)

Diabetic Medicine (3.241)

Diabetes (8.3)

Diabetes Care (8.1)

Diabetes/Metabolism Research and Reviews (2.968)

Diabetes Research and Clinical Practice (2.741)

Diabetes Technology and Therapeutics (2.205)

Diabetologia (6.487)

European Journal of Vascular and Endovascular Surgery (2.820)

The Foot (N/A)

Foot and Ankle International (1.474)

International Journal of Lower Extremity Wounds (1.250)

International Wound Journal (1.6)

Journal of the American Podiatric Medicine Association (0.57)

Journal of Cardiovascular Surgery (1.351)

Journal of Diabetes and its Complications (2.076)

Journal of Foot and Ankle Surgery (0.860)

Journal of Vascular Surgery (2.879)

Journal of Wound Care (N/A)

PLOS One (3.73)

Seminars in Vascular Surgery (1.015)

Wound Repair and Regeneration (2.757)

Chinese Journal of Burns (N/A)

*Most recent published impact factor from journal

Table 1: We identified 1286 “relevant” articles in 659 different journals published during 2012. This table classifies the 659 different journals based on their general medical specialty/primary readership.

Table 2: We identified 26 journals that published at least 10 “relevant” articles during 2012. This table simply lists these journals alphabetically. Does anyone at this conference regularly read every journal on this list?