Interview on the diabetic foot with David G. Armstrong, Professor of Surgery at the University of Southern California.
Interview on the diabetic foot with David G. Armstrong, Professor of Surgery at the University of Southern California.
Welcome to the Diabetes Technology Report podcast. I'm David Klonoff. I'm an endocrinologist at UCSF and Sutter Health. Today we've got a very special guest to interview. My colleague, dr David Kerr will introduce himself and our guest.
David Kerr:Hello everyone and welcome to Diabetes Technology Report. What a pleasure to have David Armstrong with us today. We know you extremely well. I think most of the diabetes world are familiar with your work, but just give us a little bit about your background to set the scene.
David Armstrong:My goodness, how far do you want to go back, professor Kerr? Well, I'm a second generation podiatrist. Actually, I'm a toe doctor. I work at the end of the body. I grew up in my father's office clinic in Santa Maria, california, but I am now a professor of surgery at the Keck School of Medicine of USC, looking out the window here in Los Angeles, where even when it's not sunny, it's sunny. So I bring you welcome from Southern California to you Northern California types. Well, thank you so much In my world.
David Kerr:in the UK it was once said that the diabetic fruit is a Cinderella speciality of diabetes care. Do you think I still the case among the perceptions of people who interact with people with diabetes?
David Armstrong:Yeah, you can use a fairy tale, I think, to describe it, but I don't even know if it's a kind of a grim, if you will, fairy tale.
David Armstrong:So how's that?
David Armstrong:There we go Off to a good start, but I think it's a beautiful and elegant way to start, because I guess if you were sort of not writing a fairy tale, but if you were like an evil deity and you were sort of contemplating it to humanity, you wouldn't think about something like some of these terrible pandemics that we've gone through.
David Armstrong:You wouldn't think of HIV, aids, you wouldn't even think of cancer or a heart attack, although these are horrible conditions. You think of something that was silent and sinister, and so you might start with a non-communicable disease, not like cancer or heart disease or cardiovascular disease, but like diabetes. And then, within diabetes, if you were trying to create the most kind of quiet, silent, sinister syndrome, you'd pick the area that's sort of at the end of the body covered by a shoe or a sock, and so from that standpoint it is a Cinderella specialty. But really the problem is how quiet and silent this problem is and our efforts really are to try to maybe add a little bit of volume to that, to try to help our patients move through the world a little bit better, hopefully with both limbs.
David Kerr:So do you think it's changed recently, though, with the use of technology? Do you think, I guess, is technology making a contribution to reducing the burden related to food disease for people with diabetes?
David Armstrong:Yeah, that's a great question. By the way, even if it wasn't a great question, I would say that's a great question, but that is a great question and what I would say is I think this is a really exciting time and my whole life I've always been kind of gadget oriented. I mowed lawns in the 70s to buy my first Timex Sinclair 1000 from Popular Mechanics and I've had a machine ever since then modding these things. But to see where things are headed now, I don't think I've ever been more enthusiastic. Now, I warn you, my waking state is kind of enthusiastic.
David Armstrong:But I see now this inexorable kind of linkage and merger of consumer electronics and medical devices and I see that benefiting our patients and I've never now many of our patients, quite literally. I've just come from our clinic. I'm looking at it right out of our window. It's safer for my patients, by the way, when I'm here, separated by a couple of windows from my patients, I think statistically. But for my patients who are like my family, I mean, many of our patients can't afford many of these technologies yet and we're really working our hardest to try to create technologies and ideas and methodologies that allow them to get at these things, to help them kind of move through the world better. So that was a long kind of soliloquy by saying, yes, I'm really excited, but there are definite issues that we have to get to help our patients manage their day to day, David.
David Klonoff:what are some of the technologies that you've used that have helped the most people?
David Armstrong:Yeah. So I've always thought, since I was a student, that maybe we could dose activity just like we dose a drug, and if you're ever taking pharmacology you often have a graph. Imagine this is really boring on a podcast. Imagine if you had a graph and you had like a little peak where you could have some toxicity. Then you have a safe range and then you have what's called a trough where you don't get the benefit and maybe there could be a safe range of activity. And what we always thought was that if we could ever measure activity, then maybe we could dose activity just like we dose a drug. For our patients who, with diabetes, who often will have neuropathy, they could develop a wound and the way you develop a wound is by basically repetitive steps and you can wear a hole in your foot like you'd wear a hole in a sock. So too many steps, you're out of your safe range. Too few steps, you don't get the cardio metabolic benefit of being active or just the functional benefit of being active. So there's a safe range. But we've always thought if we could only measure it, we could manage it, we could help people move into that range. And now, of course, just plain and simple wearable step counters and activity monitors. They used to be so exotic and now many, if not most, of our patients have them, so that we start there and we actually.
David Armstrong:In fact, I just left clinic where one of my partners, dr Laura Shin, is up there right now, but Dr Stephanie Wolffel is a world-class physical therapist or, if you're British, david to translate, physiotherapist. I know we have two peoples separated by a common language. But, steph, we've just had a patient heal in one of our studies really cool smart boot study. Right after that, stephanie just saw him and was talking to him about his Fitbit which he actually got for being in one of these studies and was working and looking at his last two weeks of activity and was going to ease him into a little bit better activity over the following few weeks and the following few weeks. So that sounds so simple, but yet if you're really measuring it, you can manage it. So that's one tool, dr Klonoff, and another one is well, how can you tell if someone's reaching kind of a dangerous range and so you know if you want to sound smart and who doesn't want to sound smart? I'm trying and I'm failing, but I think there's probably hope for everyone listening on the podcast and you're talking about any kind of disease, any kind of chronic disease, just sort of you know.
David Armstrong:Take a sip, whatever it is you're drinking and and say inflammation, and walk away and you'll be right, right, and they'll say, boy, she's smart or he's smart. Well, inflammation is kind of the bane of our existence as well, and when people are banging on their feet, they a wound, as one of my mentors, paul Brand, used to say a wound will heat up before it breaks down. And you can detect kind of these asymmetrical or these asymmetries and inflammation through just a simple thermometer. Now, these thermometers used to be really expensive thousands of dollars when I was studying them in the 90s, but they have gotten progressively less and less expensive.
David Armstrong:And I'm not going to say thank goodness for the pandemic, but one of the things about the pandemic that was good was that all of these thermometers that people were using to measure people's you know foreheads often capacious foreheads like Dr Kalanov's, not quite you can use on the foot as well, from some distance. Now there are ways to do it even more accurately, but people can literally check their skin temperatures and dose their activity Remember we were talking about that just as they might dose their insulin by checking their glucose. So a thermometer, a simple one, is like a glucometer for the foot, and you marry those two things together and the data now have been emerging such that it's really exciting, because there are simple things that we can use, but then there are more exotic ones that you can put into the home, and there are startups that are not even startups, they're more mature companies that have come out doing this as well. So it's really exciting just to be working in those two areas.
David Kerr:So you have the Physical activity measuring device. You have the temperature measuring device. What about capture photography imaging? Is it affected or inflamed? Are we making progress in that area?
David Armstrong:Yeah, well, remarkably, you know there. I'm not sure how much the audience knows about wounds, I'm not sure you it's. It would probably be cruel and unusual to talk to you too much about this, but I'll just tell you that, look, every second now, someone develops a diabetic foothold or somewhere around the world. Right half of these get infected and that's why there's an amputation every 20 seconds. Just to give you these numbers, these data, and One of the things that we like to Do when we're trying to assess wound healing is measure size of the wound and, remarkably, around the world we haven't done as good a job as we could. And you know, we've been taking pictures of wounds for you know, decades now and but Over the last maybe 20 years, planimetry, you know ways to trace the wounds. That has gotten better, and now there are companies and there are apps that can actually measure the wound better and better. It's still absolutely not perfect, but it's getting better and better, and so those tools are really Um extremely helpful because we can share a patient's trajectory and healing with the patient. And you know, just like you, you know, if you think about a growth chart for a, for a, a young boy or girl, uh, this is like a growth chart in reverse. You know, you can show the, you could show the wound getting smaller and smaller, and that is really Motivating, I think if you want to try to do something with your patient and not to them, so that kind of photography is helpful.
David Armstrong:Um, one other thing we've been doing that's a lot of fun has been what we call the foot selfie program, and that sounds hilarious because it kind of is. You know, we're in a Conceptual way, but you know I get so many photos of people's feet every day. I know it sounds ridiculous, but people, you'll send me them, you know they say, well, what about this and what about that? And uh, um, and so a medical student several years ago who's now starting up as a young plastic surgeon Mark's word load in georgetown, but he came up to us he said, hey, why don't we make An app to make those foot selfies kind of a A thing? So what we did was and by way of mark Mark, was to actually create just a little app that would help take people's photographs, even if they were blind, and and they would just have to say yes when the photo was being taken.
David Armstrong:And every Monday at 7 am. We take all those photos and correlate them and we have what we call Foot selfie rounds and we go through you can go through. It's amazing like 100 of these photos In just a few minutes, even without an AI based sherpa, which obviously you know we're adding on to this. But Not a day goes by when we do this where we don't spot something and and and, quite literally stop a hospitalization and it's just, it's essentially free. It was so wonderful, um, and so that whole thing is becoming a a really exciting kind of Uh program and you know we're working with colleagues here, right about 500 meters for you, david Kerr, away at uh, la, at our LA general hospital, um, with our colleagues in our specialty clinic as well, or our speciality clinic.
David Klonoff:David, we're using artificial intelligence now to interpret glucose results. Are you using artificial intelligence in your work?
David Armstrong:Yeah, that's another great question as well. We are using AI not only on wound measurement, but we're also using it to help identify characteristics within a wound, so that's one of the first things that we did. There was what was called a diabetic foot grand challenge. That was initially funded. It was run by a woman, mojhun Yap. She's great in Manchester Metropolitan University and she, along with NVIDIA, sponsored what was called the diabetic foot grand challenge, which was to try to identify, using deep learning, slash AI to identify a foot ulcer and be able to measure it in under 10 seconds, and then that actual library was to be published online and I'm happy to say that's really been taken off.
David Armstrong:So that's one characteristic of this. We've also done this for pressure injuries. We've also, with various companies and we're doing it as well looking at and trying to crawl through electronic medical records to identify characteristics associated with poor outcome in people that are at high risk for amputation, and we published on all of those right now, and it's very exciting because I think we're really seeing things that are not just interesting but they're actionable, and that's the big secret, isn't it, dr Kalanov? We don't want this information where there's paralysis of analysis, where we just have a pretty picture and we say, well, what do I do with this? So that is terrific.
David Klonoff:Well, David, you've covered a variety of technologies. I have one last question for you when do you think the field of foot disease will be in the next five to 10 years from now?
David Armstrong:Well, I'm exceedingly excited about it. I think we're starting to see now real. You know, people talk about personalized medicine and I think now we're really starting to see hyper-personalized medicine that we can give to our patients. I told you about kind of personalizing someone's kind of activity profile, but there's also aspects of personalizing a person's surgery to the point where we're now able to identify a 3D print implants that we're using. We're also able to do the same thing, even more importantly, to things like shoes, insoles, braces, and marrying all of that into something that's hyper-local and hyper-personal. So the sky's the limit, but it's exciting.
David Klonoff:Well, this was really interesting. David, thank you for speaking with us and this completes our interview. First, thank you for participating and we look forward to our listeners joining us on the next Diabetes Technology Report. This podcast is available on Spotify, the Apple Store and the Diabetes Technology Society website. So we'll see you later and bye-bye. Bye-bye.
David Armstrong:Take care.