In this video, David Armstrong, PhD, DPM, discusses how DHACM treatment led to reductions in amputations, hospital readmissions, and cost for patient with diabetic ulcers.
David G. Armstrong, DPM, MD, PhD
A recent meta-analysis in the International Wound Journal took a closer look at vitamin D deficiency and patients with diabetic foot ulcers (DFUs). Lin and colleagues’ literature search initially included over 7,500 subjects with diabetes.1 They found that those subjects with diabetic foot ulcers had significantly lower levels of vitamin D, higher prevalence of vitamin D deficiency (less than 50 nmoL/L) and more severe vitamin D deficiency than those without DFU … read more
David G. Armstrong, DPM, MD, PhD
Information about foot care provided to people with diabetes with or without their partners can have an impact on recommended foot care behavior. Think about this the next time you’re educating your patient and his/her family!
A recent study published in Applied Psychology: Health and Well-Being looked at these potential behavior differences. In a randomized parallel arm design trial, they split the cohort into two groups: one where providers gave information sheets to patients with diabetes and their spouses (dyad, n=64) and one where the information only went to the patients (individual, n=69). The patients then self-reported how many days a foot check occurred, and how many days foot protection measures took place … read more
David G. Armstrong, Professor of Surgery at the Keck School of Medicine of University of Southern California joined physicians, surgeons, engineers and scientists from around the world for the International Foot and Ankle Biomechanics conference. Originally scheduled for Rio De Janiero, Brazil in April of 2020 and chaired by Prof. Isabelle Sacco, the symposium- known as iFAB- was rescheduled in a virtual format. Armstrong, who gave the lecture outside of the high-risk clinics at the National Rehabilitation Center at Rancho Los Amigos, gave a keynote to participants from 5 continents. It was particularly poignant that the lecture be given at Rancho … read more
Aims The aim of our study was to estimate the overall rate of first hospitalizations for diabetic foot (DF) regardless of the out- come in amputations, as well as the mortality rate with their determinants in the period 2012–2016 in Piedmont Region in Italy. Methods The study included all the subjects registered in the Regional Diabetes Registry and alive as at January 1, 2012. DF cases were identified by record linkage with the regional hospital discharge database. Incident cases of diabetic foot were followed up for mortality … read more
Remission — rather than repair — needs to be the goal of treatment, according to Dr. David Armstrong, whose report on diabetic foot ulcers appears in the New England Journal of Medicine … Foot ulcers are a prevalent complication for millions of people with diabetes. Estimates indicate that as many as one-third of people with the disease will develop at least one foot ulcer over the course of their lifetime. These wounds can lead to further complications such as strokes, heart attacks, infections, loss of limbs and premature death … Yet, the morbidity and mortality directly associated with foot ulcers often go unrecognized by physicians and patients alike. Currently, the clinical focus is on repairing an ulcer’s surrounding tissue and healing the wound … read more
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David Armstrong faced a predicament. He had a patient with an open wound that he needed to clean to remove dead tissue that could prevent proper healing, or worse. Infection could lead to severe pain and require limb amputation. But he didn’t have access to an operating room. Left with few other choices, he turned to an unexpected surgical assistant: maggots … While this scene might seem like one that unfolded on the front lines of the US Civil War or in a remote field hospital, Armstrong is actually a present-day surgeon at the University of Southern California. He is one of many clinicians turning to medical maggots as a tool for treating challenging wounds … read more
The authors took a closer look at adherence to footwear usage when patients with diabetes at high-risk for ulceration had custom-made shoes.1 Researchers assessed the percentage of overall steps during which subjects wore their custom-made shoes indoors and outdoors at baseline, 1-, and 12-months post-shoe dispensing. They created two cohorts based on indoor baseline adherence to shoe gear, less than 80% (primary group, n = 23) and greater or equal to 80% (secondary group n = 8). The authors also looked at peak plantar pressures of custom vs. non-custom indoor footwear, patient-related usability of the custom shoes, and ulcer recurrence at 12 months … read more
Patients with a diabetic foot ulcer who received probiotic supplementation for 12 weeks experienced faster wound healing coupled with an improved glycemic and lipid profile compared with patients assigned placebo, according to findings from a randomized controlled trial … Sima Mohseni, of the infectious diseases and tropical medicine research center at Babol University of Medical Sciences in Iran, and colleagues analyzed data from 60 adults aged 40 years to 85 years with grade 3 diabetic foot ulcer, who randomly received either probiotic supplementation (n = 30) or placebo (n = 30) daily for 12 weeks between March and June 2016. Probiotic capsules contained lactobacillus acidophilus, lactobacillus casei, lactobacillus fermentum and Bifidobacterium bifidum. All participants also underwent standard treatment for wound care. Participants provided blood samples at baseline and 12 weeks and 3-day dietary records at baseline. Wound healing and glucose parameters served as the primary outcome … read more
New guidelines recommend healthcare providers develop and implement an individualized nutrition care plan for individuals with diabetes with or at risk of a DFU
New guidelines endorsed by the American Limb Preservation Society highlighted the importance of nutrition in wound healing for adults with diabetes, who also experience diabetic foot ulcers (DFU).
The guidelines stated that nutritional interventions were “recommended for all patients who could benefit now or in the future from nutritional care.” As such, healthcare providers should develop and implement an individualized nutrition care plan for individuals with or at risk of a DFU, who are additionally malnourished or at risk of malnutrition … read more
New guidelines endorsed by the American Limb Preservation Society highlighted the importance of nutrition in wound healing for adults with diabetes, who also experience diabetic foot ulcers (DFU) … The guidelines stated that nutritional interventions were “recommended for all patients who could benefit now or in the future from nutritional care.” As such, healthcare providers should develop and implement an individualized nutrition care plan for individuals with or at risk of a DFU, who are additionally malnourished or at risk of malnutrition … read more
A recent systematic review in the American Journal of Medicine aims to challenge the dogma surrounding antibiotic therapy for certain types of infections, including osteomyelitis.1 This constitutes superb work from Wald-Dickler and coworkers, adding to the growing body of evidence that (to coin a phrase from senior author Brad Spellberg, MD) shorter may be better and oral greater than IV … Researchers set out to evaluate if current data supports long-standing tenets regarding the superiority of IV antibiotics for the full treatment course for osteomyelitis, bacteremia and infective endocarditis. Their review included 7 randomized controlled trials regarding osteomyelitis, specifically. None of the 21 total studies among all examined infections demonstrated superiority of IV-only antibiotic treatment … read more
Skin wounds heal by coordinated induction of inflammation and tissue repair, but the initiating events are poorly defined. Here we uncover a fundamental role of commensal skin microbiota in this process and show that it is mediated by the recruitment and the activation of type I interferon (IFN)-producing plasmacytoid DC (pDC). Commensal bacteria colonizing skin wounds trigger activation of neutrophils to express the chemokine CXCL10, which recruits pDC and acts as an antimicrobial protein to kill exposed microbiota, leading to the formation of CXCL10–bacterial DNA complexes … read more
Excellent continued efforts in elucidating the role that perturbation of the wound matrix (via negative pressure wound therapy (NPWT)) has on angiogenesis, healing and regeneration. A recent study in Molecular Medicine Reports used label‑free quantitative mass spectrometry to analyze differences in granulation tissue protein expression profiles before and after NPWT for patients with diabetic foot ulcers (DFUs).1 They aimed to take a closer look at how NPWT promotes DFU healing. As such, the study identified multiple novel proteins altered by NPWT, paving the way for future studies in this area … read more
A series of great informational graphics from Dr. Armstrong …. read more
A growing body of research, as well as first-hand accounts from clinicians on the ground, indicate that a significant percentage of patients with chronic wounds have delayed preventative and emergent wound care during the COVID-19 pandemic.1 While it will take time to assess the full impact of these trends, existing evidence suggests delayed wound care can result in more severe infections, increased hospital admissions, and lead to more amputations.2 Therefore, it will be critical for providers, hospitals, outpatient departments, payers and policymakers to understand and plan for a surge in patients with untreated and unmanaged non-healing wounds and related acute-on-chronic complications as a result of delayed care during the COVID-19 pandemic … read more
Remission — rather than repair — needs to be the goal of treatment, according to Dr. David Armstrong, whose report on diabetic foot ulcers appears in the New England Journal of Medicine … Foot ulcers are a prevalent complication for millions of people with diabetes. Estimates indicate that as many as one-third of people with the disease will develop at least one foot ulcer over the course of their lifetime. These wounds can lead to further complications such as strokes, heart attacks, infections, loss of limbs and premature death … read more
in the young and middle-aged adult U.S. population
We are grateful to Linda Geiss and her coworkers at CDC for their always intriguing efforts at revealing the big picture to us. These data– which certainly aren’t welcome news– are supremely important. Do they signal what we’ve posited for some time? Did the increase in the “denominator” of people with diabetes in the mid-1990s initially reduced the proportionate pool of high risk patients (and thereby reduced amputation rates)? Was it better team care? Whatever the explanation, we have yet more data on which to ruminate … read more
Is a histologically hostile environment causing promising treatments for chronic wounds to fail? My coauthor and I tackle this question in a recent review for Nature Reviews Endocrinology.
As we say in the review, “As with so many other areas in medicine, the field of tissue repair and wound healing is littered with early-stage promise in preclinical models followed by late-stage disappointment in human trials.”1 If we understand that the wound environment is histologically hostile, many of the types of treatments we have endeavored to use in this area come into question … read more
Tuesday, September 25, 2018
Because neuroischemic complications are associated with a high rate of recurrence, this presentation proposes a slight shift in how health care providers counsel and communicate risk to their patients. If the epidemiology of this problem is comparable with that of cancer, and recurrences are common, then perhaps language commensurate with such risks should follow.
After initial healing of an index wound, patients are referred to not as being cured but rather as being “in remission.” This concept is easy for the patient and the rest of the team to understand, and it powerfully connotes the necessity for frequent follow-up and rapid intervention for inevitable minor and sometimes major complications.
This program will review tried-and-true as well as up-to-the-minute advances in biologics, consumer electronics, mechanics, medicine, and surgery that are “pushing the envelope” in extending ulcer-free, hospital-free, and activity-rich days in efforts to make prevention pay.
DPM, MD, PhD
University of Southern California
Professors David Armstrong and Charles Liu at first seemed to be an unlikely pair.
But the podiatric surgeon and neurosurgeon clicked on a personal level and promptly realized they had a lot to offer each other as Keck School of Medicine of USC collaborators.
Both were already studying how much information a person takes in through the nerves of the feet, how to preserve, repair or replace that information system, and how nerve damage can affect a patient’s mobility.
Armstrong is interested in metabolic health, mobility and neuropathy—the loss of nerve sensitivity that can occur in patients with diabetes, Liu noted.
“As a neurosurgeon, I’m interested in lower-extremity function and metabolic health, too,” he said. “In my work, I think about how to restore mobility to patients who can’t feel their legs. It’s a similar problem to diabetic foot ulcers.”