David G. Armstrong

Keck School of Medicine USC · Department of Surgery

Background: Experiencing a hyperglycaemic crisis is associated with a short- and long-term increased risk of mortality. We aimed to develop an explainable machine learning model for predicting 3-year mortality and providing individualized risk factor assessment of patients with hyperglycaemic crisis after admission. Methods: Based on five repres...

People with diabetic foot ulcers (DFUs) are commonly prescribed offloading walkers, but inadequate adherence to prescribed use can be a barrier to ulcer healing. This study examined user perspectives of offloading walkers to provide insight on ways to help promote adherence. Participants were randomized to wear: (1) irremovable, (2) removable, or (...

This manuscript constitutes a commentary on: "Retrospective cohort study of long-term outcomes and prognostic factors for survival after lower extremity amputation in patients with diabetes" by Vuorlaakso et al. (2023). We aim to contribute to the reflection of their findings to support the comprehensive management of vulnerable individuals with mu...

Background: Pressure injuries (PIs) impose a substantial burden on patients, caregivers, and healthcare systems, affecting an estimated 3 million Americans and costing nearly $18 billion annually. Accurate pressure injury staging remains clinically challenging. Over the last decade, object detection and semantic segmentation have evolved quickly w...

Objective: Evaluate the inter- and intra-rater reliability of a wound assessment tool in iPhone 12 and 13 mini modalities against a validated iPad mini/Structure Sensor configuration. Approach: We assessed a wound measurement application (eKare inSight) for result consistency in patients presenting with wounds. Assessments were analyzed using a...

Elevated levels of bacteria, including biofilm, increase the risk of chronic wound infection and inhibit healing. Addressing asymptomatic high bacterial loads is challenged by a lack of clinical terminology and diagnostic tools. This post‐hoc multicenter clinical trial analysis of 138 diabetic foot ulcers investigates fluorescence (FL)‐imaging role...

The relationship between pain/disability and angular deviation of the hallux valgus (HV), and the impact of orthotic use, laterality, and pain variability on treatment outcomes remain unclear. This was explored in post hoc analyses of a placebo-controlled trial of abobotulinumtoxinA (aboBoNT-A; Dysport®) for HV-associated pain (NCT03569098). The pr...

Importance Venous leg ulcers (VLU) are the most common cause of lower extremity ulceration that commonly occur among older individuals and are characterized by a slow healing trajectory and frequent recurrence; in the United States, VLUs affect more than 600 000 people per year with an estimated cost of $3.5 billion. Clinical trial data show that e...

Individuals with type 2 diabetes mellitus (T2DM) have an increased risk of bone metabolic disorders and bone fracture due to disease progression and clinical treatment. The effect of sodium-glucose cotransporter 2 (SGLT2) inhibitors, now greatly prescribed for the treatment of T2DM, on bone metabolism is not clear. This study aimed to explore the p...

Objective Frailty represents a state of multisystem impairment that may adversely impact people presenting with chronic limb-threatening ischemia (CLTI) and diabetes-related foot ulcers (DFUs). The aim of this systematic review was to explore the association between frailty and outcomes from CLTI and DFUs. Methods We performed a systematic literat...

Diabetic foot complications are increasingly burdensome for patients, clinicians, and society. Development of innovative therapies to support good quality basic care is a priority among those with an interest in this area. One of these involves scanning and printing tissues to match and conform to a defect (so-called 3D printing). Methods: A sing...

Background A comprehensive insight into the effect of longstanding diabetes mellitus and neuropathy on foot joint kinetics during walking is lacking. Our goal was to assess the in-vivo kinetics of major foot joints in persons with diabetes. Methods Three groups, matched for age, sex and walking speed were recruited in this study: 1) people with di...

Aims To disclose prevalence, demographic, foot characteristics as well as management and lower-extremity amputations (LEAs) of subjects with end-stage renal disease (ESRD) on diabetic foot diseases (DFDs). Methods Data were derived from the Taiwan National Health Insurance Research Database between 2004 and 2017. DFDs were defined as ulcers, infec...

The frequency of chronic cutaneous wounds are sharply increasing in aging populations. Patients with age-related diseases, such as diabetes, tumors, renal failure and stroke are prone to soft tissue and skin injury, compounded by slowed healing in aging. Imbalance of wound inflammation, loss of growth factor secretion, and impairment of tissue repa...

Artificial intelligence can use real-world data to create models capable of making predictions and medical diagnosis for diabetes and its complications. The aim of this commentary article is to provide a general perspective and present recent advances on how artificial intelligence can be applied to improve the prediction and diagnosis of six signi...

There are few data comparing outcomes after hallux amputation or partial first ray resection after diabetic foot ulcer (DFU). In a similar context, the choice to perform one of these two surgeries is attributable to clinician preference based on experience and characteristics of the patient and the DFU. Therefore, the purpose of this study was to d...

Nearly a decade ago, the Society for Vascular Surgery (SVS)'s wound, ischemia, and foot Infection (WIfI) classification was first developed to help assess overall limb threat. However, managing conditions such as diabetic foot ulcer and chronic limb-threatening ischemia can be complex. For instance, certain investigative findings might initially be...

Background: An aseptically processed dehydrated human amnion and chorion allograft(dHACA) without terminal sterilization has been shown to improve healing rates in chronic wounds. This randomized controlled trial(RCT) evaluated the safety and effectiveness of weekly and biweekly applications of dHACA plus Standard of Care (SOC) compared to SOC alo...

The incidence and economic burden of diabetic foot ulcers continues to rise throughout the world. In this prospective study, a unique device designed to offload the wound, enhance circulation and monitor patient compliance was evaluated for safety and efficacy. The device provides offloading and intermittent plantar compression to improve the pedal...

Peripheral artery disease (PAD) is the occlusion or narrowing of the arteries supplying the lower extremities. Peripheral artery disease has been estimated to affect approximately 240 million people worldwide, approximately 70% of whom are within low- or middle-income countries. Due to the ageing population and diabetes epidemic, the prevalence of...

Introduction The mechanisms for the observed disparities in diabetes-related amputation are poorly understood and could be related to access for diabetic foot ulceration (DFU) care. This qualitative study aimed to understand patients’ personal experiences navigating the healthcare system and the barriers they faced. Methods Fifteen semi-structured...

Objective The outcome of DFUs concomitant with HCE remains unknown. This study aimed to investigate mortality rates and identify risk factors of mortality in patients with DFUs-HCE. Methods 27 inpatients with DFUs-HCE were retrospectively enrolled in a cohort design, they were compared to 93 inpatients with DFUs in a city designated emergency cent...

AbobotulinumtoxinA (aboBoNT-A, Dysport® [Ipsen, Paris, France]) inhibits acetylcholine release at the neuromuscular junction and may modulate pain signaling in hallux valgus (HV). This randomized study (NCT03569098) included a double-blind phase (aboBoNT-A 300U, 500U or placebo injections into forefoot muscles) and an open-label aboBoNT-A treatment...

Objective: To assess the association between foot care by podiatric surgeons and outcomes of new diabetic foot ulceration (DFU) among patients with end-stage renal disease (ESRD) . Methods: We used the 2015 and 2016 claim data from the United States Renal Data System to identify patients (≥ 40 years and on dialysis for ≥ 12 months) with a new diagn...

Background: Proper debridement of the wound base is critical to facilitate wound granulation and closure in non-healing diabetic foot ulcers (DFUs) . A unique micro water jet device has been developed that precisely cleans acute and chronic wounds in a tissue-preserving manner while performing a precise mechanical cleaning and stimulation of the wo...

Introduction The mechanisms for the observed disparities in diabetes-related amputation are poorly understood and could be related to access for diabetic foot ulceration (DFU) care. This qualitative study aimed to understand patients’ personal experiences navigating the healthcare system and the barriers they faced. Methods Fifteen semi-structured...

Importance: It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations. Objective: To explore the association of early Medicaid expansion with outcomes...

Objective: Falls often occur in patients with diabetic neuropathy due to biomechanical alternation. The implication of diabetic peripheral neuropathy (DPN) on gait and balance remains poorly understood. Methods: A total of 11 dynamic gait, balance and electrophysiological parameters were evaluated in 176 participants. The biomechanical parameter...

INTRODUCTION Prior studies have shown a relationship between under/no insurance and increased risk of major and minor amputation in peripheral artery disease (PAD), but there is little data on the risk associated with loss of insurance in a previously insured population. We sought to address this question using insurance claims data. • Download :...

The Wound Healing Foundation (WHF) recognised a need for an unbiased consensus on the best treatment of chronic wounds. A panel of 13 experts were invited to a virtual meeting which took place on 27 March 2021. The proceedings were organised in the sub‐sections diagnosis, debridement, infection control, dressings, grafting, pain management, oxygen...

Objective To evaluate the cost-effectiveness and budget impact of using standard care (no advanced treatment, NAT) compared with an advanced treatment (AT), dehydrated human amnion/chorion membrane (DHACM), when following parameters for use (FPFU) in treating lower extremity diabetic ulcers (LEDUs). Method We analysed a retrospective cohort of Med...

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This treatise includes reviews of both of these new therapies by members of our author group (F.L.G. and M.E.E.) who participated in the clinical trials of the respective agents. Additionally, the use of negative pressure wound therapy (NPWT), which is also supported by evidence from RCTs, is reviewed. The final two sections of this compendium expl...

Diabetic foot ulcers (DFUs) pose a significant risk for infection and limb loss. Advanced wound therapies including human skin allografts have shown promise in resolving these challenging wounds. The primary objective of this randomised, prospective study was to compare the response of 100 subjects with non-healing DFUs of which 50 were treated wit...

Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and...

Background A critical factor in healing diabetic foot ulcers is patient adherence to offloading devices. We tested a smart offloading boot (SmartBoot) combined with a smartwatch app and cloud dashboard to remotely monitor patient adherence and activity. In addition, the impact of SmartBoot on balance, gait, and user experience was investigated. Me...

Diabetic foot ulcer classification systems use the presence of wound infection (bacteria present within the wound) and ischaemia (restricted blood supply) as vital clinical indicators for treatment and prediction of wound healing. Studies investigating the use of automated computerised methods of classifying infection and ischaemia within diabetic...

Aims Our primary objective was to determine whether all-cause rates of mortality and resource utilization were higher during periods of diabetic foot ulceration. In support of this objective, a secondary objective was to develop and validate an episode-of-care model for diabetic foot ulceration. Methods We evaluated data from the Medicare Limited...

Background: Recurrence of high-risk diabetic feet, after wound, healing is a common challenge among diabetic patients. Continuous use of an offloading device significantly prevents recurrence of high-risk diabetic feet, although patient adherence is imperative to ensuring this therapy's clinical efficacy. In this study, we explored clinical outcom...

Diabetic foot infections continue to be a major challenge for health care delivery systems. Following encouraging results from a pilot study using a novel purified reconstituted bilayer matrix (PRBM) to treat chronic diabetic foot ulcers (DFUs), we designed a prospective, multi-centre randomised trial comparing outcomes of PRBM at 12 weeks compared...

Background and Aims The long-term survival in people with type 2 diabetes following first diagnosis of diabetic foot complications (FDDFC) is unclear. The object is to evaluate the mortality rate in subjects with type 2 diabetes following FDDFC and the impacts of the major cardiovascular comorbidities. Methods Nationwide data were analyzed for sub...

This study aimed to explore the clinical characteristic and outcomes of inpatients with diabetic foot ulceration (DFU) in 2019 (prelockdown) and 2020 (postlockdown) due to the COVID-19 pandemic, at an emergency medical service unit. Prediction models for mortality and amputation were developed to describe the risk factors using a machine learning-b...

Diabetic foot ulcer classification systems use the presence of wound infection (bacteria present within the wound) and ischaemia (restricted blood supply) as vital clinical indicators for treatment and prediction of wound healing. Studies investigating the use of automated computerised methods of classifying infection and ischaemia within diabetic...

Background Diabetic foot ulcers (DFUs) are a leading cause of disability and morbidity. There is an unmet need for a simple, practical, home method to detect DFUs early and remotely monitor their healing. Method We developed a simple, inexpensive, smartphone-based, “ Foot Selfie” system that enables patients to photograph the plantar surface of th...

BACKGROUND Diabetic foot ulcers are a common diabetic complication leading to alarming fi gures of amputation, disability, and early mortality. The diabetic glucooxidative environment impairs the healing response, promoting the onset of a ‘wound chronicity phenotype’. In 50% of ulcers, these non-healing wounds act as an open door for developing inf...

Diabetic foot ulcer (DFU) is one of the most serious and alarming diabetic complications, which often leads to high amputation rates in diabetic patients. Machine learning is a part of the field of artificial intelligence, which can automatically learn models from data and better inform clinical decision‐making. We aimed to develop an accurate and...

This study assesses the impact of a processed microvascular tissue (PMVT) allograft on wound closure and healing in a prospective, single‐blinded, multi‐centre, randomised controlled clinical trial of 100 subjects with Wagner Grade 1 and 2 chronic neuropathic diabetic foot ulcerations. In addition to standard wound care, including standardised offl...

We present a stepwise surgical approach that can be used, in lieu of a transtibial amputation, to preserve the lower limb in the setting of severe diabetic foot infections. A 63-year-old male status post left midfoot (Lisfranc’s) amputation presented to our hospital with a 4-year history of a left foot diabetic ulcer with associated purulent draina...

Aims To evaluate the association of time in range (TIR) with amputation and all-cause mortality in hospitalized patients with diabetic foot ulcers (DFUs) Materials and Methods A retrospective analysis was performed on 303 hospitalized patients with DFUs. During hospitalization, TIR, mean blood glucose (MBG), coefficient of variation (CV), time abo...

Diabetic foot ulcers (DFUs) are at risk for detrimental complications even with current, standard of care (SOC) treatments. The primary objective of this randomised controlled trial was to compare a unique resorbable glass microfiber matrix (Mirragen; Advanced Wound Matrix [BBGFM]; ETS Wound Care, Rolla, Missouri) compared with a standard of care g...

Abstract Objective: Diabetic foot ulcers can have serious consequences, including amputation. This project aimed to develop and validate a diabetes care management model-a pocket guide on the prevention of foot ulceration to assist health professionals and scientific societies. Methods: An adaptation of the Iowa method of evidence-based practice t...

BACKGROUND Diabetic foot ulcers represent major health care complications both in terms of cost and impact to quality of life for patients with diabetic peripheral neuropathy. Temperature monitoring has been shown in previous studies to provide a useful signal of inflammation that may indicate the early presence of a foot injury. OBJECTIVE In this...

Background: Lower extremity complications of diabetes represent major health care complications both in terms of cost and impact to quality of life for patients with diabetic peripheral neuropathy. Temperature monitoring has been shown in previous studies to provide a useful signal of inflammation that may indicate the early presence of a foot inj...

Background Microvascular disease (MVD) describes systemic changes in the small vessels (~100 um diameter) that impair tissue oxygenation and perfusion. MVD is a common but poorly monitored complication of diabetes. Recent studies have demonstrated that MVD: (i) is an independent risk factor for ulceration and amputation and (ii) increases risk of a...

Objective: To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. Method: The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analys...

Lower extremity amputation due to peripheral artery disease (PAD) and diabetes (DM) is a life-altering event that identifies disparities in access to healthcare and management of disease. West Virginia (WV), a highly rural state, is an ideal location to study these disparities. The WVU longitudinal health system database was used to identify 1) ris...

Objective Diabetic foot ulcers can have serious consequences, including amputation. This project aimed to develop and validate a diabetes care management model—a pocket guide on the prevention of foot ulceration to assist health professionals and scientific societies. Methods An adaptation of the Iowa method of evidence-based practice to promote h...

Hyperbaric oxygen therapy (HBOT) and topical oxygen therapy (TOT) including continuous diffuse oxygen therapy (CDOT) are often utilized to enhance wound healing in patients with diabetic foot ulcerations. High pressure pure oxygen assists in the oxygenation of hypoxic wounds to increase perfusion. Although oxygen therapy provides wound healing bene...

The Society of Skeletal Radiology (SSR) Practice Guidelines and Technical Standards Committee identified musculoskeletal infection as a White Paper topic, and selected a Committee, tasked with developing a consensus on nomenclature for MRI of musculoskeletal infection outside the spine. The objective of the White Paper was to critically assess the...

In this study, we determined the reamputation-free survival to both limbs and to the contralateral limb only following an index amputation of any-level and assessed whether reamputation rates have changed over time. We completed a systematic search using PubMed and screened a total of 205 articles for data on reamputation rates. We reported qualita...

Biomaterial engineering has produced numerous matrices for use in tissue repair, utilizing various materials and processing methods, which can impact the ability of the products to encourage wound healing. Recently, we observed favorable clinical outcomes, using a novel purified reconstituted bilayer matrix (PRBM; Geistlich Derma-Gide) to treat chr...