How Two Health Leaders are Paving the Way in Diabetic Foot Problems with David Armstrong, Professor of Surgery and Director at Southwestern Academic Limb Salvage Alliance at Keck School of Medicine and Davide Vigano, Co-Founder & CEO at Sensoria Inc.

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: Welcome back once again to the outcomes rocket podcast where we chat with today’s most successful and inspiring health leaders. I welcome you to go to outcomesrocket.health/reviews where you can go rate and review today’s podcast because we have an amazing treat for you today. We’ve got two outstanding collaborators and contributors to the health space. I’m gonna I introduce them to you and then we’re going to dive into a topic of diabetes foot care and all the complications and opportunities within this space in medicine. We’re going to talk about artificial intelligence and we’re going to really have a great conversation. So without further ado I want to introduce my two amazing guests. First I’ve got Dr. David Armstrong. He’s a professor of surgery and director at the South Western Academic Limb Salvage Alliance also known as salsa at the Keck School of Medicine at USC. He’s an amazing contributor and has some great things to share with us today. And then we also have our other guest. His name is Davide Vigano. He’s the co-founder and CEO at Sensoria incorporated where they work to deliver healthcare solutions for the smart aging patient. So what we want to do here guys is I want to open up the mic to both of you fill in any of the gaps in the introduction that you want and then we can move forward with the show so why don’t we start with you. Dr. Armstrong.

:  Well listen it’s a pleasure to be here. Thanks a bunch. An absolute pleasure. I tell you what I just subscribed to your podcast app just given you 5 stars. After testing a Calera interview. Now let me tell you I’m just looking at all these circular talks. It’s like an entire panoply of greatness here. Every single one. This being the least interesting and we can change that. It’s a total pleasure to be with you. And by the way with my longtime friend Davide Vigano. Davide Vigano.

: Thank you Dr. Armstrong. It’s a pleasure talking to you Saul I think we have a fantastic opportunity to share more about what’s going on in the world of diabetes and the complications which is a problem of epidemic proportions right. So it’s a pleasure to be with you this morning.

: Absolutely guys. And so I always like to kick off the podcast with understanding the story behind it all and I’d love to hear from each of you. What is it that got you into health care to begin with.

: I grew up with this. I’m a doctor pediatric surgeon by training. I grew up with a problem in my dad’s office. My dad was a longtime. Podiatrist in Santa Maria California I grew up in the office. Mom and Dad as well. I saw how many problems folks had this massive unmet need in the area from a very very early age. So I guess you could say yeah I was born with a silver foot in my mouth. That just happened really bad. But you can edit that out if you like. The further we’re in the area really has been and learning about people with diabetes. And you know we talk about the scope of the problem minute. The fascinating thing about taking care of many people with diabetes is they do not have the ability to feel pain. As we all do they make it pain when they get when they have it and they don’t want it they don’t have it when they need it. And that aspect of treating the absences is a fascinating thing that’s really got me interested in medicine and surgery is the opposite.

: Yeah super fascinating and a great story there. Thank you for sharing that. Dr. Armstrong So what about you. Davide what got you into this business.

: I’ve always had a passion for health care. I’m a geek by background I’m pretty early not a medical doctor but you know my family has been impacted by multiple healthcare issues. My uncle lost him to diabete. Years ago I managed the health care solutions group at Microsoft for many years and actually contributed to starting that before it was actually sold to G two years ago. So yeah it’s health care is very very very important to me and you know health care becomes very personal very Gretry right so it’s not a passion. I think we all have the need to actually make it a priority because we all need to help solve some of the problems that health care system is facing. Selfishly right. So all we all need it at some point the chance that the consumer becomes a patient from time to time.

: This is true.

: You hear a guy like this like Davide. And by the way what a great pretty name. It’s like David wasn’t enough. You got to add a vowel. A good idea. Oh yeah.

: But the extra mile is nice. I like it

: The mellifluous isn’t it. The point is you have a you have an engineer and you’re a man like that today and mashing it up with with medicine and surgery on our hands and people talk about team science team medicine but it’s one thing to talk about it’s another to really live it. When you when you do that really great things can happen. And that’s what we’re talking about.

: Yes super interesting and actually I had a chance to interface with some of the things that you offered Davide the sensors in the socks. I was at Exponential medicine and you guys had a little booth there and it was very interesting to see the technology. And I’d like to ask both of you what is a hot topic that needs to be health leaders agenda today. And then how are you guys addressing it.

: Well let me let me get it right. Maybe I can give you the topic that you know we were there was at top of the agenda because it’s at the bottom of everyone’s agenda up until very recently. And that is the end of the body the foot in diabetes. I mean I can guarantee you there are a lot of podcasts getting recorded right now and I can gossip with you or to you that we are the only people talking about this and this is the definition of unmet need. Let me tell you why. So right now every 20 seconds someone is going up lose their foot or leg because of diabetes right now and every 20 seconds. That is tragic. There’s a lot that we can do about.

: Every 20 seconds huh

: Every 20 seconds.

: In the U.S. or worldwide?

: Worldwide. But in the U.S. If you want to I mean we can take the data where you want. Let’s talk about the problem in the U.S. U.S. alone now this problem is a problem now that. Let’s compare it to something that we all care about. Let’s compare it to cancer. I know it’s not fair to compare one problem that’s horrible to another but you know we all care about cancer. We all have family members who survived or succumb to cancer. But right now the diabetic foot and the lower extremity cost of diabetes in the United States are more expensive. And the five most expensive cancers in the United States. And like I said I’m sure there are plenty of people right now required podcast’s or lecturer’s or maybe even walkathons for breast cancer and colon cancer and lung cancer. And you know what they should be. But like I said we’re the only people talking about this problem.

: Why do you think that is. Why do you think and maybe Davide you could chime in here as well. Why. Why do you guys think this issue is not in the limelight.

: I think that’s the numbers that Dr. Armstrong are just walking us through are just unbelievable right. There are almost surreal and there are very embarrassing re on top of what you just said you know there was a 50 percent chance that the patient will have another antedated within two years and after an amputation. David correct me if I’m wrong but you know there is a five year life expectancy right so very similar to cancer. The reason why we’re not talking about it is because these numbers are medieval. Right. We should be embarrassed by them right. I mean we’re talking about amputations. Right. And between 80000 and 90000 amputations every year in the United States right. This should not happen. Unlike other issues with cancer where we don’t have the final cure there are solutions to diabetic foot complications. But we need your help in building the awareness so people know what to do. Right. Most of these people don’t feel their feet or will they suffer from a condition called peripheral property which means that their nerves are damaged. So we’re asking these people to do things that they’re not equipped to understand. Right when we tell a patient stay off your foot. It doesn’t mean the same thing that he means to us. So we think that these patients are not discipling. We think that they don’t care about their health which is not true. The problem is that their brain their system their nervous system is damaged so they need help both from a medical standpoint and they need help from the technology so we can replace some of these sensations and help them leave a healthier longer life.

: So yeah Saul, you hear this now you hear this from today. But it’s one thing for us to talk about this and he did such a great job of talking about this. But listen this is something else. Just imagine if you couldn’t feel something on your feet right. It happens so slowly. It’s like watching paint dry or watching grass grow. Right and we except slower. And so it sneaks up on you. And that is the problem with diabetes in general. You know we have about 30 31 million people with diabetes in the U.S. now about 100 million people with diabetes or diabetes in the United States. So this is a big problem. But about half of those people are going to get this problem where they lose what we call protective sensation. And if you were an evil deity and you were trying to sock it to humanity. You know what. Not yet. You wouldn’t pick all a high profile problems like heart attack or a stroke or even HIV these horrible problems that are scourges you would pick something that was silent and sinister right. It sneaks up on you. That’s the problem here. This problem is covered by bedsheets in the hospital it’s covered by shoes and socks. And imagine if you couldn’t feel the problem until it just got away from it. So that’s it. And now all of a sudden we have been working for a long time in this area are all of a sudden with a lot of the work that’s happened over the last generation are starting to get a lot of interest now from industry not just from tech but from industry as well which is really exciting because they’re all of a sudden starting see it has started to uncover this problem themselves and lift the bed sheets and see that this is a problem that’s affecting millions of their patients. The giant health plans in the U.S. and health ministries around the world and it’s also leading to massive opportunities and that is to really make a difference and that’s what the Davide has been working on a great deal and it’s frankly super exciting.

: For sure. And so let’s double click on this guys and dive a little bit deeper. The problem is clear.

: Double click on this. That’s great man. Great. So I’m click and let’s double click

: Well I got them using my three fingers wipe.

: I love it. I love it. How do we fix it. Right. There’s no doubt it’s a problem. How do we fix it.

: So I think there are multiple answers to this and I will start from the technology standpoint. And of course there is a lot more and probably more importantly on the legal side and I will let David talk about that. But there are multiple ways that we can help diabetic patients regain that kind of sensation right. That helps him or her understand what’s going on right. As David said these problems sneak up on you. Right. So a small scratch under a foot could become a diabetic poodle’s or a diabetic foot ulcer needs to be treated right. So after treatment what the doctor tells the patient to do when sorry if I’m super talking about in a very very plain terms about this but the patient needs to stay off his foot. So the cornerstone of healing of the diabetic with ulcer after treatment is what doctors call mechanical offloading right. But how do we ensure that a patient stays off his foot after surgery after the treatment of a diabetic foot ulcer. If the patient doesn’t understand what staying off his foot stabilizer doesn’t feel the pressure under his foot nervously. Right. So we’re working with the other companies because it’s not enough and isn’t sufficient to just talk that’s in Syria. And you see here that there are multiple companies that have a vested interest in helping the patients recover from that police officer. One example is optimal monitoring either the right they create specific footwear that has been proved to have the same level of efficacy of it all combat cast and these days people don’t want to be put in a total contact cast. Right. The goal of that type of footwear is to ensure that the patient is offloading the area of previous ulceration. Right. But how do we know that the patient is wearing that piece of software which is called moodle smart. How do we know the level of activity of the patient. So we inject our textile sensors into that piece of footwear we connect a device that we call Centaurea core which is basically a Fitbit for a diabetic patients raggy provides us with the right activity monitoring of the patient. It also provides alerts to the patient. But more importantly it provides us he would provide us with the ability to understand whether the patient is wearing the device is now wearing the device and the level of pressure that the patient is putting on the area previous.

: Fascinating . If the patient can’t feel get some sensors to report out where the pressure is.

: What you can’t feel can kill you. I mean that’s really that’s the if you want to know the message and maybe we can replace we can’t substitute for that sensation in other ways. And there there’s a lot of really clever ideas that are happening. And look I’ll give you the clinical in this but in terms of the you know the geek stuff to you not just what you know I mowed lawns to buy my first friggin Timex Sinclair 1000 in the set at a popular place. And ever since then I’ve been geeking around in amateur hour with gadgets up on my own. But it’s great to be with professionals like Davide to give me a little something to strive for. But this idea of monitoring our pressure and temperature and other things on the foot is not new. The we saw one of my mentors Professor Paul brand who is a fascinating guy. You have a whole podcast on him. He was raised in India and he came to the United States to work. No kidding. With people with leprosy and people with leprosy have similar problems to deal with diabetes believe we can even say sometimes that some of these people with diabetic complications are like modern day lepers. But he used to work in the 70s and late 60s. He developed technology that actually was like a little device that went into the shoe that was connected by a little wire that ran up a leg. About clunky into the ear was like little AM radio thing went to the ear and buzz in someone’s ear when they were putting too much pressure on the bottom of their feet. You want to talk about a form factor that didn’t yet exist and so what happened. Well most steps you take are not hurting the person so this thing just kept bothering people drive him crazy. So they took it out of their ear yeah let it go. We took up this mantle in the late 80s and early 90s. We try to develop something that was similar but just buzzed on a chest and he was a little tacker that would do that to give people a message saying Hey Mr. Garcia There’s a little too much pressure on your foot. That was great. The people still pour that thing off. They had to work with technologies that are now called wearables. But back then these were Analog Devices that with time stamp activity says no. And then then came one of the early adopter companies like sport brain and other stuff that would actually timestep activity. That then allowed us to dose activity like we chose a drug and that is a game changer. Now what we’re doing in healthcare today and I know that wearables now are sort of passe but it’s exciting to see this technology now weave its way into what we’re doing in healthcare on a daily basis. And now the tech from Davide from Sensoria is super exciting because. We can literally measure of variety of things we can out like almost a little intensive care unit in a fabric so it doesn’t have to just be a sock form factor or a fabric form factor to be any kind of interface. So this sort of thing is a fundamental game changer for people like me and people like us on our hands clinically who are trying to prevent the problem.

: Super interesting and quick thing here is for the listeners you’ve probably heard about these problems maybe haven’t appreciated the magnitude of the issues of diabetic foot issues. Maybe you have somebody in your life or in your community or patients that you’re seeing. And so this discussion is very meaningful. 30 million people in the U.S. with diabetes. That’s almost 10 percent. So definitely interested in hearing your thoughts. Feel free to ping us and let us know what you’re thinking about this topic. Do it underneath the show notes in LinkedIn or Twitter feeds that we share. Because I think one of the key things that Davide and David want to do is spread the word and get the conversations going. Davide you’re about to chime in there.

: Yeah I was actually going to comment on what Professor Armstrong just highlighted right. So in the world the problem is even even more acute. So according to the CDC. Well over half a billion people will suffer from diabetes by 2030. And some people believe correct me if I’m wrong. Some people say that we are already there and some people say that there are really a lot more than half a billion people right. Some people talk about 640 million people suffering from diabetes in the world. Clay percent of all of these people will suffer from some level of diabetic food complications. Right. So it’s a huge huge number. Right. So it’s not at all wearable technology it’s about injecting technology into whatever these people use and wear every day. Because we all wake up in the morning. Some of us take a shower but most of us end up wearing something great footwear socks shoes and other garments. So it’s all about really nailing those garments not adding an additional piece of plastic to the waist of these patients which will help right. So we talk about you and me. It’s UTI. It’s the internet of me is biometric sensing data that comes with the human body that clinicians and researchers can help make sense of and improve our health. Well that is I think the next wave of computing we’ve got a transparent computing referred to it as you need. These are the T. And I think there is a fantastic opportunity for all of us to collect traditional data accounting as an example. Collect also novel novel datasets like pressure level under an right. We’re not claiming that it’s not possible to collect the data with the traditional wearable technology that is in the market right now but we can right we can do that. The huge advantage that we have compared to a few years ago is that we all walk around with this mark and we all walk around with a smartwatch. Many people will walk around with additional computing devices that will allow us to surface some of these datasets turned into actionable information turned into what we call wisdom. It’s nuggets of wisdom for the specific needs that we have right for you. I suffer from diabetes. I will need specific wisdom nuggets for that. So that’s the huge advantage that we have. Right. So we can collect novel data sets and for the first time ever we can use haptic feedback or we can also use the devices that people have that they carry around all day long to help them stay healthier and manage their condition in a more efficient way.

: Isn’t that the most important thing. Saul and Davide it’s it’s making this stuff transparent and easier. And you know you see adoption of various kinds of technology and you wonder why something took off and something different. It’s usually when something just hits. It just works and it works in the background and you don’t have to think about it and that’s where we are evolving now and it’s about designs. And this is really an exciting time because we’re starting to see consumer electronics and medical devices bill better and the beneficiary is both obviously I think there’s opportunities on both of them. But we’re starting to see now that we’re starting to see medical devices that used to be. And by the way still are. Friggin ugly clunky hard to use start to go by the wayside and start to married with a little bit of good quality elegant industrial design and really just human factors elegance and that is what you’re starting to see with this is just the last five years not even the last certainly not even the last decade. But by the way if you will let’s step back and you were asking about why people should care about this and we talked about that at the outset. But here’s some more data that I think probably would suffuse every single episode that you have in the podcast. And it’s it’s this it’s that in the last decade in fact 2009 specifically that was the first year in the history of humanity. That more folks died of non-infectious diseases so-called non-communicable diseases or in CDs than from all plagues in the world combined. Now there are still way too many people dying from Ebola and Marburg on the horrible end and then even on a much larger malaria and dengue. And all these other horrible problems chikungunya. Pick your virus and pick your plague or your best to pestis in the past. But in 2009 a switch was flipped and while in the Arka time you know we may have horrible plagues from time to time but it’s likely to go back. Now we’re dealing not with disease but as one of really great thinker Steve Jones is kind of a science pundit. The UK used to say going from disease to decay and what we’re really dealing with with these non-communicable diseases heart disease cancer diabetes is we are. And arthritis all these other things we’re dealing with delaying decay and if you want to talk about the big idea it’s not about solving everything it’s not it’s not about disobeying the UK. It’s not by just acquiescing if you will or I guess you would say just say Okay okay that’s not right. Maybe we can be a little we can triangulate past you things and we can delay and tech from people are Gavitt and others in this field are revolutionizing that because now we can monitor things that usually put people to sleep which is these quiet things that just sneak up on you before they land you in the hospital or in the intensive care unit or you die from as in this case your feet really can be killing.

: Yeah. And so around this topic Dr. Armstrong and Diabaté I’d love if you guys could add a tip for the listener or the health provider the company looking to address this problem. What should they do. What do you recommend that they think about in a different way to help them tackle this issue.

: Well in my opinion there is a fantastic opportunity to join forces between the clinical world and that technology will work great for the first time. We have incredible powerful tools that can allow us to stay healthy or longer. Right. Think about something that has nothing to do with diabetes which is or you know has very very loose correlation with it which is false. Right. One third of people age 65 and bombs fall each year in this country. The number one cause of fatally non-fatal injuries. Right. It shouldn’t happen right. We should understand more about why people fall these moderate and not just the characterful dispatching and dispatching as we should have data what happens before I fall and be able to a analytics and efficient Derrida’s models that at least help us reduce the number of falls. I don’t think there is enough work and concentration and partnerships between the research and clinical world and the technology engineering world to solve this problem. Every time I talk to someone the best thing they can do as an aging baby boomer right is we are dependent device. We turn the focus group what people refer to those pendants as they refer to them as the death button because as them. Armstrong was talking about those medical devices are seen as a stigma. People don’t want to hear them right. It’s just that they forget about them. They don’t forget about them. They don’t want to be seen wearing. So it is not just a clinical problem it is an engineering problem as well and we need to join forces with the clinical community. And I wish we were there right. We were just the beginning of a journey here but we need more help and we need more people that care about smart aging and living longer. But the quality of life is as important as good as living longer and longer in a painful way. So I think there’s so much to do in terms of partnerships. That will be a human right before humans and we all hope that we can actually deal to start building this this alliance right. This will become Internet of me alliance because I think we need it. I care more about my own data and what it can do to help me age more gracefully and healthier than my thermostat. Right. I mean yes I think that selfishly that’s what we should be focus of it.

: What a great point. Dr. Armstrong.

: Yeah. So I look there are you know so much of this stuff is easy to talk about and it’s hard to implement. But that’s why there’s so much hope now as we marry no good quality public health with sort of the assistance kind of like a tech Sherpa in a way. And that’s why I’ve never been more excited about this this area. You know I can’t tell you how many conversations I have had over the last generation. Now as I get older and lose even more hair. I can tell you. And by the way I did ball for a free and long time. So I’m like not on board. Not only that but but. But if.

: You’re handsome old man you’re a handsome man, you’re a handsome man.

: You have very low standards there. You’re great at it. No I just I don’t know if you swipe left or right. I don’t wish to do that. Just yeah. Well no but the bottom line is the bottom line is that what’s really exciting now. Is that there is a great deal of hope in this area. So I just left the operating room where I came in here to report that with a patient that had been walking on for a few days. Great guy and a really smart guy but he just didn’t know. And it was not his fault. No one poll getting the word out about this problem. This problem is the biggest problem that you’ve never heard of. I know a lot of people are carrying a torch for various kinds of diseases and you know in my area they believe and I you know we work we tend to work in a lot of different areas in medicine and technology and engineering. This problem is huge and it is getting bigger. But We now have the ability to not only treat people when they have a problem we have the ability to get out in front of it. So as an example now. We can use technology like you heard from from Davide but we also know that a wound will heat up before it breaks down. Now we can use thermometers to identify hotspots and we can look for asymmetries and see there. We’ve been doing a lot of work with that a lot of federal and not for profit funding over the last generation looking giving people thermometers so they can dose their activity by checking their skin temperature just like they does their insulin checking their glucose. There are now companies that have come out that have been doing this in this field through smart socks as you’ve already heard with Davida siren care. Another company that has a smart platform that you can step on like part of metrics that can literally scan a foot and say Mr. Garcia your big toe is hotter than your other big toe. You’re about to ulcerate. Why don’t you take it easy. And we’re going to get you to see Chuck Jones on this unscheduled visit on Friday because we have access to his medical records at problems. And that solution I should say is merging now and it’s really really exciting because in the past prevention hasn’t paid and it’s been the bane of my existence both in the operating room now in the clinic but now for the first time you’ve heard people talking about going from volume to value. Well God bless it because I feel like prevention starting to pay and this problem is biggest problem you never heard about. At the end of the body hopefully going to be one of the beneficiaries. And we’re going to hopefully try to eliminate unnecessary imputations over the next generation.

: No super super thoughtful input there and listeners. I hope you took away some really great tidbits here from Dr. Armstrong and David Day on the magnitude of the problem. Some solutions that you could think through and also hopefully you’re leaving with some connections that you didn’t make before about how foot ulcers or foot problems can lead to false. Right. Something that’s high on your list of things to avoid. Let’s make these associations and so really want to thank these two gentlemen for joining us today. And what I’d love to do is just give you both an opportunity to give a closing thought and then the best place where the listeners can get a hold of you.

: The best place to get a hold of us is at sensoriahealth.com. Anyone that has an interest or a passion for what we do as Dr. Armstrong was saying the foot is the foundation of the human body. And that is to say that they humans were these a masterpiece of engineering work or so. It works fantastic and it works. There are so many moving parts in the foot. From an engineering perspective that when something breaks down it becomes a really big problem very very quickly right. So that is where you can find us if you have a passion for I mean you’ve got a passion for keeping people healthier get in touch with us info@sensoriahealth.com.

: Awesome. Thank you Davide. And Dr. Armstrong.

: Yeah look all I have to tell you is want one little tip that you can take away as a patient. You’re going you happen to have diabetes. I know someone has diabetes and they come to your regular doctor is it just tell them to knock their socks off literally just take your shoes and socks off. When are you going to see the doctor or the nurse practitioner or the nurse and the battle for some. No problem. Not that that have a look at your feet because there’s often not as much of a reason to look at them and sometimes they can spot a problem where they ever start. That’s one little tip. It’s FREE for you but for those and for all kinds of data next generation technology from what we talked about today to wearable robots to spray on skin. What you can go to our blog which is diabetic foot online.com where you can. Find me on Twitter at G.G. Armstrong. Obviously you can google us and find us at USC that you at the University of Southern California look here’s to making a difference here is helping people move through the world a little better are a little leery of keeping a few more legs on a few more bodies. I think that’s what we all are. We have diabetes or not. And Saul, thanks a million for doing this. You’re terrific.

: Hey guys. Breashears You both. This has been an educational session. So a big thank you goes to you Dr. Armstrong as well as you David A big thanks for me as well as the listeners. Guys have a great rest of the day.

Takes for tuning into the outcomes rocket podcast if you want the show notes, inspiration, transcripts and everything that we talked about on this episode. Just go to outcomesrocket.health. And again don’t forget to check out the amazing Healthcare Thinkathon where we could get together took form the blueprint for the future of healthcare. You can find more information on that and how to get involved in our theme which is implementation is innovation. Just go to outcomesrocket.health/conference that’s outcomesrocket.health/conference be one of the 200 that will participate. Looking forward to seeing you there.

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