Surgical management of the diabetic foot:The current evidence

The prevalence of diabetes mellitus and its associated complications,particularly diabetic foot pathologies,poses significant healthcare challenges and economic burdens globally.This review synthesises current evidence on the surgical management of the diabetic foot,focusing on the interplay between neuropathy,ischemia,and infection that commonly culminates in ulcers,infections,and,in severe cases,amputations.The escalating incidence of diabetes mellitus underscores the urgency for effective management strategies,as diabetic foot complications are a leading cause of hospital admissions among diabetic patients,significantly impacting morbidity and mortality rates.This review explores the pathophysiological mechanisms underlying diabetic foot complications and further examines diabetic foot ulcers,infections,and skeletal pathologies such as Charcot arthropathy,emphasising the critical role of early diagnosis,comprehensive management strategies,and interdisciplinary care in mitigating adverse outcomes.In addressing surgical interventions,this review evaluates conservative surgeries,amputations,and reconstructive procedures,highlighting the importance of tailored approaches based on individual patient profiles and the specific characteristics of foot pathologies.The integration of advanced diagnostic tools,novel surgical techniques,and postoperative care,including offloading and infection control,are discussed in the context of optimising healing and preserving limb function.

Impact of tibial transverse transport in tissue regeneration and wound healing with perspective on diabetic foot ulcers

In this editorial,we comment on an article by Liao et al published in the current issue of the World Journal of Diabetes.We focus on the clinical significance of tibial transverse transport(TTT)as an effective treatment for patients with diabetic foot ulcers(DFU).TTT has been associated with tissue regeneration,improved blood circulation,reduced amputation rates,and increased expression of early angiogenic factors.Mechanistically,TTT can influence macrophage polarization and growth factor upregulation.Despite this potential,the limitations and conflicting results of existing studies justify the need for further research into its optimal application and development.These clinical implications highlight the efficacy of TTT in recalcitrant DFU and provide lasting stimuli for tissue re-generation,and blood vessel and bone marrow improvement.Immunomodu-lation via systemic responses contributes to its therapeutic potential.Future studies should investigate the underlying molecular mechanisms to enhance our understanding and the efficacy of TTT.This manuscript emphasizes the potential of TTT in limb preservation and diabetic wound healing and suggests avenues for preventive measures against limb amputation in diabetes and peripheral artery disease.Here,we highlight the clinical significance of the TTT and its importance in healing DFU to promote the use of this technique in tissue regeneration.

Portraying Diabetic Foot Ulcers: Comparative Evaluation of Diabetic Foot Infections versus Diabetic Foot Ulcers

Background: Confusion often arises in caring for diabetic foot infections and ulcers, especially with antimicrobials;we aim to shed light on this entity and alert healthcare workers to its stewardship. Methods: Records were reviewed between February 2016 and September 2023. Data for patients diagnosed with diabetes and foot ulcers, infected or not, were examined following ICD 9 search terms. Records for patients were included if they were prediabetic/diabetic adults with foot ulcers, more than 18 years old, and on antidiabetic treatment. Patients were excluded if they insulin resistant, with normal HgbA1c levels, wheel-chair dependent, bed-bound, non-diabetic patients, diabetic patients who had vascular lower limb surgery earlier to ulcers, diabetic patients who had aortocoronary bypass, deep venous thrombosis within six months, malignancy, and severe clinical depression. A modified IWGDF/IDSA guidelines definitions for DFI and DFU was considered. Statistical analysis was done using R programming. Statistical methods were employed as appropriate, and a significant P-value was considered for P Results: Most characteristics were well balanced between DFI and DFU, on imaging osteomyelitis and tissue swelling were significantly more in DFI. Endovascular radiological procedures showed angiograms to be considerably more in DFI, while angioplasty was more in DFU, in addition to smoking. Bacteremia was uncommon, and swab cultures were mostly polymicrobial in both ulcers;no clear association with blood bacteria was detected with the polymicrobial growth, though few were concordant. Antimicrobials prescribed for both ulcers were not statistically different except for carbapenems, which were more in DFI (P Conclusion: Attention should be paid to best practices while caring for diabetic ulcers. These include swab culture interpretations, the use of antimicrobials, and plan management according to DFI or DFU to utilize either local care or combination with antimicrobials.

Home-based Detection and Prediction of Diabetic Foot Ulcers at Early Stage Using Sensor Technology and Supervised Learning

For years,foot ulcers linked with diabetes mellitus and neuropathy have significantly impacted diabetic patients’ health-related quality of life(HRQoL). Diabetes foot ulcers impact15% of all diabetic patients at some point in their lives. The facilities and resources used for DFU detection and treatment are only available at hospitals and clinics,which results in the unavailability of feasible and timely detection at an early stage. This necessitates the development of an at-home DFU detection system that enables timely predictions and seamless communication with users,thereby preventing amputations due to neglect and severity. This paper proposes a feasible system consisting of three major modules:an IoT device that works to sense foot nodes to send vibrations onto a foot sole,a machine learning model based on supervised learning which predicts the level of severity of the DFU using four different classification techniques including XGBoost,K-SVM,Random Forest,and Decision tree,and a mobile application that acts as an interface between the sensors and the patient. Based on the severity levels,necessary steps for prevention,treatment,and medications are recommended via the application.

Quality Assessment of Online Patient Education Materials for Diabetic Foot

Background: The quality of online Arabic educational materials for diabetic foot syndrome (DFS) is unknown. This study evaluated Arabic websites as patients’ sources of information for DFS. Methods: The study assessed patient-related websites about DFS using a modified Ensuring Quality of Information for Patients (EQIP) tool (score 0 - 35). Specific terms were searched in Google to identify DFS websites;eligibility criteria were applied to 20 pages of search results to select the included websites. Data on country of origin, source types and subtypes, and website traffic were extracted. Additional therapeutic information regarding prevention and conservative, pharmacological, and surgical treatments was also recorded and analyzed. Results: Among 559 websites, 157 were eligible for inclusion. The median EQIP score was 16 out of 35, indicating poor quality in one of three domains (content, identification, or structure). Most sources originated from Arab countries (75.8%) were non-governmental (94.9%), and were medical information websites (46.5%). High-scoring websites were significantly more likely than low-scoring websites to describe information on prevention (30.9% vs. 2.9%, p = 0.001), conservative treatment (34.1% vs. 13%, p = 0.002), or pharmacological treatment (32.5% vs. 16.8%, p = 0.024). There were increased odds of scoring high if a website provided information on prevention (OR = 12.9, 95% CI [1.68 - 98.57], p = 0.014). Conclusion: Most Arabic online patient information on DFS is of poor quality. Quality control measures are needed to ensure accurate health information for the public.

Research progress and challenges in stem cell therapy for diabetic foot: Bibliometric analysis and perspectives

BACKGROUND Stem cell therapy has shown great potential for treating diabetic foot(DF).AIM To conduct a bibliometric analysis of studies on the use of stem cell therapy for DF over the past two decades,with the aim of depicting the current global research landscape,identifying the most influential research hotspots,and providing insights for future research directions.METHODS We searched the Web of Science Core Collection database for all relevant studies on the use of stem cell therapy in DF.Bibliometric analysis was carried out using CiteSpace,VOSviewer,and R(4.3.1)to identify the most notable studies.RESULTS A search was conducted to identify publications related to the use of stem cells for DF treatment.A total of 542 articles published from 2000 to 2023 were identified.The United States had published the most papers on this subject.In this field,Iran’s Shahid Beheshti University Medical Sciences demonstrated the highest productivity.Furthermore,Dr.Bayat from the same university has been an outstanding researcher in this field.Stem Cell Research&Therapy is the journal with the highest number of publications in this field.The main keywords were“diabetic foot ulcers,”“wound healing,”and“angiogenesis.”CONCLUSION This study systematically illustrated the advances in the use of stem cell therapy to treat DF over the past 23 years.Current research findings suggested that the hotspots in this field include stem cell dressings,exosomes,wound healing,and adipose-derived stem cells.Future research should also focus on the clinical translation of stem cell therapies for DF.

Global trends in publications regarding macrophages-related diabetic foot ulcers in the last two decades

BACKGROUND Diabetic foot ulcers(DFUs)are one of the most severe and popular complications of diabetes.The persistent non-healing of DFUs is the leading cause of amputation,which causes significant mental and financial stress to patients and their families.Macrophages are critical cells in wound healing and perform essential roles in all phases of wound healing.However,no studies have been carried out to systematically illustrate this area from a scientometric point of view.Although there have been some bibliometric studies on diabetes,reports focusing on the investigation of macrophages in DFUs are lacking.AIM To perform a bibliometric analysis to systematically assess the current state of research on macrophage-related DFUs.METHODS The publications of macrophage-related DFUs from January 1,2004,to December 31,2023,were retrieved from the Web of Science Core Collection on January 9,2024.Four different analytical tools:VOSviewer(v1.6.19),CiteSpace(v6.2.R4),HistCite(v12.03.07),and Excel 2021 were used for the scientometric research.RESULTS A total of 330 articles on macrophage-related DFUs were retrieved.The most published countries,institutions,journals,and authors in this field were China,Shanghai Jiao Tong University of China,Wound Repair and Regeneration,and Aristidis Veves.Through the analysis of keyword co-occurrence networks,historical direct citation networks,thematic maps,and trend topics maps,we synthesized the prevailing research hotspots and emerging trends in this field.CONCLUSION Our bibliometric analysis provides a comprehensive overview of macrophage-related DFUs research and insights into promising upcoming research.

Non-surgical treatment of diabetic foot ulcers on the dorsum of the foot with polydeoxyribonucleotide injection:Two case reports

BACKGROUND Diabetic foot ulcers are caused by a variety of factors,including peripheral neuropathy,peripheral arterial disease,impaired wound healing mechanisms,and repetitive trauma.Patients with diabetic foot ulcer on the dorsum of the foot are often treated surgically.However,the right non-surgical therapy must be chosen if surgical choices are contraindicated or if the patient prefers conservative treatment over surgery.CASE SUMMARY The purpose of this case report is to highlight the efficacy of polydeoxyribonucleotide(PDRN)injection as a non-surgical treatment option for diabetic foot ulcers on the dorsum of the foot,particularly in patients who choose against surgical intervention.This case report presents two cases of diabetic foot ulcers located on the dorsum of the foot that were successfully treated with PDRN injection as a non-surgical intervention.CONCLUSION If the patient declines surgery for diabetic ulcers with Wagner grade II or below,PDRN injection can be effective if necrotic tissue is removed and the wound bed kept clean.

Effect of foot reflexology on an infant with sensorineural hearing loss:A case report

BACKGROUND Our study contributes to the further understanding of the mechanism of foot reflexology.Foot reflexology has been reported to affect hearing recovery,but no physiological evidence has been provided.This lack of evidence hampers the acceptance of the technique in clinical practice.CASE SUMMARY A girl was taken to North Sichuan Medical University Affiliated Hospital for a hearing screen by her parents.Her parents reported that her hearing level was the same as when she was born.The girl was diagnosed with sensorineural hearing loss(SNHL)by a doctor in the otolaryngology department.After we introduced the foot reflexology project,the parents agreed to participate in the experiment.After 6 months of foot reflexology treatment,the hearing threshold of the girl recovered to a normal level,below 30 dB.CONCLUSION Foot reflexology should be encouraged in clinical practice and for families of infants with SNHL.

Acute effect of foot strike patterns on in vivo tibiotalar and subtalar joint kinematics during barefoot running

Background:Foot kinematics,such as excessive eversion and malalignment of the hindfoot,are believed to be associated with running-related injuries.The maj ority of studies to date show that different foot strike patterns influence these specific foot and ankle kinematics.However,technical deficiencies in traditional motion capture approaches limit knowledge of in vivo joint kinematics with respect to rearfoot and forefoot strike patterns(RFS and FFS,respectively).This study uses a high-speed dual fluoroscopic imaging system(DFIS)to determine the effects of different foot strike patterns on 3D in vivo tibiotalar and subtalar joints kinematics.Methods:Fifteen healthy male recreational runners underwent foot computed tomography scanning for the construction of 3-dimensional models.A high-speed DFIS(100 Hz)was used to collect 6 degrees of freedom kinematics for participants’tibiotalar and subtalar joints when they adopted RFS and FFS in barefoot condition.Results:Compared with RFS,FFS exhibited greater internal rotation at 0%-20%of the stance phase in the tibiotalar joint.The peak internal rotation angle of the tibiotalar joint under FFS was greater than under RFS(p<0.001,Cohen’s d=0.92).RFS showed more dorsiflexion at 0%-20%of the stance phase in the tibiotalar joint than FFS.RFS also presented a larger anterior translation(p<0.001,Cohen’s d=1.28)in the subtalar joint at i nitial contact than FFS.Conclusion:Running with acute barefoot FFS increases the internal rotation of the tibiotalar joint in the early stance.The use of high-speed DFIS to quantify the movement of the tibiotalar and subtalar joint was critical to revealing the effects of RF S and FFS during running.

Developing a novel big dataset and a deep neural network to predict the bearing capacity of a ring footing

The accurate prediction of the bearing capacity of ring footings,which is crucial for civil engineering projects,has historically posed significant challenges.Previous research in this area has been constrained by considering only a limited number of parameters or utilizing relatively small datasets.To overcome these limitations,a comprehensive finite element limit analysis(FELA)was conducted to predict the bearing capacity of ring footings.The study considered a range of effective parameters,including clay undrained shear strength,heterogeneity factor of clay,soil friction angle of the sand layer,radius ratio of the ring footing,sand layer thickness,and the interface between the ring footing and the soil.An extensive dataset comprising 80,000 samples was assembled,exceeding the limitations of previous research.The availability of this dataset enabled more robust and statistically significant analyses and predictions of ring footing bearing capacity.In light of the time-intensive nature of gathering a substantial dataset,a customized deep neural network(DNN)was developed specifically to predict the bearing capacity of the dataset rapidly.Both computational and comparative results indicate that the proposed DNN(i.e.DNN-4)can accurately predict the bearing capacity of a soil with an R2 value greater than 0.99 and a mean squared error(MSE)below 0.009 in a fraction of 1 s,reflecting the effectiveness and efficiency of the proposed method.

Therapeutic Effectiveness of Leukocyte-and Platelet-rich Fibrin for Diabetic Foot Ulcers:A Retrospective Study

Objective Diabetic foot ulcer(DFU)is one of the most serious complications of diabetes.Leukocyte-and platelet-rich fibrin(L-PRF)is a second-generation autologous platelet-rich plasma.This study aims to investigate the clinical effects of L-PRF in patients with diabetes in real clinical practice.Methods Patients with DFU who received L-PRF treatment and standard of care(SOC)from 2018 to 2019 in Tongji Hospital were enrolled.The clinical information including patient characteristics,wound evaluation(area,severity,infection,blood supply),SOC of DFU,and images of ulcers was retrospectively extracted and analyzed.L-PRF treatment was performed every 7±2 days until the ulcer exhibited complete epithelialization or an overall percent volume reduction(PVR)greater than 80%.Therapeutic effectiveness,including overall PVR and the overall and weekly healing rates,was evaluated.Results Totally,26 patients with DFU were enrolled,and they had an ulcer duration of 47.0(35.0,72.3)days.The severity and infection of ulcers varied,as indicated by the Site,Ischemia,Neuropathy,Bacterial Infection,and Depth(SINBAD)scores of 2–6,Wagner grades of 1–4,and the Perfusion,Extent,Depth,Infection and Sensation(PEDIS)scores of 2–4.The initial ulcer volume before L-PRF treatment was 4.94(1.50,13.83)cm3,and the final ulcer volume was 0.35(0.03,1.76)cm3.The median number of L-PRF doses was 3(2,5).A total of 11 patients achieved complete epithelialization after the fifth week of treatment,and 19 patients achieved at least an 80%volume reduction after the seventh week.The overall wound-healing rate was 1.47(0.63,3.29)cm3/week,and the healing rate was faster in the first 2 weeks than in the remaining weeks.Concurrent treatment did not change the percentage of complete epithelialization or healing rate.Conclusion Adding L-PRF to SOC significantly improved wound healing in patients with DFU independent of the ankle brachial index,SINBAD score,or Wagner grade,indicating that this method is appropriate for DFU treatment under different clinical conditions.

Foot and ankle surgery:Tourniquet placement site to cause as little postoperative pain as possible

There is controversy in the literature on where to place the tourniquet(thigh,calf,ankle)for foot and ankle surgery.While some authors prefer the ankle tourniquet to the calf tourniquet,others state that the surgeon can decide between using the thigh tourniquet or the ankle tourniquet,since there was no difference in postoperative pain between them.Where to place the tourniquet during foot and ankle surgery to cause the least possible postoperative pain to the patient as a result of the tourniquet is a common question in clinical practice.The reality is that,unfortunately,there is no consensus on this issue.Perhaps the only possible way to answer this question would be to conduct a comparative study with sufficient statistical power to reach scientifically sound conclusions.It does not seem easy to carry out such a study,but it would be important to be able to answer the question posed in the title of this Editorial once and for all.

Effects of foot reflexology on disease

In this article,we review a recently published article to explore the significance of foot reflexology in modern medical practice.With the advancement of modern medicine,we are increasingly committed to finding the specific physiological mechanisms of foot reflexes to treat diseases,thereby better proving the therapy’s effectiveness.It has been reported that foot reflexes can activate the cerebral cor-tex and organs corresponding to the feet,stimulating blood flow,nutrition and nerves through neural and endocrine regulation to achieve the purpose of treating and preventing diseases and promoting health.The therapy shows unique po-tential and value,and provides a new perspective on integrating traditional me-dicine and modern medicine.

Prevalence and risk factors of wound complications after transtibial amputation in patients with diabetic foot

BACKGROUND Diabetic foot(DMF)complications are common and are increasing in incidence.Risk factors related to wound complications are yet to be established after transtibial amputation under the diagnosis of DMF infection.AIM To analyze the prognosis and risk factors related to wound complications after transtibial amputation in patients with diabetes.METHODS This retrospective cohort study included seventy-two patients with DMF complications who underwent transtibial amputation between April 2014 and March 2023.The groups were categorized based on the occurrence of wound complications,and we compared demographic data between the complication group and the non-complication group to analyze risk factors.Moreover,a multivariate logistic regression analysis was performed to identify risk factors.RESULTS The average follow-up period was 36.2 months.Among the 72 cases,31(43.1%)had wound complications.Of these,12 cases(16.7%)received further treatment,such as debridement,soft tissue stump revision,and re-amputation at the proximal level.In a group that required further management due to wound complications after transtibial amputation,the hemoglobin A1c(HbA1c)level was 9.32,while the other group that did not require any treatment had a 7.54 HbA1c level.The prevalence of a history of kidney transplantation with wound complications after transtibial amputation surgery in DMF patients was significantly greater than in cases without wound complications(P=0.02).Other factors did not show significant differences.CONCLUSION Approximately 43.1%of the patients with transtibial amputation surgery experienced wound complications,and 16.7%required additional surgical treatment.High HbA1c levels and kidney transplant history are risk factors for postoperative wound complications.

Clinical efficacy of endovascular revascularization combined with vacuum-assisted closure for the treatment of diabetic foot

BACKGROUND The diabetic foot is a common cause of disability and death,and comorbid foot infections usually lead to prolonged hospitalization,high healthcare costs,and a significant increase in amputation rates.And most diabetic foot trauma is complicated by lower extremity arteriopathy,which becomes an independent risk factor for major amputation in diabetic foot patients.AIM To establish the efficacy and safety of endovascular revascularization(ER)combined with vacuum-assisted closure(VAC)for the treatment of diabetic foot.METHODS Clinical data were collected from 40 patients with diabetic foot admitted to the Second Affiliated Hospital of Soochow University from April 2018 to April 2022.Diabetic foot lesions were graded according to Wagner’s classification,and blood flow to the lower extremity was evaluated using the ankle-brachial index test and computerized tomography angiography of the lower extremity arteries.Continuous subcutaneous insulin infusion pumps were used to achieve glycemic control.Lower limb revascularization was facilitated by percutaneous transluminal balloon angioplasty(BA)or stenting.Wounds were cleaned by nibbling debridement.Wound granulation tissue growth was induced by VAC,and wound repair was performed by skin grafting or skin flap transplantation.RESULTS Of the 35 cases treated with lower limb revascularization,34 were successful with a revascularization success rate of 97%.Of these,6 cases underwent stenting after BA of the superficial femoral artery,and 1 received popliteal artery stent implantation.In the 25 cases treated with infrapopliteal artery revascularization,39 arteries were reconstructed,7 of which were treated by drug-coated BA and the remaining 32 with plain old BA.VAC was performed in 32 wounds.Twenty-four cases of skin grafting and 2 cases of skin flap transplantation were performed.Two patients underwent major amputations,whereas 17 had minor amputations,accounting for a success limb salvage rate of 95%.CONCLUSION ER in combination with VAC is a safe and effective treatment for diabetic foot that can significantly improve limb salvage rates.The use of VAC after ER simplifies and facilitates wound repair.

Is it possible to foot reflexology for infants with sensorineural hearing loss?

Foot reflexology is a non-invasive and safe complementary therapy that works by massaging the reflex zones of the feet and exerts systemic or whole-body regulation through meridian nerve conduction.This therapy is commonly used in the treatment of various conditions such as autism and Parkinson's disease.However,there is limited reporting on the use of foot reflexology therapy for infants with sensorineural hearing loss(SNHL).Currently,there is no definitive conclusion on how foot reflexology therapy can influence hearing.This editorial holds some guiding significance regarding this clinical issue.The aim is to present physiological evidence of how foot reflexology therapy can impact infants with SNHL,thereby enhancing clinician’s awareness of foot reflexology in treating infants with SNHL.

Prognostic Factors for Diabetic Foot at CNHU-HKM

Introduction: Predictions on the prevalence of diabetes mellitus, according to the International Diabetes Federation, indicated 9.3% in 2019 and nearly 10.9% of the general population in 2045. In Benin, the increase in this prevalence, according to the World Health Organization (WHO), is constantly increasing. Diabetic foot is one of its most common complications. The aim of this work was to study the prognostic factors of diabetic foot in the Department of Endocrinology, Metabolism and Nutrition of the CNHU-HKM of Cotonou. Patients and method: This is a descriptive and analytical retrospective study of the prognostic factors of diabetic foot over a period of 3 years from January 2019 to December 2021 in patients who have been hospitalized or followed on an outpatient basis for diabetic foot in the Endocrinology, Metabolism and Nutrition Department of the CNHU-HKM of Cotonou. Results: A total of 112 patients were included in this study. The average age of the patients was 59.70 ± 2.10 years. A male predominance was noted with a sex ratio (M/F) of 1.7. Mixed gangrene and phlegmons were the most common lesions. According to the classification of diabetic feet according to the University of Texas, 59.1% of patients had a 100% risk of amputation. Ten patients died from sepsis (8.9%). The average blood glucose on admission was 2.74 ± 0.23 g/l, reflecting the glycemic imbalance in these patients. There is a statistically significant association between the duration of progression of diabetes, the type of lesion and amputation. Patients whose diabetes has lasted more than 30 years and patients who are not monitored have a greater risk of death. Conclusion: Diabetic patients most often consulted at a late stage, compromising conservative treatment. The duration of diabetes and the type of lesion on admission were the main factors leading to amputation, thus compromising the functional prognosis. As for death, it was mainly linked to irregular monitoring of diabetes and the duration of diabetes. Effective prevention and management of diabetic feet requires patient education about the diabetic foot and systematic screening of at-risk feet in consultation.

Additional comments on foot reflexology treatment for sensorineural hearing loss in infant

Currently,treatment options for infant sensorineural hearing loss(SNHL)are limited.This article describes a novel case of SNHL in an infant successfully treated with foot reflexology,along with observed brain activity changes before and after treatment,as indicated by functional magnetic resonance imaging.Hence,this commentary discusses the case and our viewpoints regarding foot reflexology for treating SNHL.

Delayed treatment of diabetic foot ulcer in patients with type 2 diabetes and its prediction model

BACKGROUND Diabetic foot(DF)is a serious complication of type 2 diabetes.This study aimed to investigate the factors associated with DF occurrence and the role of delayed medical care in a cohort of patients with type 2 diabetes.AIM To reveal the impact of delayed medical treatment on the development of DF in patients with type 2 diabetes and to establish a predictive model for DF.METHODS In this retrospective cohort study,292 patients with type 2 diabetes who underwent examination at our hospital from January 2023 to December 2023 were selected and divided into the DF group(n=82,DF)and nondiabetic foot group(n=210,NDF).Differential and correlation analyses of demographic indicators,laboratory parameters,and delayed medical treatment were conducted for the two groups.Logistic regression was applied to determine influencing factors.Receiver operating characteristic(ROC)analysis was performed,and indicators with good predictive value were selected to establish a combined predictive model.RESULTS The DF group had significantly higher body mass index(BMI)(P<0.001),disease duration(P=0.012),plasma glucose levels(P<0.001),and HbA1c(P<0.001)than the NDF group.The NDF group had significantly higher Acute Thrombosis and Myocardial Infarction Health Service System(ATMHSS)scores(P<0.001)and a significantly lower delayed medical treatment rate(72.38%vs 13.41%,P<0.001).BMI,duration of diabetes,plasma glucose levels,HbA1c,diabetic peripheral neuropathy,and nephropathy were all positively correlated with DF occurrence.ATMHSS scores were negatively correlated with delayed time to seek medical treatment.The logistic regression model revealed that BMI,duration of diabetes,plasma glucose levels,HbA1c,presence of diabetic peripheral neuropathy and nephropathy,ATMHSS scores,and delayed time to seek medical treatment were influencing factors for DF.ROC analysis indicated that plasma glucose levels,HbA1c,and delayed medical treatment had good predictive value with an area under the curve of 0.933 for the combined predictive model.CONCLUSION Delayed medical treatment significantly affects the probability of DF occurrence in patients with diabetes.Plasma glucose levels,HbA1c levels,and the combined predictive model of delayed medical treatment demonstrate good predictive value.