Diabetic Foot: Epidemiological, Therapeutic and Evolutionary Aspects in the Department of Medicine and Endocrinology of the Hospital in Mali, Mali

Introduction: The diabetic foot remains a public health problem due to its high frequency, difficult and costly management. The aim of this study was to determine the epidemiological, therapeutic and evolutionary aspects of the diabetic foot in a hospital setting Metronidazole used 36 cases (38.29%). Amputation was performed in 35 cases (37.2%). Deaths concerned 5 patients (9.6%) with hypoglycemia as the main cause in 4 cases. Conclusion: Diabetic foot is a frequent complication of diabetes. The establishment of a multidisciplinary team should contribute to the improvement of the prognosis of the diabetic foot in a management center.


Introduction
According to the WHO, the number of people with diabetes worldwide has increased from 108 to 422 million over the past 30 years [1]. In Belgium, this number increased from around 300,000 to over 500,000 individuals between 2001 and 2011 [2]. Projections for 2030 are over one million [3]. In Africa, the number of diabetics was estimated at 14.2 million people in 2015 and 34.2 million are expected in 2040 [4].
The diabetic foot is defined according to the international consensus on the diabetic foot (developed by IWGDF: International Working Group on Diabetic Foot) of 2007 as any Infection, ulceration or destruction of the deep tissues of the foot associated with neuropathy and/or peripheral arterial disease of the lower limbs in diabetics [5].
These lesions in ill-balanced patients, difficult and expensive to treat most often lead to amputation, which makes this pathology a major public health problem, especially noting that every 30 seconds, a lower limb will be lost due to the diabetes [6].
Diabetic foot is a frequent and serious complication of diabetes with a very high rate of amputations of the lower limbs and often dramatic socio-economic and psychological consequences [7].
In Africa, foot injuries in diabetics are unfortunately very common. Poverty, poor hygiene and barefoot walking interact to aggravate the impact of foot injuries caused by diabetes [8]. In Mali there are few studies on diabetic foot [9] and there is an increase in the number of cases in the department. The objective of this study was to describe the epidemiological, therapeutic and evolutionary profile of the diabetic foot in a hospital setting in Mali.

Methodology
We conducted a retrospective, descriptive, cross-sectional study between September 1, 2011 and December 31, 2015 among diabetic patients aged 14 and over who arrived in the endocrinology/medicine department of the hospital in Mali.
-Duration: 4 years and 3 months. -Be 14 years old and over. -All diabetic patients who arrive in the endocrinology department of the hospital in Mali with a foot infection. -We collected clinical, paraclinical and therapeutic data from these patients. -Voluntary and informed consent was given in writing before being enrolled in the study. Non-inclusion criteria: We excluded from our series the incomplete files as well as the other causes apart from the diabetic foot.
Information was collected from patient charts using survey forms on which diabetic foot lesions were described according to the Texas classification (see Table 1). The questionnaires were entered and analyzed on Excel 2007 and SPSS version 20.0 software after data verification.

Discussion
The study included 94 cases out of a total of 828 hospitalized patients, for a prevalence of 11.35%. This hospital prevalence is close to those reported by Djim. F et al. [9] and Koffi D [10] respectively 16.37% and 15.29%. In Africa, it is estimated overall at 5.5% [11] and in France (ENTRED), the prevalence is 6% [12].  and 73 years [18]. This age difference can be explained by the young age of onset of diabetes in African populations, but above all by poor treatment compliance by our patients. The reasons for this poor compliance are multiple: the non-acceptance of diabetes, traditional therapy, beliefs and especially poverty [19]. Women were in the majority (61.7%) against 38.3% for men with a sex ratio of 0.62%. This female predominance has been noted by some authors such as Samaké D [20]. On the other hand, the male predominance which has been studied by Dr Merad M S et al. [16] (sex ratio M/F 2.33) is a phenomenon confirmed by several authors. Sani et al. [13] found a sex ratio of 2.46; it is 2.5 for Amoussou-Guenou [21]. The generally recognized poor adherence to therapy in men explained this male predominance [22].
Housewives were the most represented in our study (50%). This same predominance was observed by Djim F et al. [9] 53.3%.
The majority of our patients were not educated with 54.3%. This same result was observed by Traoré D.Y [23] 55.5% and Nghario L et al. [14] 47%. In fact, ignorance of the diabetic status due to illiteracy has also been reported in a variable proportion in the African literature: 13.1% in Niger [24]; 27.9% in Tanzania [25].
The socio-economic level was low in 42.6%, Nghario L et al. [14] found a low level in 66.10% of patients. The Doppler ultrasound was abnormal in 51% of our patients. Djim F C. et al. [9] had 48.6% arteriopathy of the lower limbs and 20% obliteration. The presence of germs was noted in 59.6% of samples taken from wounds.
Nghario L et al. [14] had reported in 50% of his samples.
Among the germs isolated, staphylococcus aureus was found more in 22.4%, the same germ was the most isolated in 16.13% in Djim F C. et al. [9]. On the other hand, in the Aouam study [26], the most frequently found germ was Pseudomonas aeruginosa. A study done in India and published in 2017 found poly-microbial infections in 54% with other mono-microbial in 43%. [27]. In Morocco the bacteriological sample carried out had objectified the multisensitive Staphylococcus aureus in 28.23% [28].
According to the University of Texas classification, the foot was classified as This result was with Djim F et al. [9] in Mali with 95.7% insulin therapy and Dr L. Elazizi et al. [29] had performed insulin therapy in 77.20% of patients. The most widely used antibiotic therapy was the combination Ciprofloxacin + Metronidazole in 38.29% of cases, the same combination found in Djim F et al. [9] at 37.8%. Similarly, this antibiotic therapy was generally introduced by Dr L.
Amputation was performed in 37.2% of our patients including 24.3% in the lower 1/3 of the leg, 16.3% in the upper 1/3 of the leg and a disarticulation of the big toe in 24, 3% of cases. SANI.R et al. [13] found amputation in 37 cases (41.1%), of which the amputation site was the foot in 23 cases (62.2%) followed by the leg in 11 cases (29, 7%) and the thigh in 3 cases. Case (8.1%), as well as authors such as Sidibé AT et al. [30] and Merad M S et al. [16] reported respectively 41.36% and 34% of amputations in their studies.
The outcome was favorable in 90.4% of cases, other favorable results have been reported by authors such as Koffi D [10] which reported 91.70% and 71% of cases in Assia EL Ouarradi [31].

Conclusion
Foot lesions are relatively frequent in our diabetic patients, and are responsible for high mortality and morbidity. A delay in management with lesions received at advanced stages is always noted. The management of the diabetic foot must be multidisciplinary.