週邊血管再生比率增加 因糖尿病截肢比率降低
作者：Becky McCall
出處：WebMD醫學新聞
October 9, 2009 (奧地利維也納) — 義大利在1999年實施糖尿病足國際臨床指南之後，週邊血管再生術的比率增加，糖尿病足重度截肢比率降低。在這段期間，重度截肢比率降低，保留腳部的輕微截肢比率增加。
截肢比率資料發表於歐洲糖尿病協會第45屆年會。
第一作者、義大利Pistoia綜合醫院的Roberto Anichini醫師向Medscape Diabetes and Endocrinology表示，腳踝以上的重度截肢進一步地減少，而經皮血管再生術這種非手術型糖尿病足方式增加，治療糖尿病足的中心數也增加。義大利現在有超過250家機構使用跨科方法，而且，我們在義大利也發現一般開業醫師治療糖尿病足的方法有所改善。
我們的研究資料來自義大利的DRG登記中心，包括所有糖尿病患的住院資訊，以及2001至2005年間的糖尿病足問題。此研究在義大利以5年時間蒐集了糖尿病足問題(潰瘍、壞疽、糖尿病相關下肢截肢、非糖尿病相關下肢截肢)住院的完整詳盡資料。
資料分析顯示，從2001至2005年，糖尿病患各種原因的住院比率顯著增加，從2001年的每1000名住院中有9.2人，增加到2005年的每1000名住院中有10.24人，在這段期間，糖尿病盛行率從每1000人中有3,9人增加到4.2人。糖尿病足問題的分析顯示，從2001至2005年，患部潰瘍住院比率增加42%、因壞疽住院比率增加28%、因週邊動脈阻塞疾病住院比率增加27%。在這段研究期間，糖尿病相關下肢截肢與非糖尿病相關下肢截肢比率約為3比1。
Anichini醫師指出，在2001年，血管糖尿病足手術總件數為4,549件(2,285件為血管內週邊血管再生之血管修復、2,264件手術或週邊繞道手術)；此數據在2005年增加到10,325件，其中，與一般手術相比，週邊血管修復件數顯著增加(n= 7,735人)。總截肢比率增加約0.2%，但重度截肢比率減少3.3% (每100,000名糖尿病患者中有4件減少到3.6件)。
Anichini醫師表示，自1999年後，義大利對於糖尿病照護有了一般共識。血管再生術是其中重要的一部份，其他方法包括各區域醫院的良好服務。在義大利，我們認為我們可以解決截肢問題。我們有超過80個中心可以讓病患接受血管再生術治療。血管再生術治療數增加4倍，有部份與可進行此手術的這些中心數目增加有關， 但是我們相信，血管再生術比一般手術方法更好。
研究結束之後，我們持續蒐集血管再生術的初步資料，顯示重度截肢比率持續降低，血管再生術治療比率則是增加。我認為我們接近截肢的最低可能性。這可能很難再降低，因為我們有許多病患較年長。
不過，在某些病患還可以有改善空間。Anichini醫師結論表示，舉例來說，我們發現，腎病變病患的截肢比率是沒有腎病變病患的2.5倍以上；在透析病患中，此一差距拉大到超過3.5倍。特別注意這些病患將可以減少其截肢。
英國倫敦國王學院醫院的Michael Edmonds醫師對前述結論提出建議時表示，跨科別處置糖尿病足有其助益。這些資料持續顯示，多科別之疾病處置方式是治療相關問題與減少截肢的最佳方法，就如同義大利這些研究者所顯示的一般。血管再生術很有效，應比目前更廣被運用。理想的話，每個嚴重缺血病患都應進行末梢血管修復術。
義大利糖尿病足研究小組SID-AMD資助本研究。Anichini醫師與 Edmonds醫師皆宣告沒有相關財務關係。
歐洲糖尿病研究協會 (EASD)第45屆年會：摘要218。發表於2009年10月2日。
Increased Peripheral Revascularization Rates Lead to Reduced Rates of Diabetic Amputations
By Becky McCall
Medscape Medical News
October 9, 2009 (Vienna, Austria) — A reduction in major amputations associated with diabetic foot followed the increased rates of peripheral revascularization that occurred after implementation of the International Consensus on Diabetic Foot guidelines in 1999 in Italy. The reduction in major amputations was associated with an increase in minor amputations, which preserve the leg, over the same time period.
Data on amputation rates were presented here at the European Association for the Study of Diabetes 45th Annual Meeting
"Further to the reduction in major amputations that occur above the ankle, we have seen an increase in [percutaneous] revascularization — a nonsurgical intervention for treating diabetic foot. We have also seen an increase in the number of centers that treat diabetic foot. There are now more than 250 in Italy [using] a multidisciplinary approach. Also, in Italy, we have seen an improvement in the approach to diabetic foot by general practitioners," lead investigator Roberto Anichini, MD, from the General Hospital of Pistoia, Italy, told Medscape Diabetes and Endocrinology.
Study data were drawn from the Italian Register of DRG, which contains information about all hospital admissions for diabetic patients, including diabetic foot problems occurring between 2001 and 2005. The study gathered accurate and complete data on hospitalizations for diabetic foot problems (ulcers, gangrene, diabetes-related lower extremity amputations, and nondiabetes-related lower extremity amputations) in Italy over a 5-year period.
Data analysis showed that from 2001 to 2005, the all-cause hospitalization rate for diabetes patients significantly increased, from 9.2 per 1000 inhabitants in 2001 to 10.24 per 1000 inhabitants in 2005, while the prevalence of diabetes increased from 3.9 to 4.2 per 100 inhabitants over the same time period. A breakdown of diabetic foot problems showed that from 2001 to 2005, hospitalization for ulcers increased by 42%, for gangrene increased by 28%, and for peripheral arterial occlusive disease increased by 27%. The ratio between diabetes- and nondiabetes-related lower extremity amputations was about 3:1 over the study period.
Dr. Anichini noted that in 2001, the total number of vascular diabetic foot procedures was 4549 (2285 endovascular peripheral revascularization angioplasties and 2264 surgical procedures or peripheral bypasses); this figure increased to 10,325 vascular procedures in 2005, with a significant increase of peripheral angioplasties (n = 7735), compared with surgical procedures. The number of total amputations increased by 0.2%, while the number of major amputations decreased by 3.3% (from 4 to 3.6 per 100,000 people with diabetes).
"Since 1999, diabetes care has been generally reorganized in Italy. Revascularization has become an important part of this, along with other measures, such as having well-serviced district hospitals. In Italy, we think that we can resolve the amputation problem. We have more than 80 centers where patients can receive revascularization treatment. The 4-fold increase in revascularization treatment is probably linked to a rise in the number of centers that can carry out these procedures, but we also believe that revascularization is preferable to the surgical approach," said Dr. Anichini.
Since the end of this study, the preliminary data we have continued to gather on revascularization "show a continuation of the trend to decrease major amputations and increase revascularization treatment. I think we are near the lowest possible level of amputation. It [will be] difficult to drop this further because many of our patients are older," he added.
However, there is scope for improvement in special groups of patients. "For example, we found that patients with nephropathy have an amputation rate more than 2.5 times that of patients without nephropathy; in patients on dialysis this difference is more than 3.5 times. Particular attention to these patients could reduce amputations in these populations," concluded Dr. Anichini.
Commenting on the results, Michael Edmonds, MD, from King's College Hospital in London, United Kingdom, recognized the benefits of an interdisciplinary approach to managing diabetic foot. "These data continue to demonstrate that the multidisciplinary approach to disease management is the best way of treating the problem and reducing amputations, as our Italians colleagues have shown very well. Revascularization is very efficient and should be done more often than it is currently. Ideally, distal angioplasty should be available to every patient who has significant ischemia," he said.
The study was funded by the Italian Diabetic Foot Study Group SID-AMD. Dr. Anichini and Dr. Edmonds have disclosed no relevant financial relationships.
European Association for the Study of Diabetes (EASD) 45th Annual Meeting: Abstract 218. Presented October 2, 2009.
