Carine Van Den Broeke

Assessment of stiffness of the hypertrophied left ventricle of bicyclists using left ventricular inflow doppler velocimetry

Sixteen male bicyclists and 16 control subjects were studied to assess whether the left ventricular hypertrophy of athletes is associated with changes in diastolic left ventricular function. The cyclists had a larger left ventricular internal diameter on echocardiography (55.2 versus 47.9 mm; p less than 0.001) and a disproportionate increase in wall thickness relative to the internal diameter (0.48 versus 0.41; p less than 0.01), indicating a mixed eccentric-concentric type of hypertrophy. Left ventricular inflow Doppler velocimetry showed similar results in athletes and control subjects for peak flow velocities in the atrial contraction phase (30 versus 32 cm/s; p = NS) and in the early diastolic rapid filling phase (71 versus 67 cm/s; p = NS). The similar ratio of both velocities, that is, 0.43 in the cyclists and 0.49 in the control subjects, suggests that left ventricular distensibility is unaltered in cyclists. It is concluded that the left ventricular hypertrophy observed in cyclists is not associated with changes in ventricular stiffness, as estimated from left ventricular inflow Doppler velocimetry.

Left ventricular dynamics during exercise in elite marathon runners

To assess left ventricular structure and function at rest and during exercise in endurance athletes, 10 elite marathon runners, aged 28 to 37 years, and 10 matched nonathletes were studied by echocardiography and supine bicycle ergometry. Each athletes best marathon time was less than 2 h 16 min. Echocardiography was performed at rest, at a 60 W work load and at an individually adjusted work load, at which heart rate was 110 beats/min (physical working capacity 110 [PWC110]). Oxygen uptake at PWC110 averaged (+/- SD) 1.14 +/- 0.2 liters/min in the nonathletes and 2.0 +/- 0.2 liters/min in the runners (p less than 0.001). The left ventricular internal diameter at end-diastole was similar at the three activity levels in the control subjects but increased significantly from rest to exercise in the runners (p less than 0.001). Left ventricular systolic meridional wall stress remained unchanged during exercise in the nonathletes but was significantly higher at PWC110 in the athletes (p less than 0.05). Both the systolic peak velocity of posterior wall endocardial displacement and fractional shortening of the left ventricular internal diameter increased with exercise; at PWC110 the endocardial peak velocity was higher in the runners than in the control subjects (p less than 0.01). The endocardial peak velocity during relaxation was comparable in athletes and control subjects at rest, increased similarly at a 60 W work load, but was higher in the runners at PWC110 (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project.

BackgroundType 2 diabetes mellitus is a complex, progressive disease which requires a variety of quality improvement strategies. Limited information is available on the feasibility and effectiveness of interdisciplinary diabetes care teams (IDCT) operating on the interface between primary and specialty care. A first study hypothesis was that the implementation of an IDCT is feasible in a health care setting with limited tradition in shared care. A second hypothesis was that patients who make use of an IDCT would have significantly better outcomes compared to non-users of the IDCT after an 18-month intervention period. A third hypothesis was that patients who used the IDCT in an Advanced quality Improvement Program (AQIP) would have significantly better outcomes compared to users of a Usual Quality Improvement Program (UQIP).MethodsThis investigation comprised a two-arm cluster randomized trial conducted in a primary care setting in Belgium. Primary care physicians (PCPs, n = 120) and their patients with type 2 diabetes mellitus (n = 2495) were included and subjects were randomly assigned to the intervention arms. The IDCT acted as a cornerstone to both the intervention arms, but the number, type and intensity of IDCT related interventions varied depending upon the intervention arm.ResultsFinal registration included 67 PCPs and 1577 patients in the AQIP and 53 PCPs and 918 patients in the UQIP. 84% of the PCPs made use of the IDCT. The expected participation rate in patients (30%) was not attained, with 12,5% of the patients using the IDCT. When comparing users and non-users of the IDCT (irrespective of the intervention arm) and after 18 months of intervention the use of the IDCT was significantly associated with improvements in HbA1c, LDL-cholesterol, an increase in statins and anti-platelet therapy as well as the number of targets that were reached. When comparing users of the IDCT in the two intervention arms no significant differences were noted, except for anti-platelet therapy.ConclusionIDCTs operating on the interface between primary and specialty care are associated with improved outcomes of care. More research is required on what team and program characteristics contribute to improvements in diabetes care.Trial registrationNTR 1369.

Type 2 Diabetes in Primary Care in Belgium: Need for Structured Shared Care

OBJECTIVE To picture the profile of type 2 diabetic patients in Belgium and to study the quality of care in the primary care setting, with regard, to multi-factorial approach of the disease. METHODS Observational study of all known DM2-patients registered by 120 volunteer general practitioners. Quality of care was evaluated by the achievement of three major treatment targets: HbA1c<7%; Systolic Blood Pressure </=130 mmHg; LDL-Cholesterol<100 mg/dl (ADA 2003). Multivariate analysis was performed. RESULTS 2495 DM2-patients were included with a mean age of 68+/-12 years and 51% being women. One fifth of the patients had microvascular complications and 27% had macrovascular complications. Sixty-eight percent received oral anti-diabetic drugs and 19% were on insulin. Satisfactory glycaemic control (HbA1c<7%) was achieved in 54% of the patients, with however glucose control deteriorating with disease progression despite more intensive hypoglycaemic treatment. Systolic blood pressure targets were reached in 50%. Statin use was present in 39% and LDL levels<100 mg/dl were reached in 42%. 59% of insulin treated patients were followed up in shared care with specialised diabetes centres. These patients obtained lower values for HbA1c (7.5+/-1.2% vs. 7.8+/-1.5%, p=0.038) and LDL-C (90+/-34 vs. 111+/-37, p<0.001) compared to insulin-treated patients only followed up in primary care. CONCLUSION Overall metabolic control in type 2 diabetic patients in primary care in Belgium was acceptable for glucose control, but major room for improvement exists especially for statin use and blood pressure control. Clinical inertia is present and the presence of more structured care in specialised diabetes centres, focusing on therapeutic guidelines, may explain the better overall metabolic control in patients followed up in shared care with these centres.

Start improving the quality of care for people with type 2 diabetes through a general practice support program: A cluster randomized trial

AIMS To evaluate the effectiveness of a two-arm quality improvement program (QIP) to support general practice with limited tradition in chronic care on type 2 diabetes patient outcomes. METHODS During 18 months, we performed a cluster randomized trial with randomization of General Practices. The usual QIP (UQIP: 53 GPs, 918 patients) merged standard interventions including evidence-based treatment protocol, annual benchmarking, postgraduate education, case-coaching for GPs and patient education. The advanced QIP (AQIP: 67 GPs, 1577 patients) introduced additional interventions focussing on intensified follow-up, shared care and patient behavioural changes. Main outcomes were HbA1c, systolic blood pressure (SBP), and low density lipoprotein cholesterol (LDL-C), analyzed by generalized estimating equations and linear mixed models. RESULTS In UQIP, endpoints improved significantly after intervention: HbA1c -0.4%, 95% CI [-0.4; -0. 3]; SBP -3mmHg, 95% CI [-4; -1]; LDL-C -13mg/dl, 95% CI [-15; -11]. In AQIP, there were no significant additional improvements in outcomes: HbA1c -0.4%, 95% CI [-0.4; -0.3]; SBP -4mmHg, 95% CI [-5; -2]; LDL-C -14mg/dl, 95% CI [-15; -11]. CONCLUSIONS A multifaceted program merging standard interventions in support of general practice induced significant improvements in the quality of diabetes care. Intensified follow-up in AQIP with focus on shared care and patient behaviour changes did not yield additional benefit.

Maximum oxygen uptake and cardiac size and function in twins

The contribution of heredity to the interindividual variability of maximum oxygen uptake and of cardiac size and function of healthy male twins, age 18 to 31 years, was studied to evaluate the role of the heart in the inheritance of aerobic power. Twelve pairs of monozygotic and 12 pairs of dizygotic twins were examined. Weight (p less than 0.05), relative weight (Quetelet index) (p less than 0.01) and skinfold thickness (p less than 0.01) were found to be genetically determined, as well as heart rate at rest (p less than 0.05) and systolic blood pressure (p less than 0.05). Genetic variation was significant (p less than 0.05) both for absolute and for weight-adjusted oxygen uptake, measured at peak exercise on the bicycle ergometer. However, the influence of inheritance on aerobic power was not associated with a significant genetic effect on the end-diastolic left ventricular internal diameter or on its fractional shortening as assessed by echocardiography. Genetic variation had a significant (p less than 0.05) effect on left ventricular mass, but this could be attributed to the inheritance of body size. These data indicate that cardiac factors are not significantly involved in the inheritance of aerobic power and suggest that cardiac hypertrophy in athletes is secondary to training.

Long-term evolution of renal function in patients with type 2 diabetes mellitus: a registry-based retrospective cohort study

Objectives To picture the 10-year evolution of renal function in patients with type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) and to describe the risk factors for severe decline. Setting Primary registration network with 97 general practitioners working in 55 practices sending routinely collected patient data. Participants From the database, we selected all patients aged 40 years or older with T2DM and at least two creatinine measurements in two different years with an interval of at least 3 months. Based on the last available value of estimated glomerular filtration rate calculated by the modification of diet in renal disease (MDRD) equation, patients were divided into grades of CKD. Severe decline (decline of >4 mL/min/year) and ‘certain drop’ (CD, year-to-year decline >10 mL/min) were determined in patients with CKD. Determinants of severe decline and CD were investigated with logistic regression and longitudinal logistic regression analysis, respectively. Primary outcome measure Kidney function (MDRD). Results 4041 patients, 1980 women, were included. The mean age was 71 years, mean diabetes duration was 7.7 years; 1514 (38%) suffered from CKD, 231 (15%) presented with severe decline and 18% of the patients with CKD presented with two or more CDs. Younger age, male gender, mean glycated haemoglobin and a higher number of CDs were significantly associated with the presence of severe decline (p<0.05); statins and higher diastolic blood pressure were significantly associated with the absence of severe decline (p<0.001). ACE inhibitors, other antihypertensive drugs and antidiabetic drugs including insulin therapy were specific determinants of CD. Conclusions CKD is highly prevalent in patients with T2DM; a minority of patients evolve into severe decline that is associated with younger age, male gender, ‘CD’ and manageable factors such as blood pressure, blood glucose, associated drugs prescriptions and statin therapy. Further prospective observational and experimental research is needed to clarify the nature of those associations.

A Validation of the French Version of the Attitudes to Aging Questionnaire (AAQ): Factor Structure, Reliability and Validity

Introduction: The Attitudes to Aging Questionnaire (AAQ) was developed to measure attitudes toward the aging process as a personal experience from the perspective of older people. The present study aimed to validate the French version of the AAQ. Participants and methods: This study examined factor structure, acceptability, reliability and validity of the AAQ’s French version in 238 Belgian adults aged 60 years or older. In addition, participants provided information on demographics, self-perception of their mental and physical health (single items), quality of life (WHOQOL-OLD) and social desirability (DS-36). Results: Exploratory Factor Analysis produced a three-factor solution accounting for 36.9% of the variance. No floor or ceiling effects were found. The internal consistency, measured by Cronbach’s alpha coefficients for the AAQ subscales were 0.62 (Physical Change), 0.74 (Psychological Growth), and 0.75 (Psychosocial Loss). A priori expected associations were found between AAQ subscales, self-reported health and quality of life, indicating good convergent validity. The scale also showed a good ability to discriminate between people with lower and higher education levels, supporting adequate known-groups validity. Finally, we confirmed the need to control for social desirability biases when assessing self-reported attitudes toward one’s own aging. Conclusion: The data support the usefulness of the French version of the AAQ for the assessment of attitudes toward their own aging in older people.

Care trajectories are associated with quality improvement in the treatment of patients with uncontrolled type 2 diabetes: A registry based cohort study

AIMS To analyse whether care trajectories (CT) were associated with increased prevalence of parenteral hypoglycemic treatment (PHT=insulin or GLP-1 analogues), statin therapy or RAAS-inhibition. Introduced in 2009 in Belgium, CTs target patients with type 2 diabetes mellitus (T2DM), in need for or with PHT. METHODS Retrospective study based on a registry with 97 general practitioners. The evolution in treatment since 2006 was compared between patients with vs. without a CT, using longitudinal logistic regression. RESULTS Comparing patients with (N=271) vs. without a CT (N=4424), we noted significant differences (p<0.05) in diabetes duration (10.1 vs. 7.3 years), HbA1c (7.5 vs. 6.9%), LDL-C (85 vs. 98mg/dl), microvascular complications (26 vs. 16%). Moreover, in 2006, parenteral treatment (OR 52.1), statins (OR 4.1) and RAAS-inhibition (OR 9.6) were significantly more prevalent (p<0.001). Between 2006 and 2011, the prevalence rose in both groups regarding all three treatments, but rose significantly faster (p<0.05) after 2009 in the CT-group. CONCLUSIONS Patients enrolled in a CT differ from other patients even before the start of this initiative with more intense hypoglycemic and cardiovascular treatment. Yet, they presented higher HbA1c-levels and more complications. Enrolment in a CT is associated with additional treatment intensification.

Monitoring modifiable cardiovascular risk in type 2 diabetes care in general practice: the use of an aggregated z-score.

Background:Because many patients in usual care reach the diabetes treatment goals, it may be more efficacious to focus quality improvement efforts on those general practice populations requiring additional support. We therefore developed a tool based on a composite end point considering blood pressure, lipids, and glycaemia. Methods:We created an aggregated zA-score, calculated as the average of 3 z-scores testing whether the mean practice values of hemoglobin A1c, low density lipoprotein cholesterol, and systolic blood pressure are significantly higher than the corresponding ADA-target (respectively 7%, 100 mg/dL, and 130 mm Hg). This score was used with 100 general practitioners who participated in a Quality Improvement Program. We defined the cut-off value (COV) to determine “Practices Requiring Support” (zA <COV) using a receivers operating characteristics curve with the mean practice CHD risk as gold standard. To further test the z-score validity, we calculated the correlation coefficient between the z-score and the mean practice CHD risk and the improvement in the z-score after the Quality Improvement Program. Results:The COV was −1.22 and was valid to discriminate between practices at higher risk from practices at lower CHD risk (24% ± 4% vs. 19% ± 4%). The correlation coefficient was −0.515 (P = 0.001). The average z-score increased from −1.21 ± 0.97 at baseline to 0.49 ± 1.01 after the intervention (P < 0.001). Conclusion:This scoring system is useful to picture practice populations with diabetes who are at high cardiovascular risk because of modifiable risk factors. Although the unadjusted z-score cannot be used to compare physicians, this technique can be used to evaluate improvement efforts over time.