Dietary intake of micronutrients and the risk of developing bladder cancer: results from the Belgian case-control study on bladder cancer risk.

OBJECTIVE: We aimed to investigate the effect of dietary intake of micronutrients that are metabolized and excreted via the urinary tract on bladder cancer risk. METHODS: A semi-quantitative 322 item food frequency questionnaire (FFQ) was used to collect dietary data from 200 bladder cancer cases and 386 control subjects participating in the Belgian case-control study on bladder cancer risk. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using unconditional logistic regression adjusting for age, sex, smoking characteristics, occupational exposures, and energy intake. RESULTS: We observed a positive association between calcium intake and bladder cancer (OR: 1.77; 95% CI: 1.00-3.15; p-trend = 0.049) and increased odds, although not statistically significant, for highest tertile of phosphorus intake (OR: 1.82; 95% CI: 0.95-3.49; p-trend = 0.06). We identified possible modification of the effects of both calcium and phosphorus by level of magnesium intake. Increased odds of bladder cancer were also observed for participants with highest intake of phosphorus and lowest intake of vitamin D (OR: 4.25; 95% CI: 1.44-12.55) and among older participants with the highest intakes of calcium (OR: 1.90; 95% CI: 1.08-3.36) and phosphorus (OR: 2.02; 95% CI: 1.05-3.92). CONCLUSION: The positive associations we observed between bladder cancer and intake of calcium and phosphorus require confirmation by other studies. The balances between inter-related micronutrients also warrant further examination.

Study rationale and design of OPTIMISE, a randomised controlled trial on the effect of benchmarking on quality of care in type 2 diabetes mellitus.

BACKGROUND: To investigate the effect of physician- and patient-specific feedback with benchmarking on the quality of care in adults with type 2 diabetes mellitus (T2DM). METHODS: Study centres in six European countries were randomised to either a benchmarking or control group. Physicians in both groups received feedback on modifiable outcome indicators (glycated haemoglobin [HbA1c], glycaemia, total cholesterol, high density lipoprotein-cholesterol, low density lipoprotein [LDL]-cholesterol and triglycerides) for each patient at 0, 4, 8 and 12 months, based on the four times yearly control visits recommended by international guidelines. The benchmarking group also received comparative results on three critical quality indicators of vascular risk (HbA1c, LDL-cholesterol and systolic blood pressure [SBP]), checked against the results of their colleagues from the same country, and versus pre-set targets. After 12 months of follow up, the percentage of patients achieving the pre-determined targets for the three critical quality indicators will be assessed in the two groups. RESULTS: Recruitment was completed in December 2008 with 3994 evaluable patients. CONCLUSIONS: This paper discusses the study rationale and design of OPTIMISE, a randomised controlled study, that will help assess whether benchmarking is a useful clinical tool for improving outcomes in T2DM in primary care. TRIAL REGISTRATION: NCT00681850.

Effect of obesity and/or sleep apnea on chemosensitivity: differences between men and women.

The purpose of this study was to identify if obesity or obstructive sleep apnea (OSA) influence hypercapnic response (HCR) and hypoxic response (HR) taking into account differences between gender. Data are expressed in % predicted based on reference values of our laboratory ('Respir. Physiol. 113 (1998) 157'). Obese women without OSA (n=117, body mass index (BMI) 43+/-8 kg/m(2)) demonstrated an increased ventilatory (VE) and occlusion pressure (P(0.1)) HCR and HR slope: VE HCR 113 (NS), VE HCR/vital capacity (VC) 126 (P<0.05), P(0.1) HCR 130 (P<0.05), VE HR 136 (P<0.05), VE HR/VC 154 (P<0.001) and P(0.1) HR 210 (P<0.001) % predicted. Obese women with OSA (n=34, BMI 42+/-9 kg/m(2)) presented similar increased values for HCR and even more increased values for HR than obese women without OSA matched for age, height and BMI: VE HR 155 (P=NS), VE HR/VC 205 (P<0.05) and P(0.1) HR 273 (P<0.05) % predicted. In obese men (without or with OSA) HCR and HR values were similar to our reference values.

Assessment of isokinetic muscle strength in women who are obese.

STUDY DESIGN: Cross-sectional study of isokinetic trunk and knee muscle strength in women who are obese. OBJECTIVE: To provide reference values, to identify variables that affect peripheral muscle strength, and to provide recommendations for isokinetic testing of trunk and knee muscles in women who are obese and morbidly obese. BACKGROUND: The assessment of peripheral muscle strength is useful for the quantification of possible loss of strength, for exercise prescription, and for the evaluation of the effect of training programs in obese individuals. METHODS AND MEASURES: Isokinetic trunk and leg muscle strength was assessed in 241 women who were obese (18-65 years, body mass index (BMI) > or = 30 kg/m2). Trunk flexion and extension peak torque (PT) was measured using the Cybex TEF dynamometer; trunk rotation (TR) PT was measured using the Cybex TORSO dynamometer; and knee flexion/extension (KFE) PT was measured using the Cybex 350 dynamometer. Body composition was assessed using the bioelectrical impedance method; physical activity was assessed using the Baecke questionnaire; and peak VO2 was assessed using an incremental exercise capacity test on a bicycle ergometer. To identify variables related to muscle strength, Pearson correlations were computed and a stepwise multiple regression analysis was performed. RESULTS: Pearson correlation coefficients of all strength measurements at 60 degrees/s revealed low-to-moderate negative associations with age and positive associations with mass, height, fat free mass (FFM), and peak VO2 (P < 0.05), except for gravity-uncorrected trunk extension strength, which was not related to mass. The sports index of the Baecke questionnaire was associated with TR PT (r = 0.20, P < 0.01) and KFE PT (r = 0.18, P < 0.05). CONCLUSION: The weight of the trunk accounts largely for the measured trunk extensor and flexor strength in women who are obese. Contributing variables of isokinetic trunk flexion and extension strength in women who are obese are age, height, and FFM; whereas sports activities and aerobic fitness are contributing factors for trunk rotational and knee extension strength. Recommendations for measuring isokinetic muscle strength in individuals who are obese are provided.

Xanthelasma and lipoma in Leonardo da Vinci's Mona Lisa.

The painting Mona Lisa in the Louvre, Paris, by Leonardo da Vinci (1503-1506), shows skin alterations at the inner end of the left upper eyelid similar to xanthelasma, and a swelling of the dorsum of the right hand suggestive of a subcutaneous lipoma. These findings in a 25-30 year old woman, who died at the age of 37, may be indicative of essential hyperlipidemia, a strong risk factor for ischemic heart disease in middle age. As far as is known, this portrait of Mona Lisa painted in 1506 is the first evidence that xanthelasma and lipoma were prevalent in the sixteenth century, long before the first description by Addison and Gall in 1851.

Optimal type 2 diabetes mellitus management: the randomised controlled OPTIMISE benchmarking study: baseline results from six European countries.

BACKGROUND: Micro- and macrovascular complications of type 2 diabetes have an adverse impact on survival, quality of life and healthcare costs. The OPTIMISE (OPtimal Type 2 dIabetes Management Including benchmarking and Standard trEatment) trial comparing physicians' individual performances with a peer group evaluates the hypothesis that benchmarking, using assessments of change in three critical quality indicators of vascular risk: glycated haemoglobin (HbA1c), low-density lipoprotein-cholesterol (LDL-C) and systolic blood pressure (SBP), may improve quality of care in type 2 diabetes in the primary care setting. DESIGN: This was a randomised, controlled study of 3980 patients with type 2 diabetes. METHODS: Six European countries participated in the OPTIMISE study (NCT00681850). Quality of care was assessed by the percentage of patients achieving pre-set targets for the three critical quality indicators over 12 months. Physicians were randomly assigned to receive either benchmarked or non-benchmarked feedback. All physicians received feedback on six of their patients' modifiable outcome indicators (HbA1c, fasting glycaemia, total cholesterol, high-density lipoprotein-cholesterol (HDL-C), LDL-C and triglycerides). Physicians in the benchmarking group additionally received information on levels of control achieved for the three critical quality indicators compared with colleagues. RESULTS: At baseline, the percentage of evaluable patients (N = 3980) achieving pre-set targets was 51.2% (HbA1c; n = 2028/3964); 34.9% (LDL-C; n = 1350/3865); 27.3% (systolic blood pressure; n = 911/3337). CONCLUSIONS: OPTIMISE confirms that target achievement in the primary care setting is suboptimal for all three critical quality indicators. This represents an unmet but modifiable need to revisit the mechanisms and management of improving care in type 2 diabetes. OPTIMISE will help to assess whether benchmarking is a useful clinical tool for improving outcomes in type 2 diabetes.

Benchmarking is associated with improved quality of care in type 2 diabetes: the OPTIMISE randomized, controlled trial.

OBJECTIVE: To assess prospectively the effect of benchmarking on quality of primary care for patients with type 2 diabetes by using three major modifiable cardiovascular risk factors as critical quality indicators. RESEARCH DESIGN AND METHODS: Primary care physicians treating patients with type 2 diabetes in six European countries were randomized to give standard care (control group) or standard care with feedback benchmarked against other centers in each country (benchmarking group). In both groups, laboratory tests were performed every 4 months. The primary end point was the percentage of patients achieving preset targets of the critical quality indicators HbA1c, LDL cholesterol, and systolic blood pressure (SBP) after 12 months of follow-up. RESULTS: Of 4,027 patients enrolled, 3,996 patients were evaluable and 3,487 completed 12 months of follow-up. Primary end point of HbA1c target was achieved in the benchmarking group by 58.9 vs. 62.1% in the control group (P = 0.398) after 12 months; 40.0 vs. 30.1% patients met the SBP target (P < 0.001); 54.3 vs. 49.7% met the LDL cholesterol target (P = 0.006). Percentages of patients meeting all three targets increased during the study in both groups, with a statistically significant increase observed in the benchmarking group. The percentage of patients achieving all three targets at month 12 was significantly larger in the benchmarking group than in the control group (12.5 vs. 8.1%; P < 0.001). CONCLUSIONS: In this prospective, randomized, controlled study, benchmarking was shown to be an effective tool for increasing achievement of critical quality indicators and potentially reducing patient cardiovascular residual risk profile.

Diabetes and intermediate hyperglycaemia in Kisantu, DR Congo: a cross-sectional prevalence study.

OBJECTIVES: To study the prevalence and risk markers of diabetes mellitus and intermediate hyperglycaemia (IH) in Kisantu, a semirural town in Bas-Congo province, The Democratic Republic of Congo. DESIGN: A cross-sectional population-based survey. SETTINGS: A modified WHO STEPwise strategy was used. Capillary glycaemia was measured for fasting plasma glucose and 2-h-postload glucose. Both WHO/IDF (International Diabetes Federation) 2006 and American Diabetes Association (ADA) 2003 diagnostic criteria for diabetes and IH were used. PARTICIPANTS: 1898 subjects aged ≥ 20 years. RESULTS: Response rate was 93.7%. Complete data were available for 1759 subjects (86.9%). Crude and standardised (for Doll and UN population) prevalence of diabetes were 4.8% and 4.0-4.2%. Crude IH prevalence was 5.8% (WHO/IDF) and 14.2% (ADA). Independent risk markers for diabetes (p<0.01) were male (OR 2.5), age 50-69 years (OR 2.6), family history (OR 3.5), waist (OR 4.1) and alcohol consumption (OR 0.36). In receiver operating characteristic (ROC) analysis, prediction of diabetes was slightly better by waist than body mass index (BMI). IH defined according to WHO/IDF was associated with BMI (OR 2.6, p<0.001). IH defined according to ADA was associated (p<0.05) with waist (OR 1.4), education level (OR 1.6), BMI (OR 2.4) and physical activity (OR 0.7). CONCLUSIONS: Current prevalence of diabetes in DR Congo exceeds IDF projections for 2030. The lower glucose threshold used by ADA almost triples impaired fasting glucose prevalence compared to WHO/IDF criteria. The high proportion of disorders of glycaemia made up by IH suggests the early stages of a diabetes epidemic.

Consumption of animal products, olive oil and dietary fat and results from the Belgian case-control study on bladder cancer risk.

AIM: The Western diet typically consists of high levels of saturated fat from animal products and has been associated with an increased risk of bladder cancer. Whilst olive oil, the predominant fat in the Mediterranean diet, has been associated with many health benefits its role in bladder cancer aetiology is still unknown. Therefore, we investigated the effect of intake of animal products, olive oil and other major dietary fats on bladder cancer risk. METHODS: Dietary data were collected from 200 cases and 386 controls participating in a Belgian case-control study on bladder cancer. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) by comparing the highest with the lowest tertiles of intake between cases and controls using unconditional logistic regression. Adjustment was made for age, sex, smoking characteristics, occupational exposures and calorie intake. RESULTS: There was a statistically significant inverse association between olive oil intake and bladder cancer consistent with a linear dose-response relationship: middle versus the lowest tertile (OR: 0.62; 95% CI: 0.39-0.99) and the highest versus the lowest tertile (OR: 0.47; 95% CI: 0.28-0.78; p-trend = 0.002). We also observed borderline statistically significant increased odds of bladder cancer for the highest versus the lowest intake of cheese (OR: 1.53; 95% CI: 0.95-2.46; p-trend = 0.08). No potential associations were detected for any other source or type of dietary fat. CONCLUSION: We observed evidence for a protective effect by olive oil and a possible increased risk of bladder cancer associated with a high intake of cheese. Our results require further investigation and confirmation by other studies.

Estimating prevalence of diabetes in a Congolese town was feasible.

OBJECTIVES: To study prevalence, determinants, and complications at diagnosis of diabetes and intermediate hyperglycemia (IH) in Kisantu, a semirural town in Bas-Congo province, Democratic Republic of Congo. STUDY DESIGN AND SETTING: A large-scale analytical cross-sectional population-based survey was performed in 2007 in Kisantu. After extensive sensitization, the study sample was collected using a modified World Health Organization (WHO) STEPwise strategy, taking subsequently a random sample of streets, households within streets, and inhabitants aged 20 years and older within households. After informed consent, subjects were invited to fixed sites for interview, anthropometry, clinical examination (blood pressure, monofilament, and ophthalmology), and biochemical tests (fasting capillary glucose, serum creatinine, and albuminuria). Fasting glycemia was repeated or 2-hour postload glycemia was measured the next day in subjects with an initial glycemia of 126-199 mg/dL (7.0-11.1 mmol/L) or 100-125 mg/dL (5.6-6.9 mmol/L), respectively. Hence, prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance according to both 2006 WHO/International Diabetes Federation and 2003 American Diabetes Association criteria could be evaluated. Bivariate and multivariate analyses were used for statistical analyses. RESULTS: Response rate was 93.7% (1,898 of 2,025). Complete data were available in 1,866 (92.1%) subjects. CONCLUSION: Estimating the prevalence of diabetes and IH in a small Congolese town was proven to be feasible.

[Albuminuria during the screening for diabetes in a semi-rural area (Kisantu City, DR Congo)]. / Albuminurie pathologique lors du dépistage du diabète en milieu semi-rural (cité de Kisantu en RD Congo).

OBJECTIVES: To determine the prevalence of microalbuminuria, macroalbuminuria and renal insufficiency at the time of screening for diabetes and impaired fasting glucose in the semi-rural area of Kisantu/DR Congo, and to identify determinants of pathological urinary albumin excretion (UAE). METHODS: Step 1: diabetes (81 cases) and impaired fasting glucose (148 cases) tracking in the population (1898 subjects selected by a systematic survey). Step 2: urinary albumin and serum creatinine were measured and glomerular filtration rate was estimated (modification of the diet in renal disease [MDRD] equation). The determinants of pathological UAE were assessed by logistic regression. RESULTS: The prevalence of macroalbuminuria and microalbuminuria in diabetes was 12.0 and 45.2% respectively versus 0 and 13.7% in impaired fasting glucose. Determinants of pathological UAE were: diabetes (adjusted OR [aOR]: 7.01; 95% CI: 3.48-14.11), central obesity (aOR: 2.36 [1.16-4.80]), age less that 60 years (aOR: 2.12 [1.05-4.40]), hypertension [aOR: 3.30 (1.39-7.82)] and diabetic retinopathy (aOR: 3.12 [1.54-6.26]). Renal insufficiency (MDRD<60ml/min/1.73m(2)) prevalence was 21.4% in diabetes and 3.8% in impaired fasting glucose. CONCLUSION: Microalbuminuria and macroalbuminuria are frequently detected during screening for diabetes and impaired fasting glucose in a semi-rural area in DR Congo. They are especially associated with age above 60 years, central obesity and hypertension. Early and integrated management of diabetes is essential to prevent renal failure in the population.

Effects of post-absorptive and postprandial exercise on glucoregulation in metabolic syndrome.

OBJECTIVE: The aim of this study was to investigate the effects of an acute exercise bout in the morning in the post-absorptive or postprandial state on the glycemic and insulinemic response to three standardized meals throughout the day. It is hypothesized that post-absorptive exercise enhances fat oxidation rate during exercise and thereafter attenuates the glucose and insulin response to subsequent meals. RESEARCH METHODS AND PROCEDURES: Seven sedentary males with metabolic syndrome (age, 45 +/- 11 years; BMI, 34 +/- 3 kg/m2) were studied in a crossover design comparing three conditions: no exercise, postprandial and post-absorptive exercise (at approximately 60% of the individual VO2max for 45 minutes). Substrate use was evaluated by indirect calorimetry during exercise. Venous blood samples were taken at regular (30- to 60-minute) intervals throughout the day, and glucose, insulin, and triglyceride concentrations were determined. RESULTS: During exercise, a higher fat oxidation rate was observed in the post-absorptive than the postprandial state. The glycemic response to a standardized high-carbohydrate breakfast was lower when exercising after breakfast than when exercising before breakfast. There was no effect of either exercise mode on glucose and insulin response to lunch and supper. DISCUSSION: Post-absorptive exercise has the advantage of promoting fat use, whereas postprandial exercise can attenuate the glycemic response to breakfast. Neither exercise mode acutely induces improved glucoregulation later during the day. The impact of meal timing on the effects of regular exercise training on glycemic control in this population remains to be studied.

Economic aspects of diabetic foot care in a multidisciplinary setting: a review.

BACKGROUND: To evaluate the economic aspects of diabetic foot care in a multidisciplinary setting. METHOD: A review of the English language literature, published from 1966 to November 2005. RESULTS: The results of available studies on the cost-of-illness of diabetic foot problems are difficult to compare. Nevertheless trends concerning excess of costs, protraction in time of costs, positive correlation to severity of ulcer and/or peripheral vascular disease, contribution of in-hospital stay and length of stay, and the patient's own contribution to total costs, are obvious. Only a few cost-effectiveness and cost-utility studies are available. Most use a Markov based model to predict outcome and show an acceptable result on long-term. CONCLUSIONS: Diabetic foot problems are frequent and are associated with high costs. A multidisciplinary approach to diabetic foot problems has proved to be cost saving with regard to cost of treatment itself. Nevertheless, it remained unclear if these savings could offset the overall costs involved in implementing this kind of approach. The few studies that address this issue specifically all show an acceptable cost-effectiveness, but often the profit will be evident after some years only, because long-term costs are involved. Based on these data, policymakers should foresee sufficient reimbursement for preventive and early curative measures, and not only for 'salvage manoeuvres'.

Use of selenium in chemoprevention of bladder cancer.

The anticarcinogenic potential of selenium was first identified nearly 40 years ago in geographical studies that reported lower death rates for cancer in regions with high levels of selenium. Cancer of the bladder was one of the body sites found to share this inverse association. Although many subsequent studies have been done on selenium and cancer, only a few have specifically assessed the relation with bladder cancer. However, the high recurrence rate and ability to monitor bladder urothelial-cell carcinoma make selenium a good candidate for chemoprevention. Evidence suggests that selenium is a biologically plausible, safe, and efficacious potential chemoprevention agent for bladder cancer. Large tertiary chemoprevention trials are needed to further investigate the role of selenium in the prevention of bladder cancer. Future studies should assess the best dose and form of selenium, and whether the protective effect of selenium differs between the sexes.

Orlistat treatment is safe in overweight and obese liver transplant recipients: a prospective, open label trial.

Obesity is a frequent complication following liver transplantation and is insufficiently responsive to dietary and life style advice. We studied the safety of orlistat treatment in obese and overweight liver transplant recipients (n = 15) on a stable tacrolimus-based immunosuppressive regimen. For safety reasons, the treatment period was restricted (6 months 120 mg t.i.d., 3 months 120 mg daily). Three patients dropped out, tacrolimus dose was adjusted in six of 12 remaining patients (dose reduction in 4, increase in 2, P = N.S.). All dose adjustments occurred during the 6 months of orlistat 120 mg t.i.d. therapy. No drug intolerance, adverse events or episodes of rejection occurred during the study. Efficacy of orlistat treatment in this population could not be shown, because a formal control population was not included in this safety trial. Moreover, only a significant decrease of waist circumference (P < 0.01 versus start of the study), but not of weight or body mass index, was achieved in the treated group. Orlistat treatment is well tolerated in liver transplant recipients and can be started safely, provided immunosuppressive drug levels and dietary adherence are closely monitored.

MRI demonstration of orbital lipolysis in anorexia nervosa.

The purpose of this article is to describe the orbital changes due to lipolysis in anorexia nervosa. We examined a cachectic patient with MR imaging using T1-weighted images before and after contrast enhancement. Orbital fat edema has been observed in extreme forms of cachexia and the CT and MR findings have recently been reported. The imaging appearances have been explained by the disappearance of the fat tissue and the appearance of edema due to a disturbance in the electrolyte fluid balance. In the recent literature particular attention has been paid to the increased lipid peroxidation and lipolysis in anorexia nervosa. These metabolic processes result in an increased permeability of the vessel wall endothelium, which can explain the extravasation of the contrast agent in the orbital fat on MR imaging.

The impact of reimbursement criteria on the appropriateness of 'statin' prescribing.

BACKGROUND: In Belgium, regulations restrict the reimbursement of statins to patients with total serum cholesterol above 250 mg/dl (6.41 mmol/l) after a three-month lipid-lowering diet. We investigated the possible impact of these regulations on characteristics of Belgian patients receiving a lipid-lowering drug. DESIGN: From 1998 to 2000, standard questionnaires on coronary risk factors and treatments with lipid-lowering drugs were completed by 301 GPs sampled at random in the 11 Belgian Provinces. Questionnaires had to be completed for 18 consecutive patients 35 years old or more attending GPs' practices, irrespective of the underlying motive for attendance. RESULTS: Of the 5511 patients included in the study, 1519 (28%) had established coronary disease or diabetes mellitus, or > or = 2 non-cholesterol coronary risk factors. Most (70%) of these patients were not treated with a lipid-lowering drug. Only 22% of patients with established coronary disease, 10% of patients with diabetes mellitus and 9% of patients with > or = 2 coronary risk factors were treated with a statin. Fifty-nine percent of fibrate users and 50% of statin users had a pre-treatment cholesterol level above 250 mg/dl, but had no or only one non-cholesterol coronary risk factor. CONCLUSIONS: In Belgium, the majority of patients at higher risk of coronary event do not benefit from lipid-lowering drugs, particularly the statins. In contrast, one of two statin users and three of five fibrate users should probably not receive the drug prescribed. Regulation based on blood cholesterol level encourages the overlooking of other risk factors relevant for selecting patients having the greatest chance to benefit from statin treatment.