TIM29 is required for enhanced stem cell activity during regeneration in the flatworm Macrostomum lignano.

TIM29 is a mitochondrial inner membrane protein that interacts with the protein import complex TIM22. TIM29 was shown to stabilize the TIM22 complex but its biological function remains largely unknown. Until recently, it was classified as one of the Domain of Unknown Function (DUF) genes, with a conserved protein domain DUF2366 of unclear function. Since characterizing DUF genes can provide novel biological insight, we used previously established transcriptional profiles of the germline and stem cells of the flatworm Macrostomum lignano to probe conserved DUFs for their potential role in germline biology, stem cell function, regeneration, and development. Here, we demonstrate that DUF2366/TIM29 knockdown in M. lignano has very limited effect during the normal homeostatic condition but prevents worms from adapting to a highly proliferative state required for regeneration.

Efficient transgenesis and annotated genome sequence of the regenerative flatworm model Macrostomum lignano.

Regeneration-capable flatworms are informative research models to study the mechanisms of stem cell regulation, regeneration, and tissue patterning. However, the lack of transgenesis methods considerably hampers their wider use. Here we report development of a transgenesis method for Macrostomum lignano, a basal flatworm with excellent regeneration capacity. We demonstrate that microinjection of DNA constructs into fertilized one-cell stage eggs, followed by a low dose of irradiation, frequently results in random integration of the transgene in the genome and its stable transmission through the germline. To facilitate selection of promoter regions for transgenic reporters, we assembled and annotated the M. lignano genome, including genome-wide mapping of transcription start regions, and show its utility by generating multiple stable transgenic lines expressing fluorescent proteins under several tissue-specific promoters. The reported transgenesis method and annotated genome sequence will permit sophisticated genetic studies on stem cells and regeneration using M. lignano as a model organism.

Transcriptional signatures of somatic neoblasts and germline cells in Macrostomum lignano.

The regeneration-capable flatworm Macrostomum lignano is a powerful model organism to study the biology of stem cells in vivo. As a flatworm amenable to transgenesis, it complements the historically used planarian flatworm models, such as Schmidtea mediterranea. However, information on the transcriptome and markers of stem cells in M. lignano is limited. We generated a de novo transcriptome assembly and performed the first comprehensive characterization of gene expression in the proliferating cells of M. lignano, represented by somatic stem cells, called neoblasts, and germline cells. Knockdown of a selected set of neoblast genes, including Mlig-ddx39, Mlig-rrm1, Mlig-rpa3, Mlig-cdk1, and Mlig-h2a, confirmed their crucial role for the functionality of somatic neoblasts during homeostasis and regeneration. The generated M. lignano transcriptome assembly and gene expression signatures of somatic neoblasts and germline cells will be a valuable resource for future molecular studies in M. lignano.

Skin autofluorescence as proxy of tissue AGE accumulation is dissociated from SCORE cardiovascular risk score, and remains so after 3 years.

BACKGROUND: Skin autofluorescence (SAF), as a proxy of AGE accumulation, is predictive of cardiovascular (CVD) complications in i.a. type 2 diabetes mellitus and renal failure, independently of most conventional CVD risk factors. The present exploratory substudy of the Groningen Overweight and Lifestyle (GOAL)-project addresses whether SAF is related to Systematic COronary Risk Evaluation (SCORE) risk estimation (% 10-year CVD-mortality risk) in overweight/obese persons in primary care, without diabetes/renal disease, and if after 3-year treatment of risk factors (change in, Δ) SAF is related to ΔSCORE. METHODS: In a sample of 65 participants from the GOAL study, with a body mass index (BMI) >25-40 kg/m2, hypertension and/or dyslipidemia, but without diabetes/renal disease, SAF and CVD risk factors were measured at baseline, and after 3 years of lifestyle and pharmaceutical treatment. RESULTS: At baseline, the mean SCORE risk estimation was 3.1±2.6%, mean SAF 2.04±0.5AU. In multivariate analysis SAF was strongly related to age, but not to other risk factors/SCORE. After 3 years ΔSAF was 0.34±0.45 AU (p<0.001). ΔSAF was negatively related to Δbodyweight but not to ΔSCORE%, or its components. At follow-up, SAF was higher in 11 patients with a history of CVD compared to 54 persons without CVD (p=0.002). CONCLUSIONS: Baseline and 3-year-Δ SAF are not related to (Δ)SCORE, or its components, except age, in the studied population. ΔSAF was negatively related to Δweight. As 3-year SAF was higher in persons with CVD, these results support a larger study on SAF to assess its contribution to conventional risk factors/SCORE in predicting CVD in overweight persons with low-intermediate cardiovascular risk.

Maintenance of lifestyle changes: 3-year results of the Groningen Overweight and Lifestyle study.

OBJECTIVE: This study aims to evaluate the three-year effect of lifestyle counseling by a nurse practitioner (NP) on physical activity (PA) and dietary intake compared with usual care by a general practitioner (GP). METHODS: At baseline, subjects were randomly allocated to the NP group (n = 225) or to the GP group (n = 232). The NP group received a low-intensive lifestyle intervention for three years by the NP and the GP group received one consultation by the GP and thereafter usual care. PA and dietary intake were assessed with questionnaires at baseline, 1 year follow-up and 3 year follow-up. RESULTS: After three years, leisure-time activity increased and favorable improvements towards a healthy diet were made for both groups. These three-year changes in PA and diet did not differ significantly between groups. Changes in PA and dietary habits after one year were practically maintained after 3 years, because only small relapses were found. CONCLUSION: After three years, subjects were more physically active and had a healthier diet compared to baseline. Lifestyle counseling by NP resulted in similar lifestyle changes compared to GP consultation. PRACTICE IMPLICATIONS: NPs could also advice patients at cardiovascular risk by lifestyle counseling, to possibly reduce GP barriers.

Process evaluation of a lifestyle intervention in primary care: implementation issues and the participants' satisfaction of the GOAL study.

The Groningen Overweight and Lifestyle (GOAL) intervention effectively prevents weight gain. The present study describes a process evaluation in which 214 participants in the intervention group received a structured questionnaire within 7 months (a median of 5 months) after the end of the intervention. The authors investigated the content of the intervention (on basis of the participants' recall), the participants' satisfaction of the intervention, the participants' satisfaction with the nurse practitioners (NPs), and the determinants of the participants' satisfaction. In general, the results show that the content corresponded well with the protocol for the intervention, except for the number of telephone calls and the percentage of participants with individualized goals for a healthy lifestyle. The overall satisfaction of the participants was high, and success and perceived success and a low educational level were important determinants for a higher overall satisfaction grade. Furthermore, the NP was considered to be an expert and motivational to learning and keeping up a healthy lifestyle. The authors therefore conclude that the GOAL study is feasible and indicates that the NP is well equipped to treat these patients. However, it is recommended to reinforce the advice given and the lifestyle goals after the first contact sessions.

Preventing weight gain by lifestyle intervention in a general practice setting: three-year results of a randomized controlled trial.

BACKGROUND: Weight regain after initial loss of weight is common, which indicates a need for lifestyle counseling aimed at preventing weight gain instead of weight loss. This study was conducted to determine whether structured lifestyle counseling by nurse practitioners (NPs) group compared with usual care by general practitioners (GP-UC) in overweight and obese patients can prevent (further) weight gain. METHODS: A randomized controlled trial in 11 general practice locations in the Netherlands of 457 patients (body mass index, 25-40 [calculated as weight in kilograms divided by height in meters squared]; mean age, 56 years; 52% female) with either hypertension or dyslipidemia or both. The NP group received lifestyle counseling with guidance of the NP using a standardized software program. The GP-UC group received usual care from their GP. Main outcome measures were changes in body weight, waist circumference, blood pressure, and fasting glucose and blood lipid levels after 3 years. RESULTS: In both groups, approximately 60% of the participants achieved weight maintenance after 3 years. There was no significant difference in mean (SD) weight change and change of waist circumference between the NP and GP-UC groups (weight change: NP group, -1.2% [5.8%], and GP-UC group, -0.6% [5.6%] [P = .37]; and change of waist circumference: NP group, -0.8 [7.1] cm, and GP-UC group, 0.4 [7.2] cm [P = .11]). A significant difference occurred for mean (SD) fasting glucose levels (NP group, -0.02 [0.49] mmol/L, and GP-UC group, 0.10 [0.53] mmol/L [P = .02]) (to convert to milligrams per deciliter, divide by 0.0555) but not for lipid levels and blood pressure. CONCLUSIONS: Lifestyle counseling by NPs did not lead to significantly better prevention of weight gain compared with GPs. In the majority in both groups, lifestyle counseling succeeded in preventing (further) weight gain. TRIAL REGISTRATION: trialregister.nl Identifier: NTR1365.

Changes in lifestyle habits after counselling by nurse practitioners: 1-year results of the Groningen Overweight and Lifestyle study.

OBJECTIVES: The Groningen Overweight and Lifestyle (GOAL) study primarily aims at preventing weight gain by nurse practitioners (NP) guided by a standardized computerized software program. Since favourable changes in physical activity (PA) and diet may improve health independently of weight (loss), insight into effects on lifestyle habits is essential. We examined the 1-year effects of lifestyle counselling by NP on PA and diet, compared with usual care from the general practitioner (GP-UC). DESIGN: A randomized controlled trial. SETTING: Eleven general practice locations in the Netherlands. SUBJECTS: A total of 341 GOAL participants with overweight or obesity and either hypertension or dyslipidaemia, or both, who completed an FFQ and Short Questionnaire to Assess Health-Enhancing Physical Activity (SQUASH) at baseline and after 1 year. RESULTS: After 1 year, the NP group spent 33 min/week more on walking compared with the GP-UC group who spent -5 min/week on walking (P = 0.05). No significant differences were found between the NP and GP-UC groups on the percentage of persons complying with the PA guidelines. In both groups, nutrient intake changed in a favourable direction and participants complied more often with dietary guidelines, but without overall difference between the NP and GP-UC groups. CONCLUSIONS: With the exception of an increase in walking (based on self-reported data) in the NP group, no intervention effects on PA and diet occurred. Positive changes in nutrient intake were seen in both groups.

Structured primary care for type 2 diabetes has positive effects on clinical outcomes.

BACKGROUND: Patients with type 2 diabetes have an increased risk of developing microvascular and macrovascular complications. In routine diabetes care an adequate reduction of risk factors for these complications is often not achieved. OBJECTIVE: The aim of the study was to evaluate the effects of structured diabetes care on clinical outcomes of patients with type 2 diabetes in primary care. METHODS: We performed a quasi-experimental study on the effects of structured care consisting of organizational and educational components (n = 581) compared with care-as-usual (n = 152). We assessed clinical outcomes of HbA1c, blood pressure, cholesterol, creatinine and body mass index, at baseline and after 1 year. The long-term effects in the structured care group were determined after another 2 years. RESULTS: Structured care led to improvement in HbA1c and long-term improvements in blood pressure and cholesterol compared with care-as-usual. After 1 year, the percentage of patients who did not deteriorate was higher in the structured care group, again for HbA1c, diastolic blood pressure, low-density lipoprotein cholesterol and body mass index. CONCLUSIONS: Structured diabetes care consisting of multiple components has a positive effect on clinical outcomes compared with care-as-usual. Our findings support its further implementation in order to reduce complications in type 2 diabetes patients.

Preventing weight gain: one-year results of a randomized lifestyle intervention.

BACKGROUND: Lifestyle interventions targeting prevention of weight gain may have better long-term success than when aimed at weight loss. Limited evidence exists about such an approach in the primary care setting. DESIGN: An RTC was conducted. SETTING/PARTICIPANTS: Participants were 457 overweight or obese patients (BMI=25-40 kg/m(2), mean age 56 years, 52% women) with either hypertension or dyslipidemia, or both, from 11 general practice locations in The Netherlands. INTERVENTION: In the intervention group, four individual visits to a nurse practitioner (NP) and one feedback session by telephone were scheduled for lifestyle counseling with guidance of the NP using a standardized computerized software program. The control group received usual care from their general practitioner (GP). MAIN OUTCOME MEASURES: Changes in body weight, waist circumference, blood pressure, and blood lipids after 1 year (dropout <10%). Data were collected in 2006 and 2007. Statistical analyses were conducted in 2007 and 2008. RESULTS: There were more weight losers and stabilizers in the NP group than in the general practitioner usual care (GP-UC) group (77% vs 65%; p<0.05). In men, mean weight losses were 2.3% for the NP group and 0.1% for the GP-UC group (p<0.05). Significant reductions occurred also in waist circumference but not in blood pressure, blood lipids, and fasting glucose. In women, mean weight losses were in both groups 1.6%. In the NP group, obese people lost more weight (-3.0%) than the non-obese (-1.3%; p<0.05). CONCLUSIONS: Standardized computer-guided counseling by NPs may be an effective strategy to support weight-gain prevention and weight loss in primary care, in the current trial, particularly among men. TRIAL REGISTRATION: The study was registered with the Netherlands Trial Register (NTR), www.trialregister.nl, study no. TC 1365.

Self-measurement of blood pressure at home reduces the need for antihypertensive drugs: a randomized, controlled trial.

It is still uncertain whether one can safely base treatment decisions on self-measurement of blood pressure. In the present study, we investigated whether antihypertensive treatment based on self-measurement of blood pressure leads to the use of less medication without the loss of blood pressure control. We randomly assigned 430 hypertensive patients to receive treatment either on the basis of self-measured pressures (n=216) or office pressures (OPs; n=214). During 1-year follow-up, blood pressure was measured by office measurement (10 visits), ambulatory monitoring (start and end), and self-measurement (8 times, self-pressure group only). In addition, drug use, associated costs, and degree of target organ damage (echocardiography and microalbuminuria) were assessed. The self-pressure group used less medication than the OP group (1.47 versus 2.48 drug steps; P<0.001) with lower costs ($3222 versus $4420 per 100 patients per month; P<0.001) but without significant differences in systolic and diastolic OP values (1.6/1.0 mm Hg; P=0.25/0.20), in changes in left ventricular mass index (-6.5 g/m(2) versus -5.6 g/m(2); P=0.72), or in median urinary microalbumin concentration (-1.7 versus -1.5 mg per 24 hours; P=0.87). Nevertheless, 24-hour ambulatory blood pressure values at the end of the trial were higher in the self-pressure than in the OP group: 125.9 versus 123.8 mm Hg (P<0.05) for systolic and 77.2 versus 76.1 mm Hg (P<0.05) for diastolic blood pressure. These data show that self-measurement leads to less medication use than office blood pressure measurement without leading to significant differences in OP values or target organ damage. Ambulatory values, however, remain slightly elevated for the self-pressure group.

Determinants for the adoption of angiotensin II receptor blockers by general practitioners.

Results of studies conducted 10-20 years ago show the prominence of commercial information sources in the adoption process of new drugs. Over the past decade, there has been a growing emphasis on practicing evidence-based medicine in drug prescribing. This raises the question whether professional information sources currently counterbalance the influence of commercial information sources in the adoption process. The aim of this study was to identify determinants influencing the adoption of a new drug class, the angiotensin II receptor blockers (ARBs), by general practitioners (GPs) in The Netherlands. A retrospective study was conducted to assess prevalent ARB prescribing for hypertensive patients using the Integrated Primary Care Information (IPCI) database. We conducted a survey among all GPs who participated in the IPCI project in 2003 to assess their exposure to commercial and professional information sources, perceived benefits and risks of ARBs, perceived influences of the professional network, and general characteristics. Multilevel logistic regression was applied to identify determinants of ARB adoption while adjusting for patient characteristics. Data were obtained from 70 GPs and 9470 treated hypertensive patients. A total of 1093 patients received ARBs (12%). GPs who reported frequent use of commercial information sources were more likely to prescribe ARBs routinely in preference to other antihypertensives, whereas GPs who used a prescribing decision support system and those who were involved in pharmacotherapy education were less likely to prescribe ARBs. Other factors that were associated with higher levels of ARB adoption included a more positive perception of ARBs regarding their effectiveness in lowering blood pressure, and working in single-handed practices or in rural areas. Aside from determinants related to the patient population, adoption of a new drug class among Dutch GPs is still determined more by their reliance on promotional information than by their use of professional information sources.

Uptake of angiotensin II receptor blockers in the treatment of hypertension.

OBJECTIVE: To examine trends in prescribing of angiotensin II receptor blockers (ARBs) as initial and second-line treatment of hypertension. METHODS: We performed a cohort study in the Integrated Primary Care Information database, a general practice research database in The Netherlands. We included hypertensive patients who were newly treated with antihypertensive drugs between 1996 and 1999. Initial treatment was defined as the first prescribed antihypertensive drug after diagnosis of hypertension. As second-line treatment, we considered prescriptions of a second antihypertensive drug class, either as switch or addition. We used logistic regression and Cox proportional hazard analysis to estimate time trends in use of ARBs as initial or second-line treatment. RESULTS: In total, 8% of the 3,102 newly treated hypertensive patients received ARBs as initial treatment. Initial ARB use increased significantly from 4% to 10% during the period 1996-1999, whereas calcium channel blocker and angiotensin-converting enzyme inhibitor (ACE-I) use decreased. ARBs were used as second-line treatment in less than 4% of 2,544 patients who were initially treated with an antihypertensive drug other than an ARB: 2% switched to an ARB (mostly from ACE-Is) and 1% received ARBs as add-on treatment. Diuretics and beta-blockers were used five to ten times more often as add-on treatment than ARBs. CONCLUSION: ARBs achieved a position in the treatment of hypertension as initial rather than second-line therapy.

Does comorbidity explain trends in prescribing of newer antihypertensive agents?

OBJECTIVE: Concerns exist about heavily prescribing of new drugs when the evidence on hard outcomes is still limited. This has been the case for the newer classes of antihypertensives, especially in hypertensive patients without additional comorbidity. The association between comorbidity and trends in prescribing of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin II receptor blockers (ARBs) was examined for the period 1996-2000. DESIGN AND METHODS: Data were obtained from the Integrated Primary Care Information database, which contains medical records from more than 100 general practitioners in the Netherlands. Prevalent drug use in hypertensive patients was determined per calendar year. As initial treatment, the first antihypertensive drug prescribed within 1 year after diagnosis of hypertension was considered. Logistic regression was used to estimate the likelihood of receiving either ACE-I or ARBs. RESULTS: The overall prevalent ACE-I use remained stable (31%), but it increased from 33 to 41% in hypertensive patients with diabetes, heart failure, proteinuria and/or renal insufficiency. ARB use increased significantly from 2 to 12%; this trend did not differ between patients with or without specific comorbidities. Initial ACE-I use slightly decreased (from 29% to 24%), whereas initial ARB use significantly increased (from 4% to 12%). ACE-I were more likely to be the first treatment in patients with diabetes [odds ratio (OR)=3.9; 95% confidence interval (CI) 3.2-4.9] or hypercholesterolemia (OR=1.4; 95% CI 1.1-1.8). ARBs were more likely to be the initial treatment in patients with asthma/chronic obstructive pulmonary disease (OR=1.6; 1.2-2.3), diabetes (OR=2.1; 1.5-2.9) or hypercholesterolemia (OR=1.7; 1.2-2.4). CONCLUSIONS: The increased use of ACE-I is mostly restricted to hypertensive patients with comorbidities for which their use has been recommended. Trends in prescribing of ARBs are not related to relevant comorbidities.