The metabolic syndrome and cancer: Is the metabolic syndrome useful for predicting cancer risk above and beyond its individual components?

AIMS: The metabolic syndrome (MetS) is a risk factor for cancer. However, it is not known if the MetS confers a greater cancer risk than the sum of its individual components, which components drive the association, or if the MetS predicts future cancer risk. MATERIALS AND METHODS: We linked 20,648 participants from the Australian and New Zealand Diabetes and Cancer Collaboration with complete data on the MetS to national cancer registries and used Cox proportional hazards models to estimate associations of the MetS, the number of positive MetS components, and each of the five MetS components separately with the risk for overall, colorectal, prostate and breast cancer. Hazard ratios (HR) and 95% confidence intervals (95%CI) are reported. We assessed predictive ability of the MetS using Harrell's c-statistic. RESULTS: The MetS was inversely associated with prostate cancer (HR 0.85; 95% CI 0.72-0.99). We found no evidence of an association between the MetS overall, colorectal and breast cancers. For those with five positive MetS components the HR was 1.12 (1.02-1.48) and 2.07 (1.26-3.39) for overall, and colorectal cancer, respectively, compared with those with zero positive MetS components. Greater waist circumference (WC) (1.38; 1.13-1.70) and elevated blood pressure (1.29; 1.01-1.64) were associated with colorectal cancer. Elevated WC and triglycerides were (inversely) associated with prostate cancer. MetS models were only poor to moderate discriminators for all cancer outcomes. CONCLUSIONS: We show that the MetS is (inversely) associated with prostate cancer, but is not associated with overall, colorectal or breast cancer. Although, persons with five positive components of the MetS are at a 1.2 and 2.1 increased risk for overall and colorectal cancer, respectively, and these associations appear to be driven, largely, by elevated WC and BP. We also demonstrate that the MetS is only a moderate discriminator of cancer risk.

Using quality indicators to compare outcomes of permanent cardiac pacemaker implantation among publicly and privately funded patients.

BACKGROUND: Funding source/insurance status has been associated with disparity in the management and outcomes of cardiovascular disease, with poorer outcomes among disadvantaged groups. AIM: Using proposed quality indicators for permanent pacemaker (PPM) implantation and administrative data, this study aimed to determine whether quality indicator-based outcomes of PPM implantation were comparable for publicly and privately funded patients within Australia's two-tier health system. METHODS: A population-based cohort study of adults implanted with a PPM between 1995 and 2009 in Western Australia. The association of funding outcomes derived from linked administrative data was tested in multivariate logistic regression models. RESULTS: There were 9748 PPMs implanted, 48% being among privately funded patients. The mean age was 75 years for both public and private patients. Private patients had better health status (fewer with cardiac conditions and lower non-cardiac comorbidity scores), were less likely to be an emergency admission (33% vs 60%, P < 0.001) and more likely to have dual- or triple-chamber pacing. Mean length of stay was significantly greater for private patients (4.3 (standard deviation 6.3) vs 5.1 (6.8) days <0.001), related to longer elective admissions. Crude mortality was lower for private patients in-hospital (0.7 vs 1.3%), 30-day post-procedure (1.3 vs 2.1%) and at 1 year (7.3 vs 9.5%). Emergency admission, comorbidity and other demographic and clinical factors, not funding source, were significant predictors of these outcomes. CONCLUSIONS: There was no difference between publicly and privately funded patients in study outcomes, after adjustment for demographic and clinical factors. The exception was longer hospital stay for elective PPM among privately funded patients.

Comparison of the management and in-hospital outcomes of acute coronary syndrome patients in Australia and New Zealand: results from the binational SNAPSHOT acute coronary syndrome 2012 audit.

BACKGROUND/AIMS: We aimed to assess differences in patient management, and outcomes, of Australian and New Zealand patients admitted with a suspected or confirmed acute coronary syndrome (ACS). METHODS: We used comprehensive data from the binational Australia and New Zealand ACS 'SNAPSHOT' audit, acquired on individual patients admitted between 00.00 h on 14 May 2012 to 24.00 h on 27 May 2012. RESULTS: There were 4387 patient admissions, 3381 (77%) in Australia and 1006 (23%) in New Zealand; Australian patients were slightly younger (67 vs 69 years, P = 0.0044). Of the 2356 patients with confirmed ACS, Australian patients were at a lower cardiovascular risk with a lower median Global Registry Acute Coronary Events score (147 vs 154 P = 0.0008), but as likely to receive an invasive coronary angiogram (58% vs 54%, P = 0.082), or revascularisation with percutaneous coronary intervention (32% vs 31%, P = 0.92) or coronary artery bypass graft surgery (7.0% vs 5.6%, P = 0.32). Of the 1937 non-segment elevation myocardial infarction/unstable angina pectoris (NSTEMI/UAP) patients, Australian patients had a shorter time to angiography (46 h vs 67 h, P < 0.0001). However, at discharge, Australian NSTEMI/UAP survivors were less likely to receive aspirin (84% vs 89%, P = 0.0079, a second anti-platelet agent (57% vs 63%, P = 0.050) or a beta blocker (67% vs 77%, P = 0.0002). In-hospital death rates were not different (2.7% vs 3.2%, P = 0.55) between Australia and New Zealand. CONCLUSIONS: Overall more similarities were seen, than differences, in the management of suspected or confirmed ACS patients between Australia and New Zealand. However, in several management areas, both countries could improve the service delivery to this high-risk patient group.

Evaluation of long-term clinical and health service outcomes following coronary artery revascularisation in Western Australia (WACARP): a population-based cohort study protocol.

INTRODUCTION: Coronary artery bypass grafting (CABG) and percutaneous coronary interventions (PCI) are procedures commonly performed on patients with significant obstructive coronary artery disease to relieve symptoms of ischaemia, improve survival or both. Although the efficacy of both procedures at the individual level has been established, the impact of advances in coronary artery revascularisation procedures (CARP) on long-term outcomes and cost-effectiveness at the population level are yet to be assessed. Our aim is to evaluate a minimum of 6-year outcomes and costs for the total population of patients who had CARP in Western Australia (WA) in 2000-2005. METHODS AND ANALYSIS: This retrospective population cohort study will link clinical and administrative health data for a previously defined cohort including all patients in WA who had a CARP in the period 2000-2005. The cohort consists of 19,014 patients who had 21,175 procedures (15,429 PCI and 5746 CABG). We are now collecting a minimum of 6 years follow-up of morbidity and mortality data for the cohort using the WA Data Linkage System, clinical registries and hospital records, with 12 years follow-up for cases in the year 2000. Comparison of long-term outcomes for different CARP will be reported (PCI vs CABG; bare metal stents vs drug-eluting stents vs CABG). Cost-effectiveness analysis of CARP from the perspective of the healthcare sector will be performed using individual level cost data and average costs from Australian Refined Diagnosis Related Groups. ETHICS AND DISSEMINATION: This study has received ethics approval from the University of Western Australia, the Western Australian Department of Health and all participating hospitals. Being a large population cohort study, approval included a waiver of informed consent. All findings will be presented at local, national and international healthcare/academic conferences and published in peer-reviewed journals.

Choice of secondary prevention improves risk factors after acute coronary syndrome: 1-year follow-up of the CHOICE (Choice of Health Options In prevention of Cardiovascular Events) randomised controlled trial.

OBJECTIVE: To determine the effect of a new CHOICE (Choice of Health Options In prevention of Cardiovascular Events) programme on cardiovascular risk factors in acute coronary syndrome (ACS) survivors. DESIGN: Single-blind randomised controlled trial. SETTING: Tertiary referral hospital in Sydney Australia. PATIENTS: 144 ACS survivors who were not accessing standard cardiac rehabilitation. Data were also collected on a further 64 ACS survivors attending standard cardiac rehabilitation. INTERVENTION: The CHOICE group (n = 72) participated in a brief, patient-centred, modular programme comprising a clinic visit plus telephone support, encompassing mandatory cholesterol lowering and tailored preferential risk modification. The control group (n = 72) participated in continuing conventional care but no centrally coordinated secondary prevention. MAIN OUTCOME MEASURES: Values for total cholesterol, systolic blood pressure, smoking status and physical activity. RESULTS: CHOICE and control groups were well matched at baseline. At 12 months, the CHOICE group (n = 67) had significantly better risk factor levels than controls (n = 69) for total cholesterol (TC) (mean (SEM) 4.0 (0.1) vs 4.7 (0.1) mmol/l, p<0.001), systolic blood pressure (131.6 (1.8) vs 143.9 (2.3) mm Hg, p<0.001), body mass index (28.9 (0.7) vs 31.2 (0.7) kg/m(2), p = 0.025) and physical activity (1369.1 (167.2) vs 715.1 (103.5) METS/kg/min, p = 0.001) as well as a better knowledge of risk factor targets. Also at 1 year, fewer CHOICE participants (21%) had three or more risk factors above widely recommended levels then controls (72%) (p<0.001). CONCLUSIONS: Participation in a brief CHOICE programme significantly improved the modifiable risk profiles and risk factor knowledge of ACS survivors over 12 months. CHOICE is an effective alternative for dealing with the widespread underuse of existing secondary prevention programmes. TRIAL REGISTRATION NUMBER: ISRCTN42984084.

A controlled trial of circuit weight training on aerobic capacity and myocardial oxygen demand in men after coronary artery bypass surgery.

BACKGROUND: Cardiovascular benefits of resistance training in cardiac patients have been suggested but not studied in a randomized, controlled trial of circuit weight training (CWT) without an aerobic exercise component. The purpose of the current study was to examine the effects of 10 weeks of CWT on muscular strength, peak oxygen consumption (peak VO2), and myocardial oxygen demand (mVO2) in men after coronary artery bypass surgery. METHODS: Twenty-six, post-coronary bypass male subjects (mean 19 months after bypass), aged 60 +/- 8.5 years, were randomly allocated to 10 weeks of CWT at 40 to 60% of maximum voluntary contraction (n = 12) or to a control group (n = 14). Muscular strength was assessed using a modified one repetition maximum technique. Peak VO2 was recorded during symptom-limited treadmill exercise. Rate pressure product, as an indirect measure of mVO2, was measured during isometric, isodynamic, and dynamic exercise. RESULTS: No ischemic symptoms nor electrocardiographic changes were recorded during testing or training. Strength increased by 18% (P < 0.005) in five out of seven exercises in the training group, but was unchanged in the control group. Training did not improve peak VO2. Rate pressure product during isometric and isodynamic exercise decreased from pre- to post-testing (P < 0.05) but was equivalent to that seen in the control group. CONCLUSIONS: Moderate intensity CWT is safe and can improve strength in selected low-risk patients after coronary artery bypass surgery. However, it does not significantly increase peak VO2 nor reduce mVO2 during isometric, isodynamic, and dynamic exercise.

A specific activity questionnaire to measure the functional capacity of cardiac patients.

Exercise testing is often performed in persons with cardiac disease to measure their functional capacity. Physical activity questionnaires assessing functional capacity have been used a low-cost and convenient alternative to exercise testing, but have not been well validated against measured oxygen consumption in a cardiac population. This study assesses the ability of a simple, 13-item activity questionnaire, known as the Specific Activity Questionnaire (SAQ), to measure functional capacity prospectively in a large sample of cardiac patients. Ninety-seven consecutive cardiac outpatients (85 men and 12 women aged 59 +/- 10 years [mean +/- SD]) completed the SAQ before an elective symptom-limited treadmill test. Subjects returned within 10 days to repeat the treadmill test, following the same protocol, with the additional measurement of peak oxygen consumption, VO2 (ml x kg(-1)min(-1)), using open circuit spirometry. The SAQ score was significantly related to measured peak VO2(r=0.57, p<0.001). Stepwise multiple linear regression analysis found that the addition of patient age, height, and body weight to SAQ score improved the measurement of peak VO2, accounting for 51% of the sample variance (R=0.71, p<0.001). Peak VO2 was obtained from the following regression formula: [formula: see text]. Thus SAQ, a simple 13-item self-administered activity questionnaire, is able to provide a moderately good measure of functional capacity in cardiac patients and may be useful tool in studies of the cardiac population when formal exercise testing is impractical or uneconomical.

Upper-limb and lower-limb exercise training in patients with chronic airflow obstruction.

We designed a randomized controlled study to evaluate the benefit of upper-limb exercise training, alone and in combination with walking training, in patients with severe CAO. In an outpatient department supervised by a physiotherapist, we evaluated 28 patients with severe stable CAO (FEV1, 32 percent of predicted). Patients were randomly allocated to either a control (eight), upper-limb (six), lower-limb (seven), or combined (seven) exercise group. The upper-limb group trained with a circuit of upper-limb exercises, the lower-limb group by walking, and the combined group with both. Exercise was for one hour three times per week for eight weeks. Assessment before and after training included pulmonary function, mouth pressures, respiratory muscle endurance, maximal bicycle exercise test, maximal and submaximal arm ergometer, six-minute walking distance, and a scale of well-being (Bandura scale). Twenty-six patients completed the program. There was a significant improvement (Wilcoxon rank sum test) in the following: six-minute walking distance in the lower-limb (p less than 0.005) and combined (p less than 0.003) groups; arm ergometer in the upper-limb (p less than 0.005) and combined (p less than 0.04) groups; and the scale of well-being in the combined (p less than 0.005) group. There was no significant change in any other parameter measured. We conclude that exercise training improves exercise performance in severe CAO, that the training is specific for the muscle group trained, and that upper-limb exercises should be included in training programs for these patients.