The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence

OBJECTIVES

To evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes. It also sought to explore the reasons for non-adherence to cardiac rehabilitation programmes.

DESIGN

An individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes.

SETTING

Four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands in England, for 2 years from 1 February 2002.

PARTICIPANTS

A total of 525 patients who had experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks.

INTERVENTIONS

All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification. The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education. The home-based programme consisted of an appropriate version of the Heart Manual, home visits and telephone contact. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at 3 weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Where needed, follow-up was made by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English.

MAIN OUTCOME MEASURES

Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire 6, 9 and 12 weeks.

RESULTS

No clinically or statistically significant differences were found in any of the primary or secondary outcome measures between the home- and centre-based groups. Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both arms between baseline and the 6-month follow-up. Five or more contacts with a cardiac rehabilitation nurse were received by 96% of home-based participants, whereas only 56% of centre-based participants attended this many rehabilitation classes. The direct rehabilitation costs to the health service were significantly higher for the home-based programme (mean cost 198 pounds versus 157 pounds for the centre-based programme), but when patient costs were included the mean cost of the centre-based arm rose to 182 pounds. Patients' reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems limited some patients' ability to exercise. Most non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. The home-based patients' lack of motivation to exercise on their own at home was a major factor in non-adherence. The focus groups revealed little diversity of views among patients from each programme. Patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual.

CONCLUSIONS

A home-based cardiac rehabilitation programme for low- to moderate-risk patients does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes. Different reasons were given by home and hospital cardiac rehabilitation patients for not taking up or adhering to cardiac rehabilitation, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation. Research is recommended into cardiac rehabilitation in patients from ethnic minority groups; measurement tools to assess physical activity and dietary change; evaluating the Heart Manual in patients who decline centre-based cardiac rehabilitation; the implementation of home-based programmes in the UK; and strategies that sustain physical activity in the long term.

The p53 knowledgebase: an integrated information resource for p53 research

The p53 tumor suppressor protein plays a central role in maintaining genomic integrity by occupying a nodal point in the DNA damage control pathway. Here it integrates a wide variety of signals, responding in one of several ways, that is, cell cycle arrest, senescence or programmed cell death (apoptosis). Mutations in the tumor suppressor gene tp53, which affects the key transcriptional regulatory processes in cell growth and death, occur frequently in cancer and helps explain why p53 has been called the guardian of the genome. There is a vast body of published knowledge on all aspects of p53's role in cancer. To facilitate research, it would be helpful if this information could be collected, curated and updated in a format that is easily accessible to the user community. To this end, we initiated the p53 knowledgebase project (http://p53.bii.a-star.edu.sg). The p53 knowledgebase is a user-friendly web portal incorporating visualization and analysis tools that integrates information from the published literature with other manually curated information to facilitate knowledge discovery. This includes curated information on sequence, structural, mutation, polymorphisms, protein-protein interactions, transcription factors, transcriptional targets, antibodies and post-translational modifications that involve p53. The goal is to collect and maintain all relevant data on p53 and present it in an easily accessible format that will be useful to researchers in the field.

The Women’s Health Initiative randomized trial of calcium plus vitamin D: Effects on breast cancer and arthralgias

LBA6

Background: Calcium (Ca) and vitamin D (D) have been associated with reduced breast cancer and breast density in observational studies. Randomized trials have not evaluated Ca/D supplementation for breast cancer prevention. Methods: We randomized 36,282 postmenopausal women without prior breast cancer from 40 WHI centers to 1000 mg of elemental calcium as calcium carbonate and 400 IU of vitamin D3 (N = 18,176) daily or matching placebo (N = 18,106); 54% were also randomized one year previously to hormone therapy (HT) or placebo; conjugated equine estrogen (CEE) plus medroxyprogesterone acetate or CEE alone (the latter for those with prior hysterectomy). Ca/D effects on hip fracture and colorectal cancer have been reported (NEJM 2006). We report here pathologically confirmed invasive breast cancer as a secondary outcome of the Ca/D trial. Baseline serum 25(OH) D levels (in 1787 women) and serial joint symptoms (pain/stiffness and hand/feet swelling 0–3 scale, in a 6% sample) were also assessed. Results: Breast cancer incidence did not differ between Ca/D and placebo randomization groups (528 and 546 cases in Ca/D and placebo; hazard ratio 0.96; 95 percent confidence interval (CI), 0.85, 1.09). While SEER stage and abnormal mammogram frequency were similar between groups, breast cancers were smaller in the Ca/D group (1.54 cm (1.23), mean (SD) versus 1.71 (1.29), P = 0.05). Total vitamin D baseline intake was associated with lower breast cancer risk in the placebo group. Baseline vitamin D (nmol per liter) deficiency was common (≥30, sufficient (n = 266), 16 ≤ 30, insufficient (277), < 16, deficient (743)) but was not related to joint pain (seen in 72.2%, 74.0%, 74.6%, of sufficiency and deficiency groups, respectively). Joint symptoms were lower in women randomized to CEE alone (P < 0.01) but did not significantly differ by Ca/D group assignment and no significant interactions were seen between HT and Ca/D. Conclusion: Among healthy postmenopausal women, Ca/D supplementation did not reduce breast cancer risk but the cancers in those randomized to Ca/D were somewhat smaller. Exogenous estrogen use but not Ca/D supplementation influences arthralgias.

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Novel molecular basis of an Inab phenotype

The Cromer blood group system consists of ten high-prevalence and three low-prevalence antigens carried on decay-accelerating factor (DAF). DAF is found in the cell membranes of RBCs, granulocytes, platelets, and lymphocytes and is widely represented in other body tissues. Sequence analyses of DNA were performed on a blood sample from a 91-year-old Japanese woman whose serum contained an alloantibody to a high-prevalence antigen in the Cromer blood group system (anti-IFC). A blood sample from her daughter was also studied. Sequence analysis revealed a substitution of 508C7>T in exon 4 of DAF in the proband. The proband's daughter was heterozygous for 508C/T. This study describes an Inab phenotype in which the 508C>T nonsense mutation is predicted to change arginine at amino acid residue 136 to a stop codon. This change is in SCR 3 of DAF. This study reports on the molecular basis of a new proband with the Inab phenotype who had no history of intestinal disorders.

Delivery of herpes simplex thymidine kinase bystander effect by engineered human mesothelial cells for the treatment of ovarian cancer

BACKGROUND

Resistance to conventional chemotherapy is a major clinical problem for ovarian cancer, and long-term survival for patients with advanced-stage disease is rare. Other therapeutic strategies, such as gene therapy, have been explored but several limitations exist, which include low viral vector transduction efficiency, host immune response to the vector, and vector toxicity.

METHODS

We developed a cell-based therapy that exploits human mesothelial cells to deliver anticancer modalities for treatment of ovarian cancer. As a proof of concept, we genetically engineered mesothelial with the herpes simplex virus thymidine kinase/ganciclovir (HSVTK/GCV) system to deliver cytotoxicity to human ovarian cancer cells. This system is well characterized, and has been widely used in different gene-therapy based strategies.

RESULTS

Our results demonstrate that HSVTK-modified mesothelial cells are sensitive to GCV killing in vitro and support the HSVTK bystander effect. Engineered mesothelial cells can deliver the HSVTK bystander effect to human ovarian cancer cell-lines, as well as to primary ovarian cancer cells. A significant reduction of tumor growth and prolongation of survival in s.c. and i.p. xenograft mouse models of ovarian cancer are obtained with as little as 1% of HSVTK-expressing mesothelial cells. Intraperitoneal administration of HSVTK-expressing mesothelial cells in an established mouse model of ovarian cancer results in a statistically significant prolonged survival of treated animals. Importantly, distribution studies showed that mesothelial cells localize preferentially to tumor sites.

DISCUSSION

Our study demonstrates the feasibility of using a mesothelial cell-based therapy for treatment of ovarian cancer, and suggests that this strategy should be further explored.

[Structural organization and control of expression of the sop-operon of linear plasmid prophage N15]

Stable inheritance of bacterial chromosomes and low-copy-number plasmids depends on the active partition of replicated molecules between daughter cells. The partition mechanism is well known for circular plasmids F and P1. The mechanism of partition of linear replicons was studied with the example of bacteriophage N15, which persists as a linear plasmid with covalently closed ends on lysogeny, rather than integrating into the Escherichia coli chromosome. Since stable inheritance of N15 is due to the sop operon homologous to sop of the F plasmid, the control of expression of the N15 sop genes was analyzed. The sop promoter (Psop) contains a binding site for bacterial IHF and five CTTTGC copies, which overlap the -35 and -10 elements. The Sop proteins were shown to interact with a Psop-containing DNA fragment in vitro. Transcription of the sop operon is regulated by the Sop proteins: SopA represses Psop, and SopB enhances the repression, having no effect on the promoter activity in the absence of SopA. In N15 lysogenic cells, Psop proved to be repressed. This regulatory mechanism was assumed to ensure production of SopA and SopB in amounts required for the segregation stability of N15 and to neutralize occasional fluctuations of their concentration in the cell.

Improving cancer therapy by non-genotoxic activation of p53

Inactivation of p53 function is a common event in cancer. Approximately 50% of human tumours express mutant p53 and there is evidence that in others, including many childhood tumours, p53 function is impaired in other ways. These defects in p53 function may be due to the alteration of cellular factors that modulate p53 or to the expression of viral oncoproteins. Radiotherapy and many of the chemotherapeutic drugs currently used in cancer treatment are potent activators of p53. However, most of these therapies have a serious drawback, and that is the long-term consequences of their DNA damaging effects. Here, we review the discoveries in p53 research that are most significant to the development of new therapies based on the induction of the transcriptional activity of p53 in a non-genotoxic way and discuss the situations in which this type of approach may be most beneficial.

Ethnic differences in blood pressure and the prevalence of hypertension in England

The objective of this study was to examine the prevalence of hypertension and mean blood pressures among Afro-Caribbeans and South-Asians in England compared with Caucasians. Data from the Birmingham Factory Screen, Birmingham INTERSALT volunteers, and four West Midlands churches were combined into a single database (n = 2853), since all three studies employed identical methods. The cohort comprised 2169 (76%) Caucasians (71% men); 453 (16%) Afro-Caribbean (60% men); and 231 (8%) South-Asian men. The results were that overall prevalence of hypertension (> or =160/95 mm Hg or taking antihypertensives) was greater in both Afro-Caribbean men (31%) and women (34%) (both P < 0.001), compared with Caucasians (19% and 13% respectively), while South-Asian men had a similar overall prevalence to Caucasians (16%). Compared with Caucasians, Afro-Caribbeans had significantly higher mean systolic blood pressure, with higher mean diastolic blood pressures evident among Afro-Caribbean women. After adjustment for age, body mass index, smoking, and weekly alcohol intake, the odds ratios (95% CI) for being hypertensive were 1.56 (1.14 to 2.13; P = 0.005) and 2.40 (1.51 to 3.81; P = 0.0002) for Afro-Caribbean men and women, respectively and 1.31 (0.88 to 1.97; P = 0.19) for South-Asian men, compared with Caucasians. In conclusion the prevalence of hypertension and mean blood pressures are higher among Afro-Caribbeans compared with Caucasians. South-Asian men had similar rates of hypertension and mean blood pressures to Caucasians.

Role of the ATP-binding site of SopA protein in partition of the F plasmid

SopA belongs to a large family of bacterial partition protein ATPases. It helps stabilize the F plasmid by acting as the primary repressor of transcription of the sopAB operon, preventing the destabilizing effects of Sop protein excess. It is also thought to act directly in the F partition mechanism. We have examined the role of SopA in partition and repression by observing the consequences of replacing an invariant ATP-binding site lysine, K120, by glutamine or arginine. Circular dichroism studies of the purified mutant proteins revealed no major differences from wild-type, but in the presence of ADP or ATP each protein showed a characteristic spectrum which suggested a distinct conformational change. The K120Q mutant retained most of the wild-type ATPase activity while the K120R mutant lost it. In neither case was the residual activity stimulated by SopB, as occurs for wild-type SopA. The strength of sop promoter repression by the mutant SopA proteins alone was comparable to that resulting from SopB-enhancement of wild-type SopA, but SopB enhanced repression by the mutant SopA proteins either slightly (K120R) or not at all (K120Q). Mini-Fs in which the sop operon was controlled by a constitutive promoter were destabilized by the mutations, demonstrating the need for SopA and its ATP-binding site in the partition process. The K120R mini-F was lost at the same rate as a mini-F lacking the sopC centromere, the K120Q mutant was lost faster. SopAK120R at high levels was more effective than SopA(+) in disrupting the partition complex, whereas SopAK120Q did not disrupt it at all. These results suggest that one function of SopA in the partition mechanism is to break the paired plasmid structure to allow F molecules to segregate to daughter cells.

Elution characteristics of tobramycin from polycaprolactone in a rabbit model

This study investigated the elution characteristics of tobramycin from polycaprolactone, a bioabsorbable polymer, in a rabbit model. Sixty rabbits were divided into two groups. Group 1 had polycaprolactone rods impregnated with 6% tobramycin surgically implanted into the proximal femoral intramedullary canal. Group 2 received polymethylmethacrylate rods of like size, shape, and antibiotic concentration. Serum and urine samples were obtained, and tobramycin levels were determined via fluorescent immunosorbent assay. Rabbits were sacrificed as long as 56 days after surgery. Local bone tobramycin concentration was determined using the agar diffusion method. Polycaprolactone delivered a significantly higher peak bone concentration of tobramycin (22.4 microg/mL) than did polymethylmethacrylate (13.59 microg/mL). Polycaprolactone also had a more gradual decrease in local tobramycin concentration than did polymethylmethacrylate. Neither polycaprolactone nor polymethylmethacrylate yielded consistently detectable (> 0.1 microg/mL) serum tobramycin levels. Urine concentrations mirrored those seen in bone, with polycaprolactone achieving significantly higher tobramycin concentrations than did polymethylmethacrylate. Polycaprolactone had superior elution characteristics compared with polymethylmethacrylate in this lapine model, suggesting that polycaprolactone might be a promising local antibiotic delivery vehicle for the treatment of osteomyelitis.