Rachael A Hughes

An informal school-based peer-led intervention for smoking prevention in adolescence (ASSIST): a cluster randomised trial

Summary Background Schools in many countries undertake programmes for smoking prevention, but systematic reviews have shown mixed evidence of their effectiveness. Most peer-led approaches have been classroom-based, and rigorous assessments are scarce. We assessed the effectiveness of a peer-led intervention that aimed to prevent smoking uptake in secondary schools. Methods We undertook a cluster randomised controlled trial of 10 730 students aged 12–13 years in 59 schools in England and Wales. 29 schools (5372 students) were randomly assigned by stratified block randomisation to the control group to continue their usual smoking education and 30 (5358 students) to the intervention group. The intervention (ASSIST [A Stop Smoking In Schools Trial] programme) consisted of training influential students to act as peer supporters during informal interactions outside the classroom to encourage their peers not to smoke. Follow-up was immediately after the intervention and at 1 and 2 years. Primary outcomes were smoking in the past week in both the school year group and in a group at high risk of regular smoking uptake, which was identified at baseline as occasional, experimental, or ex-smokers. Analysis was by intention to treat. This study is registered, number ISRCTN55572965. Findings The odds ratio of being a smoker in intervention compared with control schools was 0·75 (95% CI 0·55–1·01) immediately after the intervention (n=9349 students), 0·77 (0·59–0·99) at 1-year follow-up (n=9147), and 0·85 (0·72–1·01) at 2-year follow-up (n=8756). The corresponding odds ratios for the high-risk group were 0·79 (0·55–1·13 [n=3561]), 0·75 (0·56–0·99 [n=3483]), and 0·85 (0·70–1·02 [n=3294]), respectively. In a three-tier multilevel model with data from all three follow-ups, the odds of being a smoker in intervention compared with control schools was 0·78 (0·64–0·96). Interpretation The results suggest that, if implemented on a population basis, the ASSIST intervention could lead to a reduction in adolescent smoking prevalence of public-health importance. Funding MRC (UK).

Long-term immunologic response to antiretroviral therapy in low-income countries: a collaborative analysis of prospective studies

Background: Few data are available on the long-term immunologic response to antiretroviral therapy (ART) in resource-limited settings, where ART is being rapidly scaled up using a public health approach, with a limited repertoire of drugs. Objectives: To describe immunologic response to ART among ART patients in a network of cohorts from sub-Saharan Africa, Latin America, and Asia. Study population/methods: Treatment-naive patients aged 15 and older from 27 treatment programs were eligible. Multilevel, linear mixed models were used to assess associations between predictor variables and CD4 cell count trajectories following ART initiation. Results: Of 29 175 patients initiating ART, 8933 (31%) were excluded due to insufficient follow-up time and early lost to follow-up or death. The remaining 19 967 patients contributed 39 200 person-years on ART and 71 067 CD4 cell count measurements. The median baseline CD4 cell count was 114 cells/μl, with 35% having less than 100 cells/μl. Substantial intersite variation in baseline CD4 cell count was observed (range 61–181 cells/μl). Women had higher median baseline CD4 cell counts than men (121 vs. 104 cells/μl). The median CD4 cell count increased from 114 cells/μl at ART initiation to 230 [interquartile range (IQR) 144–338] at 6 months, 263 (IQR 175–376) at 1 year, 336 (IQR 224–472) at 2 years, 372 (IQR 242–537) at 3 years, 377 (IQR 221–561) at 4 years, and 395 (IQR 240–592) at 5 years. In multivariable models, baseline CD4 cell count was the most important determinant of subsequent CD4 cell count trajectories. Conclusion: These data demonstrate robust and sustained CD4 response to ART among patients remaining on therapy. Public health and programmatic interventions leading to earlier HIV diagnosis and initiation of ART could substantially improve patient outcomes in resource-limited settings.

Associations of gestational weight gain with maternal body mass index, waist circumference, and blood pressure measured 16 y after pregnancy: the Avon Longitudinal Study of Parents and Children (ALSPAC)

Background: Little is known about associations of gestational weight gain (GWG) with long-term maternal health. Objective: We aimed to examine associations of prepregnancy weight and GWG with maternal body mass index (BMI; in kg/m2), waist circumference (WC), systolic blood pressure (SBP), and diastolic blood pressure (DBP) 16 y after pregnancy. Design: This is a prospective study in 2356 mothers from the Avon Longitudinal Study of Parents and Children (ALSPAC)—a population-based pregnancy cohort. Results: Women with low GWG by Institute of Medicine recommendations had a lower mean BMI (−1.56; 95% CI: −2.12, −1.00) and WC (−3.37 cm; −4.91, −1.83 cm) than did women who gained weight as recommended. Women with a high GWG had a greater mean BMI (2.90; 2.27, 3.52), WC (5.84 cm; 4.15, 7.54 cm), SBP (2.87 mm Hg; 1.22, 4.52 mm Hg), and DBP (1.00 mm Hg; −0.02, 2.01 mm Hg). Analyses were adjusted for age, offspring sex, social class, parity, smoking, physical activity and diet in pregnancy, mode of delivery, and breastfeeding. Women with a high GWG had 3-fold increased odds of overweight and central adiposity. On the basis of estimates from random-effects multilevel models, prepregnancy weight was positively associated with all outcomes. GWG in all stages of pregnancy was positively associated with later BMI, WC, increased odds of overweight or obesity, and central adiposity. GWG in midpregnancy (19–28 wk) was associated with later greater SBP, DBP, and central adiposity but only in women with a normal prepregnancy BMI. Conclusions: Results support initiatives aimed at optimizing prepregnancy weight. Recommendations on optimal GWG need to balance contrasting associations with different outcomes in both mothers and offspring.

Health-related quality of life among patients cured by surgery for esophageal cancer

Little is known regarding the long‐term, health‐related quality of life (HRQL) of survivors of esophagectomy for cancer.

Immediate Postnatal Growth Is Associated With Blood Pressure in Young Adulthood: The Barry Caerphilly Growth Study

There is a consistent inverse association between birth weight and systolic blood pressure; however, few studies have been able to examine the immediate postnatal period. We have examined whether accelerated postnatal growth predicts adult systolic and diastolic blood pressure. We followed up participants from the Barry Caerphilly Growth Study. Blood pressure data were obtained on 679 of the original 951 subjects (73%) aged ≈25 years. Both multivariable linear regression and spline models were used to examine the association among weight, length, and growth velocities with systolic blood pressure and diastolic blood pressure. Both statistical approaches showed that birth weight was inversely associated with systolic blood pressure. Only the spline models found that immediate (0 to 5 months) weight gain (&bgr; coefficient: 1.29 mm Hg; 95% CI: 0.36 to 2.23; P=0.007) and weight gain between 1 year and 9 months to 5 years (&bgr; coefficient: 1.44 mm Hg; 95% CI: 0.31 to 2.57; P=0.01) were independently associated with systolic blood pressure, whereas only immediate weight gain (&bgr; coefficient: 0.74 mm Hg; 95% CI: 0.08 to 1.41; P=0.03) was associated with diastolic blood pressure. This is the first study to demonstrate that only immediate postnatal growth predicts diastolic blood pressure in term births, whereas it adds further evidence that both birth weight and postnatal growth are associated with systolic blood pressure in support of both the fetal origins and growth acceleration hypotheses.

Health-related quality of life after minimally invasive oesophagectomy

Open oesophagectomy has a detrimental impact on health‐related quality of life (HRQL), with recovery taking up to a year. Minimally invasive oesophagectomy (MIO) may enable a more rapid recovery of HRQL.

Health‐related quality of life among patients with adenocarcinoma of the gastro‐oesophageal junction treated by gastrectomy or oesophagectomy

Tumours of the gastro‐oesophageal junction may be resected by total gastrectomy (TG) or transthoracic oesophagectomy (TTO). This study compared health‐related quality of life (HRQL) following these procedures.

Total synthesis of the thiopeptide amythiamicin DElectronic supplementary information (ESI) available: Spectroscopic data for synthetic 1. See http://www.rsc.org/suppdata/cc/b4/b401580k/

The first total synthesis of the thiopeptide antibiotic amythiamicin D is described.

Health-related quality of life and survival in the 2 years after surgery for gastric cancer

BACKGROUND This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer. METHODS Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for 2 years afterwards. Changes of 10 or more points on a 0-100 scale were considered clinically significant. RESULTS Some 30 patients were alive after 2 years (52%). In the first 3 months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by 6 months in patients who subsequently were alive at 2 years, although at least a third of patients experienced specific symptoms, even 6 months after surgery, especially diarrhoea. For those dying within 2 years, some postoperative functional HRQL recovery occurred, but many symptoms were common. CONCLUSIONS Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some 2 years. Patients who die within 2 years may experience limited postoperative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

Reducing Smoking in Adolescents: Cost-Effectiveness Results From the Cluster Randomized ASSIST (A Stop Smoking In Schools Trial)

Introduction: School-based smoking prevention programmes can be effective, but evidence on cost-effectiveness is lacking. We conducted a cost-effectiveness analysis of a school-based “peer-led” intervention. Methods: We evaluated the ASSIST (A Stop Smoking In Schools Trial) programme in a cluster randomized controlled trial. The ASSIST programme trained students to act as peer supporters during informal interactions to encourage their peers not to smoke. Fifty-nine secondary schools in England and Wales were randomized to receive the ASSIST programme or usual smoking education. Ten thousand seven hundred and thirty students aged 12–13 years attended participating schools. Previous work has demonstrated that the ASSIST programme achieved a 2.1% (95% CI = 0%–4.2%) reduction in smoking prevalence. We evaluated the public sector cost, prevalence of weekly smoking, and cost per additional student not smoking at 24 months. Results: The ASSIST programme cost of £32 (95% CI = £29.70–£33.80) per student. The incremental cost per student not smoking at 2 years was £1,500 (95% CI = £669–£9,947). Students in intervention schools were less likely to believe that they would be a smoker at age 16 years (odds ratio [OR] = 0.80; 95% CI = 0.66–0.96). Conclusions: A peer-led intervention reduced smoking among adolescents at a modest cost. The intervention is cost-effective under realistic assumptions regarding the extent to which reductions in adolescent smoking lead to lower smoking prevalence and/or earlier smoking cessation in adulthood. The annual cost of extending the intervention to Year 8 students in all U.K. schools would be in the region of £38 million and could result in 20,400 fewer adolescent smokers.