Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial

BACKGROUND

People with severe mental illnesses such as schizophrenia are three times more likely to smoke than the wider population, contributing to widening health inequalities. Smoking remains the largest modifiable risk factor for this health inequality, but people with severe mental illness have not historically engaged with smoking cessation services. We aimed to test the effectiveness of a combined behavioural and pharmacological smoking cessation intervention targeted specifically at people with severe mental illness.

METHODS

In the smoking cessation intervention for severe mental illness (SCIMITAR+) trial, a pragmatic, randomised controlled study, we recruited heavy smokers with bipolar disorder or schizophrenia from 16 primary care and 21 community-based mental health sites in the UK. Participants were eligible if they were aged 18 years or older, and smoked at least five cigarettes per day. Exclusion criteria included substantial comorbid drug or alcohol problems and people who lacked capacity to consent at the time of recruitment. Using computer-generated random numbers, participants were randomly assigned (1:1) to a bespoke smoking cessation intervention or to usual care. Participants, mental health specialists, and primary care physicians were unmasked to assignment. The bespoke smoking cessation intervention consisted of behavioural support from a mental health smoking cessation practitioner and pharmacological aids for smoking cessation, with adaptations for people with severe mental illness-such as, extended pre-quit sessions, cut down to quit, and home visits. Access to pharmacotherapy was via primary care after discussion with the smoking cessation specialist. Under usual care participants were offered access to local smoking cessation services not specifically designed for people with severe mental illnesses. The primary endpoint was smoking cessation at 12 months ascertained via carbon monoxide measurements below 10 parts per million and self-reported cessation for the past 7 days. Secondary endpoints were biologically verified smoking cessation at 6 months; number of cigarettes smoked per day, Fagerström Test for Nicotine Dependence (FTND) and Motivation to Quit (MTQ) questionnaire; general and mental health functioning determined via the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) questionnaire, and 12-Item Short Form Health Survey (SF-12); and body-mass index (BMI). This trial was registerd with the ISRCTN registry, number ISRCTN72955454, and is complete.

FINDINGS

Between Oct 7, 2015, and Dec 16, 2016, 526 eligible patients were randomly assigned to the bespoke smoking cessation intervention (n=265) or usual care (n=261). 309 (59%) participants were male, median age was 47·2 years (IQR 36·3-54·5), with high nicotine dependence (mean 24 cigarettes per day [SD 13·2]), and the most common severe mental disorders were schizophrenia or other psychotic illness (n=343 [65%]), bipolar disorder (n=115 [22%]), and schizoaffective disorder (n=66 [13%]). 234 (88%) of intervention participants engaged with the treatment programme and attended 6·4 (SD 3·5) quit smoking sessions, with an average duration of 39 min (SD 17; median 35 min, range 5-120). Verified quit data at 12 months were available for 219 (84%) of 261 usual care and 223 (84%) of 265 intervention participants. The proportion of participants who had quit at 12 months was higher in the intervention group than in the usual care group, but non-significantly (34 [15%] of 223 [13% of those assigned to group] vs 22 [10%] of 219 [8% of those assigned to group], risk difference 5·2%, 95% CI -1·0 to 11·4; odds ratio [OR] 1·6, 95% CI 0·9 to 2·9; p=0·10). The proportion of participants who quit at 6 months was significantly higher in the intervention group than in the usual care group (32 [14%] of 226 vs 14 [6%] of 217; risk difference 7·7%, 95% CI 2·1 to 13·3; OR 2·4, 95% CI 1·2 to 4·6; p=0·010). The incidence rate ratio for number of cigarettes smoked per day at 6 months was 0·90 (95% CI 0·80 to 1·01; p=0·079), and at 12 months was 1·00 (0·89 to 1·13; p=0·95). At both 6 months and 12 months, the intervention group was non-significantly favoured in the FTND (adjusted mean difference 6 months -0·18, 95% CI -0·53 to 0·17, p=0·32; and 12 months -0·01, -0·39 to 0·38, p=0·97) and MTQ questionnaire (adjusted mean difference 0·58, -0·01 to 1·17, p=0·056; and 12 months 0·64, 0·04 to 1·24, p=0·038). The PHQ-9 showed no difference between the groups (adjusted mean difference at 6 months 0·20, 95% CI -0·85 to 1·24 vs 12 months -0·12, -1·18 to 0·94). For the SF-12 survey, we saw evidence of improvement in physical health in the intervention group at 6 months (adjusted mean difference 1·75, 95% CI 0·21 to 3·28), but this difference was not evident at 12 months (0·59, -1·07 to 2·26); and we saw no difference in mental health between the groups at 6 or 12 months (adjusted mean difference at 6 months -0·73, 95% CI -2·82 to 1·36, and 12 months -0·41, -2·35 to 1·53). The GAD-7 questionnaire showed no difference between the groups (adjusted mean difference at 6 months -0·32 95% CI -1·26 to 0·62 vs 12 months -0·10, -1·05 to 0·86). No difference in BMI was seen between the groups (adjusted mean difference 6 months 0·16, 95% CI -0·54 to 0·85; 12 months 0·25, -0·62 to 1·13).

INTERPRETATION

This bespoke intervention is a candidate model of smoking cessation for clinicians and policy makers to address high prevalence of smoking. The incidence of quitting at 6 months shows that smoking cessation can be achieved, but the waning of this effect by 12 months means more effort is needed for sustained quitting.

FUNDING

National Institute for Health Research Health Technology Assessment Programme.

Effect of supervised aerobic exercise rehabilitation on physical fitness and quality-of-life in survivors of critical illness: an exploratory minimized controlled trial (PIX study)

Background

Evidence is limited for the effectiveness of interventions for survivors of critical illness after hospital discharge. We explored the effect of an 8-week hospital-based exercise-training programme on physical fitness and quality-of-life.

Methods

In a parallel-group minimized controlled trial, patients were recruited before hospital discharge or in the intensive care follow-up clinic and enrolled 8–16 weeks after discharge. Each week, the intervention comprised two sessions of physiotherapist-led cycle ergometer exercise (30 min, moderate intensity) plus one equivalent unsupervised exercise session. The control group received usual care. The primary outcomes were the anaerobic threshold (in ml O₂ kg⁻¹ min⁻¹) and physical function and mental health (SF-36 questionnaire v.2), measured at Weeks 9 (primary time point) and 26. Outcome assessors were blinded to group assignment.

Results

Thirty patients were allocated to the control and 29 to the intervention. For the anaerobic threshold outcome at Week 9, data were available for 17 control vs 13 intervention participants. There was a small benefit (vs control) for the anaerobic threshold of 1.8 (95% confidence interval, 0.4–3.2) ml O₂ kg⁻¹ min⁻¹. This advantage was not sustained at Week 26. There was evidence for a possible beneficial effect of the intervention on self-reported physical function at Week 9 (3.4; −1.4 to 8.2 units) and on mental health at Week 26 (4.4; −2.4 to 11.2 units). These potential benefits should be examined robustly in any subsequent definitive trial.

Conclusions

The intervention appeared to accelerate the natural recovery process and seems feasible, but the fitness benefit was only short term.

Clinical trial registration

Current Controlled Trials ISRCTN65176374 (http://www.controlled-trials.com/ISRCTN65176374).

Effect of shade on body temperature and performance of feedlot steers

A 120-d feedlot study using 164 Angus steers (BW = 396.7 ± 7.0 kg) was undertaken in Queensland Australia (24°84' S, 149°78' N) to determine the effect of shade on body temperature (T(B)) and performance. Cattle were allocated to 20 pens: 16 with an area of 144 m(2) (8 steers/pen) and 4 with an area of 168 m(2) (9 steers/pen). Treatments (10 pens/treatment) were unshaded (NS) vs. shaded (SH). Shade (3.3 m(2)/steer) was provided by 80% solar block shade cloth. Before the study (d -31), 63 steers were implanted (between the internal abdominal muscle and the peritoneum at the right side flank) with a T(B) transmitter. Within each pen, 3 steers had a T(B) transmitter. Individual T(B) was obtained every 30 min. The cattle were fed a feedlot diet and had ad libitum access to water. Water usage and DMI were recorded daily on a pen basis. Average daily gain and G:F were calculated on a pen basis. Climatic variables were obtained from an on-site weather station every 30 min. Individual panting scores (PS) were obtained daily at 0600, 1200, and 1600 h. From these, mean PS (MPS) were calculated for each pen. At slaughter (d 121), individual HCW, loin muscle area (LMA), rump fat depth (P8), 12th-rib fat depth, and marbling score were obtained. Mean T(B) was not affected (P > 0.05) by treatment (SH = 39.58°C; NS = 39.60°C). However, during a 21-d heat wave when cattle were exposed to a mean ambient temperature (T(AM)) > 30°C for 8 h each d (T(AM) between 0800 and 1800 h = 29.7°C, and 23.4°C between 1830 and 0730 h), the T(B) of SH steers (40.41 ± 0.10°C) was less (P < 0.01) than the T(B) of NS steers (41.14 ± 0.10°C). During this period, pen-MPS were greater (P < 0.05) for the NS cattle at all observation times. Over the first 6 d of the heat wave, MPS of NS steers at 1200 h was 2.47 (P < 0.01) vs. 1.39 for SH steers. Hip height, DMI, ADG, and G:F were greater (P < 0.05) for SH cattle. Exit BW (final BW) of SH steers (596.1 kg) was greater (P < 0.05) when compared with NS steers (578.6 kg). During the heat wave, DMI was 51% less for NS steers and 39% less for SH steers when compared with the pre-heat wave period (P < 0.01). The HCW of SH steers (315.4 ± 0.8 kg) was greater (P < 0.05) than for NS steers (321.4 ± 0.8 kg). No treatment differences (P > 0.05) were found for LMA, P8, or marbling score. Access to shade improved (P < 0.05) ADG and G:F, increased HCW, and decreased MPS; however, shade did not completely eliminate the impact of high heat load.

UK guidance for non-heart-beating donation

This guidance offers consensus opinion on the optimum management of non-heart-beating organ donation in adult critical care units. The guidance is not meant to dictate practice but rather to offer suggestions as to what might be considered reasonable practice. The following sections mainly relate to the medical aspects of non-heart-beating organ donation. Fuller guidance on other aspects of organ and tissue donation is available on the Society's website (www.ics.ac.uk). There are a number of parallel areas of work, such as the law on consent, the definition of death and revision of the original Code of Practice describing brainstem testing, which means that many aspects of organ donation are changing rapidly. This guidance is designed to help critical care practitioners while these issues are resolved.

A randomized controlled trial of home telecare

We have established a randomized controlled trial of home telecare. The intervention aims to address a growing problem in the National Health Service (NHS), that is, high admission rates of patients with exacerbations of chronic obstructive pulmonary disease (COPD). Equipment procurement for the trial has been difficult, as no single supplier was able to meet the project s full requirements. The fact that the service is provided by existing clinical NHS staff has advantages when considering the generalizability of the results within the NHS. However, there are also disadvantages, since existing staff have little research experience. Considerable time has been required to help staff familiarize themselves with the equipment and become comfortable with its use. This has posed a barrier to the implementation of the service.

Are the proposed limits of energy intake:basal metabolic rate and dietary nitrogen:urinary nitrogen ratios suitable for validation of food intake?

The validity of 7 d weighed records of diet obtained for pre-menopausal Mexican women was assessed by two independent methods: the energy intake:BMR (EI:BMR) and the dietary N:urinary N (DN:UN). For the latter, complete urine collections are required and completeness was assessed from measurements of para-aminobenzoic acid (PABA) excretion. There were forty-six adult female subjects in the study, thirty-four were from Mexico City and twelve were from a rural population in the Central Highlands, Mexico. However, data were rejected from five urban women for whom the PABA excretion data suggested incomplete urine collection on four or more days. BMR was measured with Oxylog portable O2 consumption meters, and physical activity level was assessed from a self-completed activity diary. An approximate relationship between the EI:BMR ratio and the DN:UN ratio suggested that the rejection limits on the EI:BMR ratio recommended by are wider than the limits on the DN:UN ratio recommended by. Using the recommended cut-off points for EI:BMR but wider limits for DN:UN, twenty-one and twenty-five women respectively had acceptable intake records by the two methods, and sixteen of them by both methods. In conclusion the modification of the DN:UN limits to 0.92 and 1.70 to set acceptable intake values makes the use of measurements of N and energy balance comparable. Urine values with PABA recoveries greater than should be rejected, as should UN values validated by less than 3 d.

Activation of extracellular signal-related protein kinases 1 and 2 of the mitogen-activated protein kinase family by lipopolysaccharide requires plasma in neutrophils from adults and newborns

Neutrophils exposed to low concentrations of gram-negative lipopolysaccharide (LPS) become primed and have an increased oxidative response to a second stimulus (e.g., formyl-methionyl-leucyl-phenylalanine [fMLP]). In studies aimed at understanding newborn sepsis, we have shown that neutrophils of newborns are not primed in response to LPS. To further understand the processes involved in LPS-mediated priming of neutrophils, we explored the role of extracellular signal-related protein kinases (ERK 1 and 2) of the mitogen-activated protein kinase family. We found that LPS activated ERK 1 and 2 in cells of both adults and newborns and that activation was plasma dependent (maximal at > or =5%) through LPS-binding protein. Although fibronectin in plasma is required for LPS-mediated priming of neutrophils of adults assessed by fMLP-triggered oxidative burst, it was not required for LPS-mediated activation of ERK 1 and 2. LPS-mediated activation was dose and time dependent; maximal activation occurred with approximately 5 ng of LPS per ml and at 10 to 40 min. We used the inhibitor PD 98059 to study the role of ERK 1 and 2 in the LPS-primed fMLP-triggered oxidative burst. While Western blotting showed that 100 microM PD 98059 completely inhibited LPS-mediated ERK activation, oxidative response to fMLP by a chemiluminescence assay revealed that the same concentration inhibited the LPS-primed oxidative burst by only 40%. We conclude that in neutrophils, LPS-mediated activation of ERK 1 and 2 requires plasma and that this activation is not dependent on fibronectin. In addition, we found that the ERK pathway is not responsible for the lack of LPS priming in neutrophils of newborns but may be required for 40% of the LPS-primed fMLP-triggered oxidative burst in cells of adults.

Collaboration among community members, local health service providers, and researchers in an urban research center in Harlem, New York

The Urban Research Center at the Center for Urban Epidemiologic Studies brings together community members and researchers working in Harlem, New York. A Community Advisory Board (CAB) composed of community members, service providers, public health professionals, and researchers was formed to assist the Center's research and interventions and to guide community partnerships. Through a collaborative process, the CAB identified three public health problems-substance use, infectious diseases, and asthma-as action priorities. To deal with substance use, the Center created a Web-based resource guide for service providers and a "survival guide" for substance users, designed to improve access to community services. To deal with infectious diseases, the Center is collaborating with local community-based organizations on an intervention that trains injection drug users to serve as peer mentors to motivate behavior change among other injection drug users. To deal with asthma, the Center is collaborating with community child care providers on an educational intervention to increase asthma awareness among day care teaching staff, enhance communication between staff and families, and improve the self-management skills of children with asthma. The Center's experience has demonstrated that active communities and responsive researchers can establish partnerships that improve community health.

"Hospital at home" versus hospital care in patients with exacerbations of chronic obstructive pulmonary disease: prospective randomised controlled trial

OBJECTIVES

To compare "hospital at home" and hospital care as an inpatient in acute exacerbations of chronic obstructive pulmonary disease.

DESIGN

Prospective randomised controlled trial with three months' follow up.

SETTING

University teaching hospital offering secondary care service to 350 000 patients.

PATIENTS

Selected patients with an exacerbation of chronic obstructive pulmonary disease where hospital admission had been recommended after medical assessment.

INTERVENTIONS

Nurse administered home care was provided as an alternative to inpatient admission.

MAIN OUTCOME MEASURES

Readmission rates at two weeks and three months, changes in forced expiratory volume in one second (FEV(1)) from baseline at these times and mortality.

RESULTS

583 patients with chronic obstructive pulmonary disease referred for admission were assessed. 192 met the criteria for home care, and 42 refused to enter the trial. 100 were randomised to home care and 50 to hospital care. On admission, FEV(1) after use of a bronchodilator was 36.1% (95% confidence interval 2.4% to 69.8%) predicted in home care and 35.1% (6.3% to 63. 9%) predicted in hospital care. No significant difference was found in FEV(1 )after use of a bronchodilator at two weeks (42.6%, 3.4% to 81.8% versus 42.1%, 5.1% to 79.1%) or three months (41.5%, 8.2% to 74.8% versus 41.9%, 6.2% to 77.6%) between the groups. 37% of patients receiving home care and 34% receiving hospital care were readmitted at three months. No significant difference was found in mortality between the groups at three months (9% versus 8%).

CONCLUSIONS

Hospital at home care is a practical alternative to emergency admission in selected patients with exacerbations of chronic obstructive pulmonary disease.

Self-regulating childhood asthma: a developmental model of family change

This article tests a model of self-regulatory development in which families' cognitive beliefs and behavioral skills for managing asthma symptoms emerge in four successive phases: asthma symptom avoidance, asthma acceptance, asthma compliance, and asthma self-regulation. Confirmatory factor analyses revealed that the hypothesized multiphase model provided the best factorial fit for phase items. Subsequent Guttman analyses of the families' phase scores revealed a high degree of sequential ordering. Finally, trend analyses of family phase differences revealed a significant negative linear relation with measures of asthma severity and a significant positive linear relation with physician care and concern measures, asthma regulatory measures, and beliefs in Western biomedical practices. Despite receiving primary care for asthma at a major metropolitan university hospital, 83% of the sample were classified as precompliant. The phase model of asthma self-regulatory development offers a qualitative approach for investigating the psychological determinants of asthma self-regulatory behavior.

Effects of induced mood states on objective and projective dependency scores

In two experiments involving a total of 144 participants (72 women and 72 men), we examined the effects of induced mood states on college students' scores on widely used objective and projective measures of dependency. In both experiments, induced mood states significantly influenced participants' scores on the projective dependency test but did not affect their scores on the objective dependency test. Findings are discussed in the context of previous studies comparing objective and projective dependency measures and with respect to theoretical frameworks that distinguish implicit from self-attributed dependency needs.

Relationships of objective and projective dependency scores to sex role orientation in college student participants

Research on the dependency-sex role orientation relationship indicates that when objective dependency measures are used, participants show positive correlations between dependency and femininity scores, and negative correlations between dependency and masculinity scores. In this study, a mixed-sex sample of 87 undergraduates (47 women and 40 men) completed widely used objective and projective measures of dependency, and a self-report measure of sex role orientation. Consistent with previous studies in this area, high objective dependency scores were associated with high femininity scores and low masculinity scores in participants of both sexes. There were no relationships between projective dependency scores and sex role orientation scores in participants of either sex. Findings are discussed in the context of theoretical frameworks that distinguish "implicit" dependency needs from "self-attributed" dependency needs. The role that sex role socialization experiences play in determining participants' willingness to acknowledge dependency-related traits and behaviors on self-report tests is also discussed.