Early initiation of substance use significantly increases one's risk of developing substance use dependence and mental disorders later in life. To interrupt this trajectory, effective prevention during the adolescent period is critical. Parents play a key role in preventing substance use and related harms among adolescents and parenting interventions have been identified as critical components of effective prevention programs. Despite this, there is currently no substance use prevention program targeting both students and parents that adopts online delivery to overcome barriers to implementation and sustainability. The Climate Schools Plus (CSP) program was developed to meet this need. CSP is an online substance use prevention program for students and parents, based on the effective Climate Schools prevention program for students. This paper describes the development of the parent component of CSP including a literature review and results of a large scoping survey of parents of Australian high school students (n = 242). This paper also includes results of beta-testing of the developed program with relevant experts (n = 10), and parents of Australian high school students (n = 15). The CSP parent component consists of 1) a webinar which introduces shared rule ranking, 2) online modules and 3) summaries of student lessons. The parent program targets evidence-based modifiable factors associated with a delay in the onset of adolescent substance use and/or lower levels of adolescent substance use in the future; namely, rule-setting, monitoring, and modelling. To date, this is the first combined parent-student substance use prevention program to adopt an online delivery method.

BackgroundEarly initiation of alcohol and cannabis use markedly increases the risk of harms associated with use, including the development of substance use and mental health disorders. To interrupt this trajectory, effective prevention during the adolescent period is critical. Despite evidence showing that parents can play a critical role in delaying substance use initiation, the majority of prevention programs focus on adolescents only. Accordingly, the Climate Schools Plus (CSP) program was developed to address this gap.ObjectiveThis paper outlines the protocol for a cluster randomized controlled trial (RCT) of the CSP program, a novel internet-based program for parents and students to prevent adolescent substance use and related harms. The CSP program builds on the success of the Climate Schools student programs, with the addition of a newly developed parenting component, which allows parents to access the internet-based content to equip them with knowledge and skills to help prevent substance use in their adolescents.MethodsA cluster RCT is being conducted with year 8 students (aged 12-14 years) and their parents from 12 Australian secondary schools between 2018 and 2020. Using blocked randomization, schools are assigned to one of the two groups to receive either the CSP program (intervention) or health education as usual (control). The primary outcomes of the trial will be any student alcohol use (≥1 standard alcoholic drink/s) and any student drinking to excess (≥5 standard alcoholic drinks). Secondary outcomes will include alcohol- and cannabis-related knowledge, alcohol use-related harms, frequency of alcohol consumption, frequency of drinking to excess, student cannabis use, parents’ self-efficacy to stop their children using alcohol, parental supply of alcohol, and parent-adolescent communication. All students and their parents will complete assessments on three occasions—baseline and 12 and 24 months postbaseline. In addition, students and parents in the intervention group will be asked to complete program evaluations on two occasions—immediately following the year 8 program and immediately following the year 9 program.ResultsAnalyses will be conducted using multilevel, mixed-effects models within an intention-to-treat framework. It is expected that students in the intervention group will have less uptake and excessive use of alcohol compared with the students in the control group.ConclusionsThis study will provide the first evaluation of a combined internet-based program for students and their parents to prevent alcohol and cannabis use.Trial RegistrationAustralian New Zealand Clinical Trials Registry ACTRN12618000153213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374178 (Archived by WebCite at http://www.webcitation.org/71E0prqfQ)Registered Report IdentifierRR1-10.2196/10849

Background: We investigated the predictive value of 11 serum biomarkers for renal and mortality endpoints in people with chronic kidney disease (CKD). Methods: Adults with CKD (n=139) were enrolled from outpatient clinics between February 2014 and November 2016. Biomarker quantification was performed using two multiplex arrays on a clinical-grade analyser. Relationships between biomarkers and renal and mortality endpoints were investigated by random forests and Cox proportional hazards regression. Results: The cohort was 56% male. Mean age was 63 years and median [IQR] CKD-EPI eGFR was 33 [24-51] mL/min/BSA. Fifty-six (40%) people developed a composite endpoint defined as  ≥40% decline in eGFR, doubling of serum creatinine, renal replacement therapy, or death over median follow-up of 5.4 [4.7-5.7] years. Prediction of the composite endpoint was better with random forests trained on serum biomarkers compared with clinical variables (area under the curve 0.81 vs 0.78). Predictive performance of biomarkers was further enhanced when considered alongside clinical variables (area under the curve 0.83 vs 0.81 for biomarkers alone). Patients (n=27, 19%) with high soluble tumour necrosis factor receptor-1 ( ≥3 ng/mL) and neutrophil gelatinase-associated lipocalin ( ≥156 ng/mL) coupled with low complement 3a des-arginine (<2,368 ng/mL) almost universally (96%) developed the composite renal and mortality endpoint. C-reactive protein (adjusted hazard ratio, 1.4; 95% confidence interval, 1.1 to 1.8), neutrophil gelatinase-associated lipocalin (adjusted hazard ratio, 2.8; 95% confidence interval, 1.3 to 6.1) and complement 3a des-arginine (adjusted hazard ratio, 0.6; 95% confidence interval, 0.4 to 0.96) independently predicted time to the composite endpoint. Conclusions: Outpatients with the triad of high soluble tumour necrosis factor receptor-1 and neutrophil gelatinase-associated lipocalin coupled with low complement 3a des-arginine had high adverse event rates over 5-year follow-up. Incorporation of serum biomarkers alongside clinical variables improved prediction of CKD progression and mortality. Our findings require confirmation in larger, more diverse patient cohorts.

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