Beyond the puff: qualitative insights into smoking behaviours and societal perceptions among university students in India

Objectives
The objective of the study was to understand the smoking behaviour of adults and how societal perceptions influence the smoking behaviour of university students.

Design
Qualitative study.

Setting
National Institute of Medical Sciences university, India.

Participants
20 face-to-face interviews were carried out among university students who were in the age group of 19–30 years using a combination of purposive sampling, followed by snowball sampling methods.

Results
Qualitative responses revealed that stress, cravings for cigarettes and mealtimes were key triggers for smoking behaviour. Many participants felt guilty about their smoking and often became irritated by advice from non-smoking friends. All participants had experienced negative health effects, including physical and sensory issues, as well as other adverse experiences. Students expressed a dislike for judgemental attitudes from society. They respected elders and found it difficult to smoke in front of them. Rather than being blamed for their smoking, they preferred supportive assistance to help them quit.

Conclusions
The study highlights the importance of understanding college students’ smoking behaviour, as it greatly influences their smoking habits. Cessation efforts should target this group and emphasise the negative experiences associated with smoking. Additionally, students recommend creating a non-judgemental and supportive environment to aid in quitting, rather than a judgemental and blaming society.

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What are the expectations of patients regarding the communication of nuclear imaging results? Insights from a French national survey of 723 patients

Objectives
There are still some controversies regarding the role of nuclear medicine practitioners in delivering imaging findings to the patients as well as content and magnitude of information to be delivered. The aim of the study was to identify the expectations of patients regarding the communication of results from a nuclear imaging examination.

Design
A national survey was conducted among patients who underwent a nuclear imaging examination. In each participating centre, a questionnaire was administered to the patients.

Setting
Primary care in France.

Participants
The study involved 723 patients from 12 French Nuclear Medicine departments (university hospitals, general hospitals, comprehensive cancer centres and private centres).

Outcome measure
The primary endpoint was to determine the proportion of patients expressing a wish to consult a nuclear medicine physician at the end of the imaging session and to assess the rationale underlying this preference.

Results
Our results indicate that a significant majority (73.2%) of patients prefer to meet primarily with the nuclear medicine physician to receive an explanation of the imaging findings. Concerning the disclosure of these results, 66.1% of the patients prefer to receive an explanation from the nuclear medicine physician, either alongside or instead of the requesting physician alone. Furthermore, nearly all patients (96.1%) who wish to meet with the nuclear medicine physician also indicate their willingness to receive the examination results, even if they are unfavourable.

Conclusions
This study underscores the clear preference of patients to interact with nuclear medicine specialists and benefit from their expertise, irrespective of whether the results are positive or negative. This emphasises the critical need for implementing standardised recommendations across countries and ensuring adequate training for nuclear physicians to actually meet this demand. This aspect is likely to distinguish a nuclear medicine physician from a scan interpreter.

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Estimating diagnostic delay in patients with pituitary adenomas in Sweden: a cross-sectional study

Objective
A delayed diagnosis of pituitary adenomas (PAs) can lead to increased morbidity and reduced quality of life. The aim was to estimate diagnostic delay and investigate the concordance between patient-reported symptoms and the medical record documentation in patients with PA.

Design
Cross-sectional study.

Setting
Seven university hospitals.

Participants
654 patients: non-functioning PA (NFPA, 314), prolactinoma (118), acromegaly (164) and Cushing’s Disease (CD, 58).

Data collection
Questionnaires and medical record extraction.

Primary and secondary outcomes
Type of first healthcare contact, delay of PA diagnosis and patient-reported symptoms and symptoms documented in medical records.

Results
First healthcare contact was usually a general practitioner. Estimated time from symptoms to diagnosis varied from 10 years (9%). The longest diagnostic delays were observed in acromegaly and CD. A longer delay was observed in women compared with men (p0.6) and for menstrual irregularities in prolactinomas (Cohen’s kappa >0.7).

Conclusion
We report a large variation in symptom duration before diagnosis with a substantial diagnostic delay in patients with CD and acromegaly. An increased awareness about endocrine diseases in the general population and health professionals may contribute to earlier diagnosis of pituitary adenomas.

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COSMOS: Interrater and Intrarater Reliability Study of a Novel Outcome Measure

Stroke, Volume 56, Issue 7, Page 1958-1964, July 1, 2025. The vast majority of patients with minor stroke achieve what are considered good or excellent outcomes on the modified Rankin Scale (0–1/0–2), yet many are dissatisfied with their outcomes. There is a need for a functional outcome measure tailored for minor stroke that better reflects the spectrum of clinical outcomes within this population. We developed the Canadian Outcome Scale for Minor Stroke (COSMOS) and performed an interrater and intrarater reliability study. COSMOS is a 7-point scale ranging from 0 (no symptoms) to 6 (loss of independence for an instrumental or basic activity of daily living or worse), which accounts for performance limitations and losses of a person’s hobbies or passions and of their employment, educational, service, or caregiving pursuits, besides just activities of daily living. One hundred test case vignettes were developed. Stroke physicians, fellows, and research nurses/staff were invited to review training materials and provide the COSMOS grade for 20 cases representing all COSMOS grades (0–6). After a minimum 2 weeks’ wash-out period, participants were asked to grade the same 20 cases again. Interrater and intrarater agreement were assessed using Cohen κ, weighted κ, percentage agreement, and intraclass correlation coefficient. Among 33 participants (18 attending physicians, 9 stroke fellows, and 6 research staff/nurses; median 12.5 years of experience), COSMOS had substantial interrater reliability (80.5% agreement [95% CI, 75.7%–85.3%]; Cohen κ, 0.77 [95% CI, 0.72–0.84]) and almost-perfect intrarater reliability overall (87.1% agreement [95% CI, 84.4%–89.7%]; Cohen κ, 0.85 [95% CI, 0.82–0.88]); weighted κ showed almost perfect agreement for both interrater (0.88 [95% CI, 0.85–0.92]) and intrarater reliability (0.92 [95% CI, 0.90–0.94]). The overall chance-adjusted simultaneous intrarater/interrater agreement using intraclass correlation coefficient was 0.95 (95% CI, 0.94–0.97). Results were similar with substantial to almost-perfect agreement when considering key subgroups based on position (attendings, fellows, research nurses/staff) and years of experience. In conclusion, the newly proposed COSMOS scale demonstrated substantial interrater and intrarater reliability. The scale merits further study in cohort studies and clinical trials of minor stroke.

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Assessing the impact of novel social media policies in the USA restricting youth exposure to food and beverage advertisements: a protocol for a difference-in-difference study

Introduction
Social media is the most prominent source of online food and beverage advertisements (ads) seen by adolescents. Companies target adolescent social media users with ads that feature calorie-dense, nutrient-poor products, and exposure to ads drives poor diet and risk for future diet-related diseases. Black, Hispanic and lower socio-economic status youth are exposed to significantly more ads than White peers. Several state-level policies in the USA have passed restricting youth from accessing social media without parental approval, and some policies have banned advertising to youth. This protocol paper describes a current study that aims to understand the impact of such policies in two states, Louisiana and Texas, as they were among the first to be implemented with racially/ethnically diverse populations.

Methods and analysis
This study employs a repeated cross-sectional difference-in-difference design in which 700 youth ages 13–17 years are being recruited each year for 5 years (Louisiana n=175, Texas n=175, matched comparisons from other states n=350). Youth screen record their mobile devices for 60 minutes while they browse social media platforms (eg, TikTok, Instagram) or use the internet. They also complete a brief survey about a variety of topics (eg, health behaviours, mental health). Adolescents are compensated for screen recording ($75) and the survey ($25). Study team members are coding recordings for several characteristics, including media platforms used, appearances of food or beverages, and food or beverage type. We will estimate the impact of policies on food and beverage ads seen per hour using Ordinary Least Squares regression models and heterogeneity-robust standard errors clustered at the state level (by year and cumulatively). We will run additional models with interaction terms with income and race/ethnicity, separately, to test the role of the policies on health disparities.

Ethics and dissemination
Study procedures have been approved by the Institutional Review Board of the NYU Grossman School of Medicine. We will distribute findings in peer-reviewed journals and at local and national conferences. To complement traditional dissemination pathways, we will create infographics to share with relevant community stakeholders. We will also share findings with policymakers in states that have passed or considered similar policies.

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Protocol for the economic evaluation of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder (RaCeR 2)

Introduction
RaCeR 2 is a pragmatic multicentre, open-label, randomised controlled trial, with full economic evaluation. The primary aim is to assess whether individualised (early) patient-directed rehabilitation (EPDR) results in less shoulder pain and disability at 12 weeks postrandomisation following surgical repair of full-thickness tears of the rotator cuff of the shoulder compared with the current standard (delayed) rehabilitation. This paper provides the protocol for the RaCeR 2 health economic evaluation.

Methods and analysis
The health economic analysis of RaCeR 2 is made up of three phases: (1) development of an initial state-transition model structure, (2) within-trial cost consequence analysis and (3) long-term model-based cost-effectiveness analysis (CEA) from the National Health Service and Personal Social Service perspective in England. Descriptive statistics (eg, mean, standard deviation, 95% confidence intervals and minimum and maximum values) will be reported for within-trial resource use, costs and health-related quality of life (HRQoL). Health state-specific costs and HRQoL will be estimated using regression model approaches and used to inform a state-transition simulation model designed to quantify the long-term costs and quality-adjusted life years (QALYs) experienced by patients over the model’s time horizon. Where appropriate, final CEA model results will be reported as cost per QALY gained for individualised EPDR versus standard (delayed) rehabilitation. Model assumptions and overall parameter uncertainty will be tested using probabilistic sensitivity analysis and scenario analyses. All regression analyses will be adjusted for baseline participant demographic and symptomatic characteristics.

Ethics and dissemination
A favourable ethical review was granted by London-Stanmore Research Ethics Committee (23/LO/0195) on 13 April 2023. Findings will be disseminated in peer-reviewed journals, at scientific conferences, and via the study website.

Trial registration number
ISRCTN11499185

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Benefits of heart valve clinics for patients: a systematic review

Objective
To evaluate the impact of heart valve clinics (HVCs) versus standard of care (SOC) on disease detection, timing of intervention and clinical outcomes in patients with valvular heart disease (VHD).

Design
A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in PROSPERO (CRD42024518787).

Data sources
PubMed, Embase, Web of Science, Scopus and the Cochrane Library from inception to 1 May 2025.

Eligibility criteria
Randomised controlled trials or cohort studies comparing patients managed in HVCs with those receiving SOC, and reporting on outcomes such as mortality, cardiac events, time to symptom reporting or symptom severity. Studies were excluded if they lacked detailed HVC protocols, single-arm designs or were published as abstracts only.

Data extraction and synthesis
Two reviewers independently screened titles, abstracts and full texts, with discrepancies resolved by a senior adjudicator. The Newcastle-Ottawa Scale (NOS) was used to assess the risk of bias. Meta-analysis was not conducted due to heterogeneity among studies.

Results
Three high-quality prospective cohort studies (N=1082) were included. Two studies reported mortality and cardiac events: one, a before-and-after controlled trial (n=382), recorded 11 deaths in the HVC group; the other reported 4 deaths in the HVC group (n=156) versus 17 deaths in the SOC group (n=156) (p

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Validation of salivary uric acid remote self-monitoring for early prediction of hypertensive disorders of pregnancy: study protocol for a prospective, observational, multicentre cohort study

Introduction
Hypertensive disorders of pregnancy (HDP), including gestational hypertension and pre-eclampsia, affect approximately 10% of pregnancies worldwide and contribute significantly to fetal and maternal morbidity and mortality. Early identification of HDP would facilitate targeted surveillance and personalised care in order to mitigate the severity of complications and improve pregnancy outcomes. Uric acid is a marker of oxidative stress, inflammation and endothelial dysfunction, and has been proposed as a predictor of hypertensive disease. Salurate is a salivary uric acid test that has the potential to identify pregnant women at risk of developing HDP several weeks before clinical manifestation.

Methods and analysis
This is a prospective, multicentre, observational, cohort study with health economics evaluation. Women aged 16 and above, with a viable singleton pregnancy at 1:300 will be eligible for recruitment. Participants will perform weekly remote salivary uric acid testing from enrolment until the conclusion of pregnancy and upload results of colourimetric paper tests via a smartphone application. We will validate a predictive algorithm that analyses colour data from several consecutive samples to detect patterns that predict whether HDP is likely to occur. The primary outcome is test performance for the prediction of HDP. Secondary outcomes include adherence to sampling and test performance for predicting gestational diabetes, stillbirth and fetal growth restriction. Data on pregnancy outcomes will be collected from the medical notes, compared with the predictions made by the algorithm and subjected to statistical analysis.

Ethics and dissemination
Approval has been obtained from Cambridge East Research Ethics Committee (REC reference 24/EE/0123), Medicines and Healthcare products Regulatory Agency (CI/2024/0038/GB) and Health Research Authority (IRAS ID 337290). Results of the study will be published in peer-reviewed journals and presented at national and international conferences.

Trial registration number
ISRCTN17992452.

Protocol version
4, 4 July 2024.

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