Support Provided by Stop-Smoking Practitioners to Co-users of Tobacco and Cannabis: A Qualitative Study.

INTRODUCTION: Co-use of tobacco and cannabis is highly prevalent among cannabis users and is associated with poorer tobacco cessation outcomes. This study explored the barriers and enablers influencing stop-smoking practitioners' ability to provide optimal support to co-users. AIMS AND METHODS: Online semi-structured interviews were audio recorded. Interviewees (n = 20) were UK-based certified stop-smoking practitioners. An interview schedule informed by the "capability", "opportunity", "motivation" (COM-B) model was designed to explore participants' perceived barriers and enablers in better supporting co-users to achieve abstinence of both substances or tobacco harm reduction. The transcripts were analyzed using framework analysis. RESULTS: Capability: Practitioners' lack of knowledge and skills undermines their delivery of smoking cessation interventions to co-users. Interestingly, when cannabis is used for medicinal reasons, practitioners feel unable to provide adequate support. Opportunity: Service recording systems play an important role in screening for co-use and supporting co-users. When responding to clients' specific needs and practitioners' uncertainties, a positive therapeutic relationship and a support network of peers and other healthcare professionals are needed. Motivation: supporting co-users is generally perceived as part of practitioners' roles but there are concerns that co-users are less likely to successfully stop smoking. CONCLUSIONS: Practitioners are willing to support co-users, but their lack of knowledge and access to an appropriate recording system are barriers to doing so. Having a supportive team and a positive therapeutic relationship is perceived as important. Identified barriers can be mostly addressed with further training to improve tobacco cessation outcomes for co-users.

Use of the 2021 UK Medical Research Council guidance to refine the Women's Wellness with Type 2 Diabetes Programme: a mixed-methods study.

BACKGROUND: The Women's Wellness with Type 2 Diabetes Programme (WWDP) is an online behavioural intervention for midlife women living with type 2 diabetes. The gender-specific intervention fosters self-efficacy, encouraging positive wellbeing behaviours to enhance diabetes and menopause outcomes. In 2016, We co-led a feasibility trial and process evaluation with 70 women aged 45-50 years from the UK and Australia. The intervention comprised an e-book, a website, and nurse consultations. The WWDP seemed to improved diabetes distress, self-efficacy, and menopausal symptoms, but with impactful, costly, diabetes nurse input, compromising feasibility and delivery by the NHS. We report WWDP refinement using the 2021 Medical Research Council (MRC) framework for complex interventions to optimise future implementation. METHODS: Intervention refinement was guided by six core MRC elements of context, programme theory, stakeholder engagement, key uncertainties, intervention refinement, and economic considerations. Critical analysis of quantitative and qualitative feasibility data, informed by self-efficacy theory, provided a deeper understanding of how the intervention was used. Eight PPI consultations took place between Sept 1, 2021, and Dec 31, 2022, with three women from diverse cultural and socioeconomic backgrounds and three female diabetes professionals to strengthen the e-book and methods of support for women undertaking the programme. FINDINGS: Context was improved by the feasibility study and the PPI consultations, making the e-book relevant to UK health care. Understanding that self-efficacy was supported through primary use of peer group, and goal setting components supported the existing programme theory. Stakeholder engagement shaped the structure of the online peer support group. The feasibility study revealed uncertainties around goal settings. These uncertainties were addressed by introducing individualised goals focusing on aspects like medication adherence. The nurse support in the intervention was replaced with peer support, which might lead to greater economic feasibility of the programme. An optimised website and individualised goal setting underpin the WWDP. INTERPRETATION: The MRC Framework provides intervention refinement structure, allowing adaptive adjustments based on emerging evidence, feedback, and contextual nuances. Limitations exist. Intervention refinements, including peer support, might affect adherence and unexpected interactions. New components could influence long-term efficacy. FUNDING: Turkish Ministry of National Education.

Effectiveness of interventions for improving physical activity level in working-age people (aged 18-60 years) with type 2 diabetes: a systematic review and meta-analysis.

BACKGROUND: The increasing prevalence of type 2 diabetes in working-age people imposes a substantial societal burden. Although physical activity is crucial for diabetes management, limited evidence exists to inform optimal strategies for promoting physical activity in this population. We aimed to determine and compare the effectiveness of interventions for increasing physical activity level in working-age people with diabetes. METHODS: In this systematic review and meta-analysis, we searched Web of Science, the Cochrane Library, Medline, Embase, PsycINFO, ClinicalTrials.gov, and ICTRP for papers published between Jan 1, 1931, and June 30, 2022, in English. Search terms included "physical activity", "diabetes", and "randomised controlled trial". We included trials reporting the effects of interventions on physical activity level (objectively or subjectively measured) in people with type 2 diabetes aged 18-60 years. Two independent reviewers conducted summary data extraction and quality assessment. We used pairwise random-effects, frequentist network meta-analyses, and meta-regression to obtain pooled effects. Heterogeneity was evaluated using I2 statistic. The risk of bias and certainty of evidence were assessed using the Cochrane risk-of-bias 2 tool and the Grading of Recommendations Assessment, Development, and Evaluation. This study is registered with PROSPERO (CRD42022323165). FINDINGS: We identified 52 trials (6257 participants) from 21 countries (32 Asia, ten North America, eight Europe, one Australia, one Africa). The overall risk of bias was classified as "some concerns" for included studies. Four types of interventions (structured exercise training, physical activity education, psychological intervention, physical activity education plus psychological intervention) were identified. Compared with control groups, the interventions showed significant effects in objectively measured (standardised mean difference 0·77, 95% CI 0·27-1·27, low certainty), subjectively measured (0·88, 0·40-1·35, very low certainty), and overall physical activity (0·82, 0·48-1·16, moderate certainty). Physical activity education exerted large effect in overall physical activity compared with control groups. Psychological intervention exerted large effects in overall physical activity compared with other interventions. Heterogeneity was high (I2=96-97%). Intervention setting (p=0·04) and facilitator (p=0·03) showed effects on heterogeneity. INTERPRETATION: Psychologically modelled education might be the most beneficial way of promoting physical activity. Intervention setting and facilitator type should be considered when designing interventions for improving physical activity level in working-age people with type 2 diabetes. Limitations of this review include restriction to the English language and considerable heterogeneity between studies. FUNDING: King's-China Scholarship Council PhD Scholarship (202108440151).

Adaptation, implementation, and evaluation of an online health sciences training program for brief smoking intervention: A pre-post study in four European countries.

BACKGROUND: Tobacco cessation intervention has a positive impact on quality of care. For health professionals, limited competency in this area may be associated with poor training during their academic programs. There is a clear need to further develop and implement training programs to improve tobacco cessation knowledge, skills, and attitudes among healthcare students. OBJECTIVES: The aim of this study was to assess the effectiveness of the innovative online training program "Brief Intervention in Smoking Cessation" for healthcare students to improve their knowledge, skills, and attitudes. DESIGN: A pre-post evaluation study with a satisfaction assessment tool was used. SETTING: Seven universities from four European countries, including Belgium, Portugal, Spain, and the United Kingdom, participated. PARTICIPANTS: One thousand and seventy-two (1072) undergraduate students participated, with 851 completing the online program. METHODS: All participants completed the "Brief Intervention in Smoking Cessation" online program, which consisted of five theoretical modules, five videos, and three virtual simulation cases between January 2020 and June 2022. Knowledge was assessed by a multiple-choice test, and practical skills were assessed by a simulation algorithm, both of which were developed by education and smoking cessation experts. Competency was achieved when students successfully completed both assessments. Satisfaction was measured using an ad hoc 16-item questionnaire. Pre-post changes in knowledge were assessed using a paired Student's t-test. RESULTS: Eighty-six percent of the students achieved smoking cessation competency. Students significantly improved their knowledge score on a scale of 0 to 10 points, with a mean pre-program score of 3.79 vs a mean post-program score of 7.33 ([-3.7 - -3.4] p < 0.001), acquiring sufficient attitudes and skills (simulation mean of 7.4 out of 10 points). Students were highly satisfied with the program (8.2 out of 10) and recommended it to other students (8.4 out of 10). CONCLUSIONS: The "Brief Intervention in Smoking Cessation" online training program is effective for the acquisition of smoking cessation competencies among European health profession students.

Differentiating people who use cannabis heavily through latent class analysis.

BACKGROUND: People who use cannabis daily or near-daily vary considerably in their daily dosage and use frequency, impacting both experienced effects and adverse consequences. This study identified heavy cannabis user groups according to consumption patterns and factors associated with class membership. METHODS: We conducted a cross-sectional study of 380 Spanish residents (61.8% male; average age = 30.3 years) who had used cannabis ≥ 3 days/week throughout the past year. Participants were recruited through chain referral and cannabis social clubs. We applied latent class analysis (LCA) to cluster participants according to use intensity. LCA indicators included frequency of weekly cannabis use, joints smoked each day, cannabis dosage, and if cannabis was consumed throughout the day or only at specific times. Associations between class membership and socio-demographics, use patterns, motives, supply sources, adverse outcomes, and use of other substances were measured using ANOVA and chi-squared tests. Multinomial regression identified the factors associated with latent class membership. RESULTS: Three latent classes (moderately heavy: 21.8%, heavy: 68.2%, very heavy: 10%) had average weekly cannabis intakes of 2.4, 5.5, and 18.3 g, respectively. Very heavy users were older ([Formula: see text]=17.77, p < 0.01), less educated [Formula: see text]=36.80, p < 0.001), and had used cannabis for longer (F = 4.62, p = 0.01). CAST scores (F = 26.51, p < 0.001) increased across the classes. The prevalence of past-month alcohol use was lower among the heaviest users ([Formula: see text]=5.95, p = 0.05). Cannabis was usually obtained from a club by very heavy users ([Formula: see text]=20.95, p < 0.001). CONCLUSIONS: People who use cannabis heavily present three groups according to frequency and quantity of cannabis consumption. Use intensity is associated with increased cannabis-related problems. Differences among heavy users must be considered in harm reduction interventions in cannabis clubs and indicated prevention.

Knowledge, attitudes, behavioral and organizational factors of health professions students for a competent smoking cessation practice: An instrument adaptation and psychometric validation study in Spanish and English samples.

BACKGROUND: To improve smoking cessation, training of health professions students is essential. However, no specific instrument is available to assess factors that may affect students' learning about smoking cessation practice. AIM: To adapt and validate the Knowledge, Attitudes, Behaviors and Organization questionnaire in the population of undergraduate health professions students. DESIGN: Methodological research. METHODS: The researchers conducted this study with 511 Spanish and 186 English health professions students from four different universities. We used a four-step approach: 1) adaptation of the items to the target population and validation of the content by a panel of experts; 2) a pilot study to test face validity; 3) linguistic adaptation of the Spanish version to English; and 4) the psychometric assessment based on construct validity, criterion validity and internal consistency. RESULTS: Exploratory factor analysis revealed four subscales for the Spanish version, namely 'Individual knowledge and skills', 'Individual attitudes and beliefs', 'Organizational support' and 'Organizational resources', which accounted for 85.1% of the variance. Confirmatory factor analysis in the holdout Spanish and English samples revealed adequate goodness-of-fit values, supporting the factor structure. Hypotheses testing demonstrated significant differences by capacitation in smoking cessation interventions and degree courses, providing further evidence regarding construct validity. All the subscales correlated positively with the criterion variables (5 A's smoking cessation model), except for the 'Organizational resources' subscale, which was not significantly correlated with the 5 A's. The overall Cronbach's alpha was.83 for the Spanish version and.88 for the English one. CONCLUSIONS: Our results provide empirical support for the use of the Knowledge, Attitudes, Behaviors and Organization questionnaire for Students as a reliable and valid instrument to assess knowledge, attitudes, behaviors and organization perceptions in health professions students, which is essential for competent smoking cessation practice. Interestingly, 'Organizational resources' subscale presented the lowest correlations among factors and did not correlate with any component of the 5 A's, suggesting the need of enhancing students' responsibility and involvement during their internships, as well as the interest of some organizations.

Barriers and facilitators to the implementation of midwife-led care for childbearing women in low- and middle-income countries: A mixed-methods systematic review.

BACKGROUND: Evidence from high-income countries demonstrate improvements in maternal and neonatal health with midwife-led care. Midwife-led care is pivotal to meet the United Nations' Sustainable Development Goals. Despite this, successful implementation of midwife-led care in low- and middle-income countries (LMICs) has been limited. It is therefore necessary to understand the factors that influence the implementation of midwife-led care. AIM: This systematic review aimed to synthesize the evidence on barriers and facilitators to the implementation of midwife-led care for childbearing women in LMICs from the perspectives of care recipients, providers and wider stakeholders. METHODS: A mixed-methods systematic review was conducted of primary research studies that expressed the views of those involved in or affected by the implementation of midwife-led care in LMICs. Reporting followed PRISMA guidelines. MEDLINE, EMBASE, PsychINFO, CINAHL, Maternity and Infant Care database (MIDIRS), Global Health and Web of Science databases were systematically searched. Methodological quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Data was analysed and synthesized using the Supporting the Use of Research Evidence (SURE) framework to identify barriers and enabling factors to implementing midwife-led care. FINDINGS: A total of 31 studies from 21 LMICs were included. At the care recipient level, women need adequate knowledge and confidence about midwife-led care to utilise services. At the care provider level, strengthening midwifery education and practice by employing experienced educators and supervisors is essential. Findings also suggest that increased collaboration between funders, professional organisations, practitioners, communities, and the government is necessary for successful implementation. However, adequate and sustained funding for midwife-led care programs is often lacking and political instability contributes to poor implementation in LMICs. CONCLUSION AND IMPLICATIONS FOR PRACTICE AND RESEARCH: There are several enabling factors which increase the success and sustainability of the midwife-led model of care in LMICs. However, current practice guidelines and strategic frameworks need to better reflect the infrastructure and resource limitations of health settings in LMICs.

Fathers' experiences of fetal attachment: A qualitative study.

Paternal-fetal attachment (PFA) is associated with the degree of emotional support offered by fathers during pregnancy and has implications for the safety and quality of a mother's labor and postnatal experiences. This study explored fathers' experiences of PFA including their understanding of the phenomenon and its manifestation. Data were collected through interviews with 10 fathers-to-be and analysis followed an interpretative phenomenological approach. Four themes emerged from the data: trigger moment; awareness of responsibility; transition to fatherhood; and emotional conflict. Most fathers experienced a trigger moment that made the reality of having a baby clear to them and which initiated or intensified feelings of attachment toward the fetus. Male family relatives, friends with children, and antenatal education groups provided support to expectant fathers. However, they felt quite lost in their role and some believed there was insufficient support for their mental health. Findings suggest that different situations can trigger the attachment process and that fathers longed to be included in perinatal care but experienced a lack of support. Raising awareness of the importance of PFA can help initiate the process in fathers and better equip them to contribute during the antenatal period and to future child development.

La afectividad paterno-fetal (PFA) se asocia con el nivel de apoyo emocional que los papás ofrecen durante el embarazo y que tiene implicaciones en cuanto a la seguridad y calidad del proceso de parto de la madre y las experiencias postnatales. Este estudio exploró las experiencias de PFA de los papás, incluyendo su comprensión del fenómeno y su manifestación. Se recogió la información a través de entrevistas con 10 futuros papás y los análisis siguieron un acercamiento fenomenológico interpretativo. Surgieron cuatro temas a partir de la información: el momento de activación del proceso; el estar consciente de la responsabilidad; la transición a la paternidad; y el conflicto emocional. La mayoría de los papás experimentaron el momento en que el proceso de parto se puso en acción como el punto que les aclaró la realidad de tener un bebé y el cual inició o intensificó los sentimientos de afectividad hacia el feto. Parientes varones de la familia y amigos con niños y grupos de educación antenatal ofrecieron apoyo a los futuros papás. Sin embargo, ellos se sintieron muy perdidos en su papel y algunos creyeron que no había apoyo suficiente para su salud mental. Los resultados indican que situaciones diferentes pueden activar el proceso de afectividad y que los papás anhelaban ser incluidos en el cuidado perinatal, pero experimentaron una falta de apoyo. Crear consciencia de la importancia de PFA puede ayudar a iniciar el proceso en los papás y equiparlos mejor para contribuir durante el período antenatal y al futuro desarrollo del niño.

L'attachement paternel-foetal (abrégé ici suivant l'anglais PFA) est lié au degré de soutien émotionnel offert par les pères durant la grossesse et a des implications pour la sécurité et la qualité du travail d'une mère et de ses expériences postnatales. Cette étude a exploré les expériences du PFA des pères y compris le compréhension du phénomène et de sa manifestation. Les données ont été recueillies durant les entretiens avec 10 futurs pères et l'analyse a suivi une approche phénoménologique interprétative. Quatre thèmes ont émergé des données: le moment de déclenchement; la prise de conscience de la responsabilité; la transition à la paternité; et le conflit émotionnel. La plupart des pères ont fait l'expérience d'un moment de déclenchement qui a clarifié la réalité d'avoir un bébé et qui a initié ou intensifié des sentiments d'attachement envers le fœtus. Des membres de la famille mâles, des amis avec des enfants et les groupes de préparation à la naissance ont offert du soutien aux futurs pères. Cependant ces derniers se sentaient très perdus dans leur rôle et certains pensaient recevoir un soutien insuffisant pour leur santé mentale. Les résultats suggèrent que des situations différentes peuvent déclencher le processus d'attachement et que les pères avaient vraiment envie d'être inclus dans le soin périnatal mais faisaient l'expérience d'un manque de soutien. La sensibilisation de l'importance du PFA peut aider à entamer le processus chez les pères et mieux les équiper à contribuer durant la période prénatale ainsi qu'au développement à venir de l'enfant.

Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study.

INTRODUCTION: Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS: An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer. RESULTS: Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed. CONCLUSIONS: The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.

The delivery of smoking cessation interventions by nurses who smoke: A meta-ethnographic synthesis.

AIMS: To gain new insights into the experiences of nurses who smoke and to understand the impact of those experiences on their delivery of smoking cessation interventions. DESIGN: A meta-ethnographic synthesis. DATA SOURCES: CINAHL, Embase, MEDLINE, PsychINFO, Web of Science and grey literature databases were searched from their inception to April 2019. REVIEW METHODS: Meta-ethnography was employed to synthesize findings from included studies. The CASP qualitative checklist was used to appraise the quality of each study, and the GRADE-CERQual approach to appraise review findings. The synthesis is reported in accordance with the eMERGe reporting guidance. RESULTS: From an initial search outcome of 6,019 citations, 13 studies were included detailing the experiences of 195 nurses who were smokers or ex-smokers. Four main themes were identified beliefs, dissonance, coping mechanisms and workplace policies. An integrated conceptual map was proposed on the basis of findings. Nurses who smoke were aware of tobacco harms and their role in addressing tobacco use, which resulted in experiences of guilt and stigma. Workplace policies played a crucial role in the creation of cognitive dissonance. Nurses used different strategies to cope with dissonance such as rationalizing smoking benefits, hiding their smoking behaviour, denial of smoking risks, and failing to engage with smoking cessation interventions. Some nurses expressed more positive aspirations to cope with their dissonance, including a willingness to quit and to embrace smoking cessation interventions with their patients. CONCLUSION: Implementing smoke-free policies and supportive interventions targeting nurses' cognitive dissonance may assist them to quit smoking and improve their engagement in smoking cessation practices.

A systematic review and Bayesian meta-analysis of interventions which target or assess co-use of tobacco and cannabis in single- or multi-substance interventions.

BACKGROUND AND AIMS: Tobacco and cannabis are commonly co-used, and evidence for the influence of co-use on quit outcomes for either substance is mixed. We sought to determine the efficacy of tobacco and/or cannabis use interventions delivered to co-users on cannabis and tobacco use outcomes. METHOD: Systematic review with meta-analysis and narrative review, using five databases and author requests for co-use data. Controlled and uncontrolled intervention studies focusing on treatment of tobacco and/or cannabis use assessing use of both pre- and post-intervention were included. Prevention interventions were excluded. Bayesian meta-analysis was used across four outcome measures: risk ratio for tobacco and cannabis cessation post-intervention separately; standardized mean change for tobacco and cannabis reduction post-intervention separately. Narrative reporting of the same outcome measures in non-randomized clinical trials (non-RCTs) and quality assessment of all included studies were conducted. RESULTS: Twenty studies (12 RCTs and eight uncontrolled) were included. Bayesian meta-analysis with informative priors based on existing data of 11 RCTs (six single-substance, five multi-substance interventions) delivered to co-users (n = up to 1117) showed weak evidence for an effect on cannabis cessation [risk ratio (RR) = 1.48, credibility interval (CrI) = 0.92, 2.49, eight studies] and no clear effect on tobacco cessation (RR = 1.10, CrI = 0.68, 1.87, nine studies). Subgroup analysis suggested that multi-substance interventions might be more effective than cannabis-targeted interventions on cannabis cessation (RR = 2.19, CrI = 1.10, 4.36 versus RR = 1.39, CrI = 0.75, 2.74). A significant intervention effect was observed on cannabis reduction (RR = 0.25, CrI = 0.03, 0.45, nine studies) but not on tobacco reduction (RR = 0.06, CrI = -0.11, 0.23, nine studies). Quality of evidence was moderate, although measurement of co-use and cannabis use requires standardization. Uncontrolled studies targeting both cannabis and tobacco use indicated feasibility and acceptability. CONCLUSIONS: Single and multi-substance interventions addressing tobacco and/or cannabis have not shown a clear effect on either tobacco or cannabis cessation and reduction among co-users. However, dual substance interventions targeting tobacco and cannabis appear feasible.

Understanding how a smoking cessation intervention changes beliefs, self-efficacy, and intention to quit: a secondary analysis of a pragmatic randomized controlled trial.

Although beliefs, self-efficacy, and intention to quit have been identified as proximal predictors of initiation or quitting in young adults, few studies have studied how these variables change after a smoking cessation intervention. To evaluate the changes in the beliefs, self-efficacy, and intention to avoid smoking and determine if these are potential mediators in quitting, following a smoking cessation intervention, aimed at tobacco-dependent college students. Single-blind, pragmatic randomized controlled trial with a 6-month follow-up. A total of 255 smoker students were recruited from September 2013 to February 2014. Participants were randomly assigned to intervention group (n = 133) or to control group (n = 122). The students in the intervention group received a multicomponent intervention based on the Theory of Triadic Influence (TTI). The strategies of this program consisted of a 50 min motivational interview conducted by a nurse and online self-help material. The follow-up included a reinforcing e-mail and group therapy. The smoking-related self-efficacy, belief, and intention scale was used to assess outcomes. Intention to quit smoking is partial moderator explaining 36.2% of the total effects in smoking cessation incidence. At 6 month follow-up, the differences in the mean scores of self-efficacy and intention related to stopping smoking were significantly higher in the intervention than in the control group. A multicomponent intervention based on the TTI, tailored to college students, positively increased the self-efficacy to avoid smoking and the intention to quit, suggesting intention as potential mediator of quitting.

A Systematic Review of Ultrasound-Detected Lipohypertrophy in Insulin-Exposed People with Diabetes.

INTRODUCTION: Lipohypertrophy (LH) is a common complication occurring in diabetes individuals. The most common methods used include palpation, visual examination and/or ultrasound (US). To date, there is limited information on the detection sensitivity among the different techniques used to identify LH. This systematic review aimed to identify studies that examined insulin-related LH using US detection to identify the prevalence, characteristics and morphology of LH, and to compare US and clinical palpation methods for detecting LH. METHODS: Three electronic databases were systematically searched for studies detecting LH using US in insulin users. Articles were screened for eligibility and included studies were appraised using quality assessment tools. The quality of the evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation, and the extracted data was synthesised narratively. RESULTS: Sixteen articles were included in the review providing data on 1722 patients. The prevalence of LH prevalence varied from 14.5% to 88% (median 56.6%). Identified risk factors for the development of included insulin injection behaviour such as a lack of injection site rotation and social factors such as low education level. Four studies compared LH detection by US to palpation, providing inconsistent results. One study showed that palpation detected 64% more LH, whilst two studies demonstrated that US identified 50% more sites and extended areas of LH (additional ~ 5 cm2). Another study provided comparable estimates between palpation and US in clinicians trained to detect LH (97%). CONCLUSION: The evidence highlights a lack of congruence in results pertaining to the detection sensitivity of US and palpation for LH sites. More research with robust study design is needed to verify whether clinically palpation is sufficient to detect LH, or whether US would increase the precision of LH assessment to help address this common clinically significant problem.

A qualitative approach exploring the experiences of smoking and quitting attempts in type 1 diabetes.

AIMS AND OBJECTIVES: To explore the experiences of smoking and quitting attempts in people with type 1 diabetes, including their perceptions of existing services for smoking cessation. BACKGROUND: In the UK, approximately a fifth of the population with type 1 diabetes smoke and despite the adverse effects of smoking, these individuals continue with their smoking habits. There is limited information on the barriers and facilitators to quitting smoking in people with type 1 diabetes. METHODS: This study adopted a qualitative study design using semi-structured individual interviews guided by PRIME theory. Participants (n = 12) were purposively sampled and recruited from two diabetes outpatient clinics in London (UK). Audio-recorded interviews were transcribed verbatim and analysed using the Framework method. RESULTS: Most smokers with type 1 diabetes reported lack of motivation to stop smoking due to the addictive nature of cigarettes. Further barriers to quitting included self-image and habits associated with smoking, such as social activities. Generally, most reported limited awareness about the risks associated with smoking and diabetes. Moreover, the perceived negative attitude towards nicotine replacement therapy and pharmacotherapy impeded their willingness to alter their smoking habits. Nonetheless, these patients suggested that informative guidance from medical professionals and strategies to tackle cravings related to nicotine as helpful approaches to improve quitting attempts. CONCLUSION: Internal and external factors influence quitting attempts among smokers with type 1 diabetes, with particular emphasis on self-image and societal norms. It is evident that existing strategies for smoking cessation recommended by the National Institute for Health and Care Excellence have either not been implemented or not well received by people with type 1 diabetes. RELEVANCE TO CLINICAL PRACTICE: Strategies and resources, such as staff training, to increase delivery of smoking cessation support to patients with diabetes are needed.

National Survey of Smoking and Smoking Cessation Education Within UK Midwifery School Curricula.

INTRODUCTION: Smoking in pregnancy in the United Kingdom remains prevalent (11%). To encourage and support pregnant smokers to quit, midwives must be adequately trained to do so. Substantial curricular gaps have been identified in the smoking cessation training of medical, nursing, and optometry schools. This study aimed to identify the extent of smoking cessation training and assessment in UK midwifery schools. METHODS: All UK undergraduate midwifery schools (n = 53) were invited to complete a web-based survey of their curricular coverage and assessment related to smoking cessation, and perceived barriers to delivering smoking cessation training. RESULTS: Twenty-nine (55%) midwifery schools responded. Most teaching was completed in the initial year of study. All reported teaching the harmful effects of tobacco use. The majority of respondents (83%) reported training students in brief intervention delivery and ways to assist quit attempts. Only 24% of schools in this study included relapse prevention in their curriculum. The most frequently reported barriers to teaching smoking cessation were "lack of knowledge amongst staff" (17%), "no space in a crowded curriculum" (17%), and "administrative problems" (13%). CONCLUSIONS: Midwifery schools are teaching the harmful effects of smoking and providing training on brief interventions. However, in some schools student midwives are not being sufficiently trained on relapse prevention or assessed in the practical skills necessary for delivering evidence-based interventions. IMPLICATIONS: Midwifery schools should revise the content and delivery of smoking cessation training to ensure midwives are equipped with the necessary knowledge and skills to contribute to the challenge of smoking cessation in pregnancy.

Internet-Delivered Self-management Support for Improving Coronary Heart Disease and Self-management-Related Outcomes: A Systematic Review.

INTRODUCTION: Coronary heart disease (CHD) is associated with significant morbidity and mortality, including mental health comorbidity, which is associated with poor outcomes. Self-management is key, but there is limited access to self-management support. Internet-delivered interventions may increase access. OBJECTIVE: The aim of this study was to conduct a systematic review to (1) determine the effectiveness of Internet-delivered CHD self-management support for improving CHD, mood, and self-management related outcomes and (2) identify and describe essential components for effectiveness. METHOD: Randomized controlled trials that met prespecified eligibility criteria were identified using a systematic search of 3 healthcare databases (Medline, PsychINFO, and Embase). RESULTS: Seven trials, which included 1321 CHD patients, were eligible for inclusion. There was considerable heterogeneity between studies in terms of the intervention content, outcomes measured, and study quality. All 7 of the studies reported significant positive between-group effects, in particular for lifestyle-related outcomes. Personalization of interventions and provision of support to promote engagement may be associated with improved outcomes, although more data are required to confirm this. The theoretical basis of interventions was poorly developed though evidence-based behavior change interventions were used. CONCLUSION: More well-designed randomized controlled trials are needed. These should also explore how interventions work and how to improve participant retention and satisfaction and examine the role of personalization and support within interventions.

Nurses' smoking habits and their professional smoking cessation practices. A systematic review and meta-analysis.

BACKGROUND: A better understanding of whether nurses' own smoking behaviours influence their engagement with smoking cessation interventions is needed. AIM: To establish whether the smoking status of nurses is associated with their professional smoking cessation practices. METHODS: Twelve electronic databases covering English and Spanish language publications from 01 Jan, 1996 to 25 Mar, 2015 were systematically searched. Studies were included if they reported nurses' smoking cessation practices in relation to their personal smoking habits. Proportions of nurses' smoking status and smoking cessation practices were pooled across studies using random effects meta-analysis. RESULTS: Fifteen studies were included in this systematic review. Levels of reportedsmoking cessation interventions were generally low across the studies. The meta-analyses suggested that nurses' personal smoking status was not associated significantly with nurses always asking patients about their smoking, but nurses who smoked were 13% less likely to advise their patients to quit and 25% less likely to arrange smoking cessation follow-up. More intense interventions (assessing motivation and assisting) were not significantly associated with the smoking status of the nurse. CONCLUSIONS: The smoking status of nurses appears to have a negative impact in the delivery of smoking cessation practices. The overall level of nurses' engagement with the delivery of smoking cessation interventions requires attention if nurses are to be effective agents of smoking cessation.