The barriers and facilitators to the design and delivery of sustainable healthcare across NHS Scotland: A forcefield analysis.

Healthcare systems around the world have set ambitious targets to design and deliver more environmentally sustainable healthcare. To achieve these targets, individuals, teams, organisations, and whole systems will have to change current attitudes, practices and processes. Change management theory advocates for early identification of the influencing forces to change, so that actions can be taken to overcome the barriers and strengthen the facilitators to increase the likelihood of success. This project undertook a forcefield analysis exercise to identify the barriers and facilitators to the design and delivery of sustainable healthcare in Scotland. The exercise identified 12 facilitators and 12 barriers to sustainable change and formulated ten recommendations to strengthen the former and overcome the latter. It is hoped that the results will raise awareness of the factors that influence the design and delivery of sustainable healthcare and will inform what actions can be taken to increase the likelihood of success.

Knowledge and attitudes towards disability in Moldova: A qualitative study of young people's views.

BACKGROUND: People with disabilities in the Republic of Moldova continue to experience considerable discrimination and social exclusion. The Moldovan government recently affirmed their commitment to promote community integration. However, there remains limited evidence to facilitate understanding of these issues, and barriers to the integrative process. OBJECTIVE: This study explored the knowledge and attitudes towards disability of young people within Moldova. METHODS: A qualitative approach was adopted and 3 semi-structured focus group interviews were conducted with schoolchildren (n = 12), aged 13-15 years. These interviews focussed on different aspects of disability, and community integration. Pictorial and written vignettes were used to stimulate discussion. The interviews were conducted and recorded in Romanian, and were subsequently translated into English to facilitate thematic data analysis. RESULTS: Identified themes included: (1) Knowledge and understanding of disability. The young people's knowledge was limited and framed by the medical model of disability; (2) Attitudes towards community integration. A bias against long-term care institutions, but differing views regarding integration; (3) Perceptions of barriers to community integration: (i) Cultural barriers. Negative, even hostile attitudes towards disability; (ii) Policy barriers. Poor support services; and (iii) Physical barriers. Ongoing issues regarding accessibility. CONCLUSIONS: People with disabilities in Moldova experience negative cultural attitudes linked to an outdated conception of disability itself. There are inadequate community support services and infrastructure which act as barriers to inclusion. At present, there can be limited interaction and participation of people with disabilities within local communities, and so few opportunities to refute persistent stereotypes and stigma surrounding disability.

Are Collapsed Cervical Discs Amenable to Total Disc Arthroplasty?: Analysis of Prospective Clinical Data With 2-Year Follow Up.

STUDY DESIGN: Analysis of prospectively collected radiographic data. OBJECTIVE: To investigate the influence of preoperative index-level range of motion (ROM) and disc height on postoperative ROM after cervical total disc arthroplasty (TDA) using compressible disc prostheses. SUMMARY OF BACKGROUND DATA: Clinical studies demonstrate benefits of motion preservation over fusion; however, questions remain unanswered as to which preoperative factors have the ability to identify patients who are most likely to have good postoperative motion, which is the primary rationale for TDA. METHODS: We analyzed prospectively collected data from a single-arm, multicenter study with 2-year follow up of 30 patients with 48 implanted levels. All received compressible cervical disc prostheses of 6 mm-height (M6C, Spinal Kinetics, Sunnyvale, CA). The influence of index-level preoperative disc height and ROM (each with two levels: below-median and above-median) on postoperative ROM was analyzed using 2 x 2 ANOVA. We further analyzed the radiographic outcomes of a subset of discs with preoperative height less than 3 mm, the so-called "collapsed" discs. RESULTS: Shorter (3.0 ± 0.4 mm) discs were significantly less mobile preoperatively than taller (4.4 ± 0.5 mm) discs (6.7° vs. 10.5°, P = 0.01). The postoperative ROM did not differ between the shorter and taller discs (5.6° vs. 5.0°, P = 0.63). Tall discs that were less mobile preoperatively had significantly smaller postoperative ROM than short discs with above-median preoperative mobility (P < 0.05). The "collapsed discs" (n = 8) were less mobile preoperatively compared with all discs combined (5.1° vs. 8.6°, P < 0.01). These discs were distracted to more than two times the preoperative height, from 2.6 to 5.7 mm, and had significantly greater postoperative ROM than all discs combined (7.6° vs. 5.3°, P < 0.05). CONCLUSION: We observed a significant interaction between preoperative index-level disc height and ROM in influencing postoperative ROM. Although limited by small sample size, the results suggest discs with preoperative height less than 3 mm may be amenable to disc arthroplasty using compressible disc prostheses. LEVEL OF EVIDENCE: 2.

High-sensitivity quantitation of cabergoline and pergolide using a triple-quadrupole mass spectrometer with enhanced mass-resolution capabilities.

Quantitative analysis of pharmaceuticals with low systemic plasma levels requires the utmost in sensitivity and selectivity from the analytical method used. A recently introduced triple-quadrupole mass spectrometer with unique enhanced mass-resolution capability was evaluated in the analysis of two such drugs, cabergoline and pergolide, in plasma. Liquid chromatographic/electrospray ionization selected reaction monitoring determination of cabergoline in plasma at unit mass-resolution demonstrated improved sensitivity (50 fg on-column), coupled with suitable accuracy and precision over a broad linear dynamic range covering five orders of magnitude (50 fg to 5 ng on-column). Liquid chromatographic/atmospheric pressure chemical ionization selective reaction monitoring determination of pergolide in plasma also attained a high level of sensitivity (500 fg on-column) at unit mass-resolution, with accuracy and precision values well within pharmaceutical industry standards. Again, a linear dynamic range covering five orders of magnitude (500 fg to 50 ng on-column) was achieved for the assay. Utility of the enhanced mass-resolution feature of the triple-quadrupole mass spectrometer in the determination of pergolide resulted in an improvement in analyte sensitivity (250 fg on-column) and linear dynamic range (250 fg to 50 ng on-column).

Accurate mass measurement at enhanced mass-resolution on a triple quadrupole mass-spectrometer for the identification of a reaction impurity and collisionally-induced fragment ions of cabergoline.

In this study, accurate mass measurements were made by electrospray ionization (ESI) on a triple quadrupole mass spectrometer operating in enhanced mass-resolution mode (peak width = 0.1 u FWMH), to give qualitative information relating to the pharmaceutical, cabergoline. Accurate mass determinations by ESI-MS were performed on a protonated impurity formed during cabergoline storage. The accurate mass measurement resulted in only one proposed elemental composition for the impurity, using reasonable elemental limits and mass tolerance for the calculation. This information was sufficient to propose a structure for the impurity where ESI-MS/MS proved consistent. The difference between the accurate mass measurement and the exact mass calculated for the proposed structure was 0.8 mmu, with a standard deviation of 0.7 mmu for replicate accurate mass determinations. Accurate mass determinations in ESI-MS/MS provided information on cabergoline fragment ions formed through collisionally-induced dissociation. Since the potential formation of isobaric ions exists for two major cabergoline fragment ions, accurate mass measurement allowed for the determination of the most probable fragment ion structures. The differences between the accurate mass measurements and exact masses calculated for the proposed fragment ions were 1.9 and 2.1 mmu, with standard deviations of 0.4 and 0.8 mmu, respectively, for replicate determinations.