Exploring the perspectives of clinical professionals and support staff on implementing supported self-management for asthma in UK general practice: an IMP2ART qualitative study

The IMP2 ART study was funded by the National Institute for Health Research, Programme Grants for Applied Research. Grant no: RP-DG-1213-10008. S.T. was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) North Thames at Bart’s Health NHS Trust. L.D. is an Academic Fellow in General Practice supported by the Scottish School of Primary Care

Biomechanical effects of polyaxial pedicle screw fixation on the lumbosacral segments with an anterior interbody cage support

BACKGROUND: Lumbosacral fusion is a relatively common procedure that is used in the management of an unstable spine. The anterior interbody cage has been involved to enhance the stability of a pedicle screw construct used at the lumbosacral junction. Biomechanical differences between polyaxial and monoaxial pedicle screws linked with various rod contours were investigated to analyze the respective effects on overall construct stiffness, cage strain, rod strain, and contact ratios at the vertebra-cage junction. METHODS: A synthetic model composed of two ultrahigh molecular weight polyethylene blocks was used with four titanium pedicle screws (two in each block) and two rods fixation to build the spinal construct along with an anterior interbody cage support. For each pair of the construct fixed with polyaxial or monoaxial screws, the linked rods were set at four configurations to simulate 0°, 7°, 14°, and 21° lordosis on the sagittal plane, and a compressive load of 300 N was applied. Strain gauges were attached to the posterior surface of the cage and to the central area of the left connecting rod. Also, the contact area between the block and the cage was measured using prescale Fuji super low pressure film for compression, flexion, lateral bending and torsion tests. RESULTS: Our main findings in the experiments with an anterior interbody cage support are as follows: 1) large segmental lordosis can decrease the stiffness of monoaxial pedicle screws constructs; 2) polyaxial screws rather than monoaxial screws combined with the cage fixation provide higher compression and flexion stiffness in 21° segmental lordosis; 3) polyaxial screws enhance the contact surface of the cage in 21° segmental lordosis. CONCLUSION: Polyaxial screws system used in conjunction with anterior cage support yields higher contact ratio, compression and flexion stiffness of spinal constructs than monoaxial screws system does in the same model when the spinal segment is set at large lordotic angles. Polyaxial pedicle screw fixation performs nearly equal percentages of vertebra-cage contact among all constructs with different sagittal alignments, therefore enhances the stabilization effect of interbody cages in the lumbosacral area

The ‘vicious cycle’ of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals’ views

Background: Personal asthma action plans (PAAPs) have been guideline recommended for years, but consistentlyunder-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimalPAAP implementation but more insight is needed into barriers to their use from the perspective of professionals,patients and primary care teams.Methods: A maximum variation sample of professional and patient participants were recruited from five demographicallydiverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitallyrecorded and data thematically analysed using NVivo.Results: Twenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, tenpractice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not valuePAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Sixpatients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting orneeding PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issuedPAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using theseand lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged.Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organisational barriersincluded professionals having difficulty accessing PAAP templates and fragmented processes including patients not beingasked to bring PAAPs to their asthma appointments.Conclusions: Primary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPswith patients; patients with out-dated PAAPs do not value or use these; professionals observing patients’ lack of interestin PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little valuein asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still notready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAPimplementation requires a whole systems approach with multi-faceted interventions addressing patient, professional andorganisational barriers