What Musculoskeletal (MSK) Conditions are Referred from Routine General Practice (GP) and what Impact does this have on Developing Innovative Care Models for Patients with MSK Conditions in Primary Care?

Introduction: The current ethos within the United Kingdom (UK) health system is to encourage community management of health problems, increasing primary care workload. Yet General Practice (GP) is currently in ‘crisis’ with significant workload pressures. GP Federations have been developed to allow more collaborative working between GP practices and help develop new innovative models of care to better manage the GP workload pressures. Musculoskeletal(MSK) conditions constitute approximately 20% of General Practice(GP) consultations and therefore the Belfast GP Federation aimed to assess the demand for MSK conditions to allow development of new primary care-based treatment pathways for these conditions. The aim of this paper is therefore to assess the demand for orthopaedic, rheumatology and chronic MSK painful conditions by assessing the referrals from 2 GP practices and the referrals to one orthopaedic Integrated Clinical Assessment and Treatment services (ICATs) clinic for these conditions and then propose innovative models of care to manage this demand within the community. Methods: Secondary care referral rates for two urban GP surgeries in the Belfast area were assessed in April, 2016 to orthopaedics, rheumatology and chronic pain clinics. The referrals to an orthopaedic ICATs clinics, staffed by one GPwSI in MSK, in May 2016 were also reviewed. The orthopaedic ICATs team receive referrals from GPs regarding musculoskeletal conditions and this particular service is based in the Southern Trust area of Northern Ireland. Results: Overall from the 2 GP surgeries there was 59 orthopaedic referrals, 11 to rheumatology and 3 to the chronic pain clinic. The commonest joint referred to the orthopaedic clinic was knee (15 referrals, 25.4%) and the commonest reason to refer to rheumatology was to exclude an inflammatory arthritis (6 referrals, 54.5%). There was then 25 referrals to ICATs, with the commonest reason for referral being neck (6 referrals, 24%) and back (4 referrals, 16%). The commonest treatment options employed within the ICAT service included joint injections (8 patients, 32%) with referral to in-house physiotherapy (8 patients, 32%). Conclusions: UK GP is currently under significant workload pressures and musculoskeletal conditions, including orthopaedic, rheumatology and chronic painful conditions, make up a significant proportion of this workload. The main musculoskeletal areas which GPs are referring to secondary care include knee and spinal conditions. To help better manage this workload within primary care we propose developing a new community-based monthly musculoskeletal clinic based within local GP surgeries, supported by a MSK educational programme open to all GPs in the area. Outcomes which will be monitored from this quality improvement work will include secondary care referrals and maintaining high patient satisfaction as well as improving GP confidence in managing MSK conditions

A Na I Absorption Map of the Small-Scale Structure in the Interstellar Gas Toward M15

Using the DensePak fiber optic array on the KPNO WIYN telescope, we have obtained high S/N echelle spectra of the Na I D wavelength region toward the central 27" x 43" of the globular cluster M15 at a spatial resolution of 4". The spectra exhibit significant interstellar Na I absorption at LSR velocities of +3 km/s (LISM component) and +68 km/s (IVC component). Both components vary appreciably in strength on these scales. The derived Na I column densities differ by a factor of 4 across the LISM absorption map and by a factor of 16 across the IVC map. Assuming distances of 500 pc and 1500 pc for the LISM and IVC clouds, these maps show evidence of significant ISM structure down to the minimum scales of 2000 AU and 6000 AU probed in these absorbers. The smallest-scale N(Na I) variations observed in the M15 LISM and IVC maps are typically comparable to or higher than the values found at similar scales in previous studies of interstellar Na I structure toward binary stars. The physical implications of the small and larger-scale Na I features observed in the M15 maps are discussed in terms of variations in the H I column density as well as in the Na ionization equilibrium.Comment: 11 pages, 3 figures, accepted for publication in ApJ Letter

A non-LTE abundance analysis of the post-AGB star ROA 5701

An analysis of high-resolution Anglo-Australian Telescope (AAT)/ University College London Echelle Spectrograph (UCLES) optical spectra for the ultraviolet (UV)-bright star ROA 5701 in the globular cluster omega Cen (NGC 5139) is performed, using non-local thermodynamic equilibrium (non-LTE) model atmospheres to estimate stellar atmospheric parameters and chemical composition. Abundances are derived for C, N, O, Mg, Si and S, and compared with those found previously by Moehler et al. We find a general metal underabundance relative to young B-type stars, consistent with the average metallicity of the cluster. Our results indicate that ROA 5701 has not undergone a gas-dust separation scenario as previously suggested. However, its abundance pattern does imply that ROA 5701 has evolved off the AGB prior to the onset of the third dredge-up.Comment: 9 pages, 2 figures. Accepted for publication in MNRAS (Online Early

The VLT-FLAMES survey of massive stars: rotation and nitrogen enrichment as the key to understanding massive star evolution

Rotation has become an important element in evolutionary models of massive stars, specifically via the prediction of rotational mixing. Here, we study a sample of stars, including rapid rotators, to constrain such models and use nitrogen enrichments as a probe of the mixing process. Chemical compositions (C, N, O, Mg and Si) have been estimated for 135 early B-type stars in the Large Magellanic Cloud with projected rotational velocities up to ~300km/s using a non-LTE TLUSTY model atmosphere grid. Evolutionary models, including rotational mixing, have been generated attempting to reproduce these observations by adjusting the overshooting and rotational mixing parameters and produce reasonable agreement with 60% of our core hydrogen burning sample. We find (excluding known binaries) a significant population of highly nitrogen enriched intrinsic slow rotators vsini less than 50km/s incompatible with our models ~20% of the sample). Furthermore, while we find fast rotators with enrichments in agreement with the models, the observation of evolved (log g less than 3.7dex) fast rotators that are relatively unenriched (a further ~20% of the sample) challenges the concept of rotational mixing. We also find that 70% of our blue supergiant sample cannot have evolved directly from the hydrogen burning main-sequence. We are left with a picture where invoking binarity and perhaps fossil magnetic fields are required to understand the surface properties of a population of massive main sequence stars.Comment: ApJL. 10 pages, 1 figure. Updated to match accepted versio

B-type supergiants in the SMC: Rotational velocities and implications for evolutionary models

High-resolution spectra for 24 SMC and Galactic B-type supergiants have been analysed to estimate the contributions of both macroturbulence and rotation to the broadening of their metal lines. Two different methodologies are considered, viz. goodness-of-fit comparisons between observed and theoretical line profiles and identifying zeros in the Fourier transforms of the observed profiles. The advantages and limitations of the two methods are briefly discussed with the latter techniques being adopted for estimated projected rotational velocities (\vsini) but the former being used to estimate macroturbulent velocities. Only one SMC supergiant, SK 191, shows a significant degree of rotational broadening (\vsini $\simeq$ 90 \kms). For the remaining targets, the distribution of projected rotational velocities are similar in both our Galactic and SMC samples with larger values being found at earlier spectral types. There is marginal evidence for the projected rotational velocities in the SMC being higher than those in the Galactic targets but any differences are only of the order of 5-10 \kms, whilst evolutionary models predict differences in this effective temperature range of typically 20 to 70 \kms. The combined sample is consistent with a linear variation of projected rotational velocity with effective temperature, which would imply rotational velocities for supergiants of 70 \kms at an effective temperature of 28 000 K (approximately B0 spectral type) decreasing to 32 \kms at 12 000 K (B8 spectral type). For all targets, the macroturbulent broadening would appear to be consistent with a Gaussian distribution (although other distributions cannot be discounted) with an $\frac{1}{e}$ half-width varying from approximately 20 \kms at B8 to 60 \kms at B0 spectral types.Comment: 4 figures, 8 pages, submitted to Astronomy and Astrophysic

Atmospheric parameters and rotational velocities for a sample of Galactic B-type supergiants

High resolution optical spectra of 57 Galactic B-type supergiant stars have been analyzed to determine their rotational and macroturbulent velocities. In addition, their atmospheric parameters (effective temperature, surface gravity and microturbulent velocity) and surface nitrogen abundances have been estimated using a non-LTE grid of model atmospheres. Comparisons of the projected rotational velocities have been made with the predictions of stellar evolutionary models and in general good agreement was found. However for a small number of targets, their observed rotational velocities were significantly larger than predicted, although their nitrogen abundances were consistent with the rest of the sample. We conclude that binarity may have played a role in generating their large rotational velocities. No correlation was found between nitrogen abundances and the current projected rotational velocities. However a correlation was found with the inferred projected rotational velocities of the main sequence precursors of our supergiant sample. This correlation is again in agreement with the predictions of single star evolutionary models that incorporate rotational mixing. The origin of the macroturbulent and microturbulent velocity fields is discussed and our results support previous theoretical studies that link the former to sub-photospheric convection and the latter to non-radial gravity mode oscillations. In addition, we have attempted to identify differential rotation in our most rapidly rotating targets.Comment: Submitted to MNRAS, 16 page

A New Measurement of the Average FUV Extinction Curve

We have measured the extinction curve in the far-ultraviolet wavelength region of (900 -- 1200 A) using spectra obtained with the Berkeley EUV/FUV spectrometer during the ORFEUS-I and the ORFEUS-II missions in 1993 and 1996. From the complete sample of early-type stars observed during these missions, we have selected pairs of stars with the same spectral type but different reddenings to measure the differential FUV extinction. We model the effects of molecular hydrogen absorption and exclude affected regions of the spectrum to determine the extinction from dust alone. We minimize errors from inaccuracies in the cataloged spectral types of the stars by making our own determinations of spectral types based on their IUE spectra. We find substantial scatter in the curves of individual star pairs and present a detailed examination of the uncertainties and their effects on each extinction curve. We find that, given the potentially large uncertainties inherent in using the pair method at FUV wavelengths, a careful analysis of measurement uncertainties is critical to assessing the true dust extinction. We present a new measurement of the average far-ultraviolet extinction curve to the Lyman limit; our new measurement is consistent with an extrapolation of the standard extinction curve of Savage & Mathis (1979).Comment: 13 pages text, 7 figures 4 tables. Sent as gzipped tar, with ms.tex and 7 figure

Chemical compositions of Four B-type Supergiants in the SMC Wing

High-resolution UCLES/AAT spectra of four B-type supergiants in the SMC South East Wing have been analysed using non-LTE model atmosphere techniques to determine their atmospheric parameters and chemical compositions. The principle aim of this analysis was to determine whether the very low metal abundances ($-$1.1 dex compared with Galactic value) previously found in the Magellanic Inter Cloud region (ICR) were also present in SMC Wing. The chemical compositions of the four targets are similar to those found in other SMC objects and appear to be incompatible with those deduced previously for the ICR. Given the close proximity of the Wing to the ICR, this is difficult to understand and some possible explanations are briefly discussed.Comment: 11 pages, 2 figues, A&A accepte

Detection of Voigt Spectral Line Profiles of Hydrogen Radio Recombination Lines toward Sagittarius B2(N)

We report the detection of Voigt spectral line profiles of radio recombination lines (RRLs) toward Sagittarius B2(N) with the 100-m Green Bank Telescope (GBT). At radio wavelengths, astronomical spectra are highly populated with RRLs, which serve as ideal probes of the physical conditions in molecular cloud complexes. An analysis of the Hn(alpha) lines presented herein shows that RRLs of higher principal quantum number (n>90) are generally divergent from their expected Gaussian profiles and, moreover, are well described by their respective Voigt profiles. This is in agreement with the theory that spectral lines experience pressure broadening as a result of electron collisions at lower radio frequencies. Given the inherent technical difficulties regarding the detection and profiling of true RRL wing spans and shapes, it is crucial that the observing instrumentation produce flat baselines as well as high sensitivity, high resolution data. The GBT has demonstrated its capabilities regarding all of these aspects, and we believe that future observations of RRL emission via the GBT will be crucial towards advancing our knowledge of the larger-scale extended structures of ionized gas in the interstellar medium (ISM)