Integrated diagnostic pathway for patients referred with suspected OSA: a model for collaboration across the primary-secondary care interface

BACKGROUND: Obstructive sleep apnoea (OSA) presents a major healthcare challenge with current UK data suggesting that only 22% of individuals have been diagnosed and treated. Promoting awareness and improving access to diagnostics are fundamental in addressing these missing cases and the recognised complications associated with untreated OSA. Diagnosis usually occurs in secondary care with data from our trust revealing long wait times to undertake tests, reach a diagnosis and start treatment. This places a considerable time and emotional burden on the patient and a financial and logistical burden on the hospital. METHODS: We introduced an integrated community-based pathway for the diagnosis of OSA. This comprised a monthly clinic run from within a local general practice (GP) supported by a 'virtual multidisciplinary team' run by the hospital specialist team. Prospective collection of process, outcome and patient satisfaction data was compared with traditional hospital-based pathway data collected retrospectively. SETTING: A central London teaching hospital and GPs within a local commissioning neighbourhood. RESULTS: Between January 2018 and February 2019, 70 were patients referred and managed along the community pathway. Compared with the hospital pathway, data demonstrated a significant reduction in the time taken: from referral to perform a sleep test (29 vs 181 days, p<0.0001), to make a diagnosis (40 vs 230 days, p<0.0001) and commence treatment (127 vs 267, p<0.0001). Patient satisfaction in the community pathway was higher across all domains (p<0.05), fewer hospital outpatient appointments were required and cost estimates suggested an overall saving of up to £290 could be achieved for each patient. CONCLUSION: An integrated community-based pathway results in more timely diagnosis of OSA within a local setting while maintaining specialist input from the hospital team. It is favoured by patients and can reduce unnecessary appointments in secondary care

STEREO Observations of Energetic Neutral Hydrogen Atoms During the 2006 December 5 Solar Flare

We report the discovery of energetic neutral hydrogen atoms (ENAs) emitted during the X9 solar event of 2006 December 5. Beginning ~1 hr following the onset of this E79 flare, the Low Energy Telescopes (LETs) on both the STEREO A and B spacecraft observed a sudden burst of 1.6-15 MeV protons beginning hours before the onset of the main solar energetic particle event at Earth. More than 70% of these particles arrived from a longitude within ±10° of the Sun, consistent with the measurement resolution. The derived emission profile at the Sun had onset and peak times remarkably similar to the GOES soft X-ray profile and continued for more than an hour. The observed arrival directions and energy spectrum argue strongly that the particle events < 5 MeV were due to ENAs. To our knowledge, this is the first reported observation of ENA emission from a solar flare/coronal mass ejection. Possible origins for the production of ENAs in a large solar event are considered. We conclude that the observed ENAs were most likely produced in the high corona and that charge-transfer reactions between accelerated protons and partially stripped coronal ions are an important source of ENAs in solar events

Isotopic Composition of Solar Wind Calcium: First in Situ Measurement by CELIAS/MTOF on Board SOHO

We present first results on the Ca isotopic abundances derived from the high resolution Mass Time-of-Flight (MTOF) spectrometer of the charge, element, and isotope analysis system (CELIAS) experiment on board the Solar and Heliospheric Observatory (SOHO). We obtain isotopic ratios 40Ca/42Ca = (128+-47) and 40Ca/44Ca = (50+-8), consistent with terrestrial values. This is the first in situ determination of the solar wind calcium isotopic composition and is important for studies of stellar modeling and solar system formation since the present-day solar Ca isotopic abundances are unchanged from their original isotopic composition in the solar nebula.Comment: 14 pages, 3 figure

Observations and Interpretations of Energetic Neutral Hydrogen Atoms from the December 5, 2006 Solar Event

We discuss recently reported observations of energetic neutral hydrogen atoms (ENAs) from an X9 solar flare/coronal mass ejection event on 5 December 2006, located at E79. The observations were made by the Low Energy Telescopes (LETs) on STEREO A and B. Prior to the arrival of the main solar energetic particle (SEP) event at Earth, both LETs observed a sudden burst of 1.6 to 15 MeV energetic neutral hydrogen atoms produced by either flare or shock-accelerated protons. RHESSI measurements of the 2.2-MeV γ-ray line provide an estimate of the number of interacting flare-accelerated protons in this event, which leads to an improved estimate of ENA production by flare-accelerated protons. Taking into account ENA losses, we find that the observed ENAs must have been produced in the high corona at heliocentric distances ≥ 2 solar radii. Although there are no CME images from this event, it is shown that CME-shock-accelerated protons can, in principle, produce a time-history consistent with the observations

New results on source and diffusion spectral features of Galactic cosmic rays: I- B/C ratio

In a previous study (Maurin et al., 2001), we explored the set of parameters describing diffusive propagation of cosmic rays (galactic convection, reacceleration, halo thickness, spectral index and normalization of the diffusion coefficient), and we identified those giving a good fit to the measured B/C ratio. This study is now extended to take into account a sixth free parameter, namely the spectral index of sources. We use an updated version of our code where the reacceleration term comes from standard minimal reacceleration models. The goal of this paper is to present a general view of the evolution of the goodness of fit to B/C data with the propagation parameters. In particular, we find that, unlike the well accepted picture, and in accordance with our previous study, a Kolmogorov-like power spectrum for diffusion is strongly disfavored. Rather, the $\chi^2$ analysis points towards $\delta\gtrsim 0.7$ along with source spectra index $\lesssim 2.0$. Two distinct energy dependences are used for the source spectra: the usual power-law in rigidity and a law modified at low energy, the second choice being only slightly preferred. We also show that the results are not much affected by a different choice for the diffusion scheme. Finally, we compare our findings to recent works, using other propagation models. This study will be further refined in a companion paper, focusing on the fluxes of cosmic ray nuclei.Comment: 32 pages, 13 figures, accepted in A&

Applications of Abundance Data and Requirements for Cosmochemical Modeling

Understanding the evolution of the universe from Big Bang to its present state requires an understanding of the evolution of the abundances of the elements and isotopes in galaxies, stars, the interstellar medium, the Sun and the heliosphere, planets and meteorites. Processes that change the state of the universe include Big Bang nucleosynthesis, star formation and stellar nucleosynthesis, galactic chemical evolution, propagation of cosmic rays, spallation, ionization and particle transport of interstellar material, formation of the solar system, solar wind emission and its fractionation (FIP/FIT effect), mixing processes in stellar interiors, condensation of material and subsequent geochemical fractionation. Here, we attempt to compile some major issues in cosmochemistry that can be addressed with a better knowledge of the respective element or isotope abundances. Present and future missions such as Genesis, Stardust, Interstellar Pathfinder, and Interstellar Probe, improvements of remote sensing instrumentation and experiments on extraterrestrial material such as meteorites, presolar grains, and lunar or returned planetary or cometary samples will result in an improved database of elemental and isotopic abundances. This includes the primordial abundances of D, ^3He, ^4He, and ^7Li, abundances of the heavier elements in stars and galaxies, the composition of the interstellar medium, solar wind and comets as well as the (highly) volatile elements in the solar system such as helium, nitrogen, oxygen or xenon

20-125 mev/nuc cosmic ray carbon nuclei intensities between 2004-2010 in solar cycle #23 as measured near the earth, at voyager 2 and also in the heliosheath at voyager 1 - modulation in a two zone heliospehre

The recovery of cosmic ray Carbon nuclei of energy ~20-125 MeV/nuc in solar cycle #23 from 2004 to 2010 has been followed at three locations, near the Earth using ACE data and at V2 between 74-92 AU and also at V1 beyond the heliospheric termination shock at between 91-113 AU. To describe the observed intensity changes and to predict the absolute intensities measured at all three locations we have used a simple spherically symmetric (no drift) two-zone heliospheric transport model with specific values for the diffusion coefficient in both the inner and outer zones. The diffusion coefficient in the outer zone is determined to be ~5-10 times smaller than that in the inner zone out to 90 AU. For both V1 and V2 the calculated C nuclei intensities agree within an average of \pm 10% with the observed intensities. Because of this agreement between V1 and V2 observations and predictions there is no need to invoke an asymmetrical squashed heliosphere or other effects to explain the V2 intensities relative to V1 as is the case for He nuclei. The combination of the diffusion parameters used in this model and the interstellar spectrum give an unusually low overall solar modulation parameter \phi = 250 MV to describe the Carbon intensities observed at the Earth in 2009. At all times both the observed and calculated spectra are very closely ~ E1.0 as would be expected in the adiabatic energy loss regime of solar modulation.Comment: 12 pages, 10 figure

Shell model calculation of the beta- and beta+ partial halflifes of 54Mn and other unique second forbidden beta decays

The nucleus 54Mn has been observed in cosmic rays. In astrophysical environments it is fully stripped of its atomic electrons and its decay is dominated by the beta- branch to the 54Fe ground state. Application of 54Mn based chronometer to study the confinement of the iron group cosmic rays requires knowledge of the corresponding halflife, but its measurement is impossible at the present time. However, the branching ratio for the related beta+ decay of 54Mn was determined recently. We use the shell model with only a minimal truncation and calculate both beta+ and beta- decay rates of 54Mn. Good agreement for the beta+ branch suggests that the calculated partial halflife of the beta- decay, (4.94 \pm 0.06) x 10^5 years, should be reliable. However, this halflife is noticeably shorter than the range 1-2 x 10^6 y indicated by the fit based on the 54Mn abundance in cosmic rays. We also evaluate other known unique second forbidden beta decays from the nuclear p and sd shells (10Be, 22Na, and two decay branches of 26Al) and show that the shell model can describe them with reasonable accuracy as well.Comment: 4 pages, RevTeX, 2 figure

Ultra-heavy cosmic-ray science--Are r-process nuclei in the cosmic rays produced in supernovae or binary neutron star mergers?

The recent detection of 60Fe in the cosmic rays provides conclusive evidence that there is a recently synthesized component (few MY) in the GCRs (Binns et al. 2016). In addition, these nuclei must have been synthesized and accelerated in supernovae near the solar system, probably in the Sco-Cen OB association subgroups, which are about 100 pc distant from the Sun. Recent theoretical work on the production of r-process nuclei appears to indicate that it is difficult for SNe to produce the solar system abundances relative to iron of r-process elements with high atomic number (Z), including the actinides (Th, U, Np, Pu, and Cm). Instead, it is believed by many that the heaviest r-process nuclei, or perhaps even all r-process nuclei, are produced in binary neutron star mergers. Since we now know that there is at least a component of the GCRs that has been recently synthesized and accelerated, models of r-process production by SNe and BNSM can be tested by measuring the relative abundances of these ultra-heavy r-process nuclei, and especially the actinides, since they are radioactive and provide clocks that give the time interval from nucleosynthesis to detection at Earth. Since BNSM are believed to be much less frequent in our galaxy than SNe (roughly 1000 times less frequent, the ratios of the actinides, each with their own half-life, will enable a clear determination of whether the heaviest r-process nuclei are synthesized in SNe or in BNSM. In addition, the r-process nuclei for the charge range from 34 to 82 can be used to constrain models of r-process production in BNSM and SNe. Thus, GCRs become a multi-messenger component in the study of BNSM and SNe.Comment: Astro2020 Science White Pape

Observations and Interpretations of Energetic Neutral Hydrogen Atoms from the December 5, 2006 Solar Event

We discuss recently reported observations of energetic neutral hydrogen atoms (ENAs) from an X9 solar flare/coronal mass ejection event on 5 December 2006, located at E79. The observations were made by the Low Energy Telescopes (LETs) on STEREO A and B. Prior to the arrival of the main solar energetic particle (SEP) event at Earth, both LETs observed a sudden burst of 1.6 to 15 MeV energetic neutral hydrogen atoms produced by either flare or shock-accelerated protons. RHESSI measurements of the 2.2-MeV gamma-ray line provide an estimate of the number of interacting flare-accelerated protons in this event, which leads to an improved estimate of ENA production by flare-accelerated protons. Taking into account ENA losses, we find that the observed ENAs must have been produced in the high corona at heliocentric distances > or equal to 2 solar radii. Although there are no CME images from this event, it is shown that CME-shock-accelerated protons can, in principle, produce a time-history consistent with the observations