Starting early: integration of self-management support into an acute stroke service.

Self-management support following stroke is rare, despite emerging evidence for impact on patient outcomes. The promotion of a common approach to self-management support across a stroke pathway requires collaboration between professionals. To date, the feasibility of self-management support in acute stroke settings has not been evaluated. The Bridges stroke self-management package (SMP) is based on self-efficacy principles. It is delivered by professionals and supported by a patient-held workbook. The aim of this project was to introduce the Bridges stroke SMP to the multidisciplinary staff of a London hyperacute and acute stroke unit. The 'Plan Do Study Act' (PDSA) cycle guided iterative stages of project development, with normalisation process theory helping to embed the intervention into existing ways of working. Questionnaires explored attitudes, beliefs and experiences of the staff who were integrating self-management support into ways of working in the acute stroke setting. Self-management support training was delivered to a total of 46 multidisciplinary stroke staff. Of the staff who attended the follow-up training, 66% had implemented Bridges self-management support with patients since initial training, and 100% felt their practice had changed. Questionnaire findings demonstrated that staff attitudes and beliefs had changed following training, particularly regarding ownership and type of rehabilitation goals set, and prioritisation of self-management support within acute stroke care. Staff initiated an audit of washing and dressing practices pre- and post-training. This was designed to evaluate the number of occasions when techniques were used by staff to facilitate patients' independence and self-management. They found that the number of occasions featuring optimum practice went from 54% at baseline to 63% at three months post-training. This project demonstrated the feasibility of integrating self-management support into an acute stroke setting. Further work is required to evaluate sustainability of the Bridges stroke SMP, to understand the barriers and opportunities involved in engaging all professional groups in integrated self-management support in acute stroke settings, and to assess patient reported outcomes

Ground Level Enhancement in the 2014 January 6 Solar Energetic Particle Event

We present a study of the 2014 January 6 solar energetic particle (SEP) event, which produced a small ground level enhancement (GLE), making it the second GLE of this unusual solar cycle 24. This event was primarily observed by the South Pole neutron monitors (increase of ~2.5%) whereas a few other neutron monitors recorded smaller increases. The associated coronal mass ejection (CME) originated behind the western limb and had the speed of 1960 km/s. The height of the CME at the start of the associated metric type II radio burst, which indicates the formation of a strong shock, was measured to be 1.61 Rs using a direct image from STEREO-A/EUVI. The CME height at the time of GLE particle release (determined using the South Pole neutron monitor data) was directly measured as 2.96 Rs, from the STEREO-A/COR1 white-light observations. These CME heights are consistent with those obtained for the GLE71, the only other GLE of the current cycle as well as cycle-23 GLEs derived using back-extrapolation. GLE72 is of special interest because it is one of the only two GLEs of cycle 24, one of the two behind-the-limb GLEs and one of the two smallest GLEs of cycles 23 and 24

Hemispherical Nature of EUV Shocks Revealed by SOHO, STEREO, and SDO Observations

EUV wave transients associated with type II radio bursts are manifestation of CME-driven shocks in the solar corona. We use recent EUV wave observations from SOHO, STEREO, and SDO for a set of CMEs to show that the EUV transients have a spherical shape in the inner corona. We demonstrate this by showing that the radius of the EUV transient on the disk observed by one instrument is approximately equal to the height of the wave above the solar surface in an orthogonal view provided by another instrument. The study also shows that the CME-driven shocks often form very low in the corona at a heliocentric distance of 1.2 Rs, even smaller than the previous estimates from STEREO/CORl data (Gopalswamy et aI., 2009, Solar Phys. 259, 227). These results have important implications for the acceleration of solar energetic particles by CME

CME Interaction with Coronal Holes and Their Interplanetary Consequences

A significant number of interplanetary (IP) shocks (-17%) during cycle 23 were not followed by drivers. The number of such "driverless" shocks steadily increased with the solar cycle with 15%, 33%, and 52% occurring in the rise, maximum, and declining phase of the solar cycle. The solar sources of 15% of the driverless shocks were very close the central meridian of the Sun (within approx.15deg), which is quite unexpected. More interestingly, all the driverless shocks with their solar sources near the solar disk center occurred during the declining phase of solar cycle 23. When we investigated the coronal environment of the source regions of driverless shocks, we found that in each case there was at least one coronal hole nearby suggesting that the coronal holes might have deflected the associated coronal mass ejections (CMEs) away from the Sun-Earth line. The presence of abundant low-latitude coronal holes during the declining phase further explains why CMEs originating close to the disk center mimic the limb CMEs, which normally lead to driverless shocks due to purely geometrical reasons. We also examined the solar source regions of shocks with drivers. For these, the coronal holes were located such that they either had no influence on the CME trajectories. or they deflected the CMEs towards the Sun-Earth line. We also obtained the open magnetic field distribution on the Sun by performing a potential field source surface extrapolation to the corona. It was found that the CMEs generally move away from the open magnetic field regions. The CME-coronal hole interaction must be widespread in the declining phase, and may have a significant impact on the geoeffectiveness of CMEs

Major Solar Eruptions and High Energy Particle Events during Solar Cycle 24

We report on a study of all major solar eruptions that occurred on the front-side of the Sun during the rise to peak phase of cycle 24 (first 62 months) in order to understand the key factors affecting the occurrence of large solar energetic particle events (SEPs) and the ground levels enhancement (GLE) events. The eruptions involve major flares with soft X-ray peak flux >/= 5.0 x10-5 Wm-2 (i.e., flare size >/= M5.0) and accompanying coronal mass ejections (CMEs). The selection criterion was based on the fact that the only front-side GLE in cycle 24 (GLE 71) had a flare size of M5.1. Only ~37% of the major eruptions from the western hemisphere resulted in large SEP events. Almost the same number of large SEP events was produced in weaker eruptions (flare size <M5.0), suggesting that the soft X-ray flare is not a good indicator of SEP or GLE events. On the other hand, the CME speed is a better indicator of SEP and GLE events because it is consistently high supporting the shock acceleration mechanism for SEPs and GLEs. We found the CME speed, magnetic connectivity to Earth, and ambient conditions as the main factors that contribute to the lack of high energy particle events during cycle 24. Several eruptions poorly connected to Earth (eastern-hemisphere or behind-the-west-limb events) resulted in very large SEP events detected by the STEREO spacecraft. Some very fast CMEs, likely to have accelerated particles to GeV energies, did not result in a GLE event because of poor latitudinal connectivity. The stringent latitudinal requirement suggests that the highest energy particles are likely accelerated in the nose part of shocks. There were also well-connected fast CMEs, which did not seem to have accelerated high energy particles due to possible unfavorable ambient conditions (high Alfven speed, overall reduction in acceleration efficiency in cycle 24).Comment: 29 pages, 5 figures, 5 tables, to be published in a special issue of Earth, Planets, and Spac

Long-Term Solar Activity Studies Using Microwave Imaging Observations and Prediction for Cycle 25

We use microwave imaging observations from the Nobeyama Radioheliograph at 17 GHz for long-term studies of solar activity. In particular, we use the polar and low-latitude brightness temperatures as proxies to the polar magnetic field and the active-regions, respectively. We also use the location of prominence eruptions as a proxy to the filament locations as a function of time. We show that the polar microwave brightness temperature is highly correlated with the polar magnetic field strength and the fast solar wind speed. We also show that the polar microwave brightness at one cycle is correlated with the low latitude brightness with a lag of about half a solar cycle. We use this correlation to predict the strength of the solar cycle: the smoothed sunspot numbers in the southern and northern hemispheres can be predicted as 89 and 59, respectively. These values indicate that cycle 25 will not be too different from cycle 24 in its strength. We also combined the rush to the pole data from Nobeyama prominences with historical data going back to 1860 to study the north-south asymmetry of sign reversal at solar poles. We find that the reversal asymmetry has a quasi-periodicity of 3-5 cycles