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

Laparoscopic ventral rectopexy in male patients with external rectal prolapse is associated with a high reoperation rate

Background Laparoscopic ventral rectopexy has been used to treat male patients with external rectal prolapse, but evidence to support this approach is scarce. The aim of this study was to evaluate the results of this new abdominal rectopexy surgical technique in men. Methods This was a retrospective multicenter study. Adult male patients who were operated on for external rectal prolapse using ventral rectopexy in five tertiary hospitals in Finland between 2006 and 2014 were included in the study. Patient demographics, detailed operative, postoperative and short-term follow-up data were collected from patient registers in participating hospitals. A questionnaire and informed consent form was sent to all patients. The questionnaire included scores for anal incontinence, obstructed defecation syndrome, urinary symptoms and sexual dysfunction. The main outcome measure was the incidence of recurrent rectal prolapse. Surgical morbidity, the need for surgical repair due to recurrent symptoms and functional outcomes were secondary outcome measures. Results A total of 52 adult male patients with symptoms caused by external rectal prolapse underwent ventral rectopexy. The questionnaire response rate was 64.4 %. Baseline clinical characteristics and perioperative results were similar in the responder and non-responder groups. A total of 9 (17.3 %) patients faced complications. There were two (3.8 %) serious surgical complications during the 30-day period after surgery that necessitated reoperation. None of the complications were mesh related. Recurrence of the prolapse was noticed in nine patients (17 %), and postoperative mucosal anal prolapse symptoms persisted in 11 patients (21 %). As a result, the reoperation rate was high. Altogether, 17 patients (33 %) underwent reoperation during the follow-up period due to postoperative complications or recurrent rectal or mucosal prolapse. According to the postoperative questionnaire data, patients under 40 had good functional results in terms of anal continence, defecation, urinary functions and sexual activity. Conclusions Laparoscopic ventral rectopexy is a safe surgical procedure in male patients with external prolapse. However, a high overall reoperation rate was noticed due to recurrent rectal and residual mucosal prolapse. This suggests that the ventral rectopexy technique should be modified or combined with other abdominal or perineal methods when treating male rectal prolapse patients.Peer reviewe