The transport of cosmic rays in self-excited magnetic turbulence

The process of diffusive shock acceleration relies on the efficacy with which hydromagnetic waves can scatter charged particles in the precursor of a shock. The growth of self-generated waves is driven by both resonant and non-resonant processes. We perform high-resolution magnetohydrodynamic simulations of the non-resonant cosmic ray driven instability, in which the unstable waves are excited beyond the linear regime. In a snapshot of the resultant field, particle transport simulations are carried out. The use of a static snapshot of the field is reasonable given that the Larmor period for particles is typically very short relative to the instability growth time. The diffusion rate is found to be close to, or below, the Bohm limit for a range of energies. This provides the first explicit demonstration that self-excited turbulence reduces the diffusion coefficient and has important implications for cosmic-ray transport and acceleration in supernova remnants.

On the maximum energy of shock-accelerated cosmic rays at ultra-relativistic shocks

The maximum energy to which cosmic rays can be accelerated at weakly magnetised ultra-relativistic shocks is investigated. We demonstrate that for such shocks, in which the scattering of energetic particles is mediated exclusively by ion skin-depth scale structures, as might be expected for a Weibel-mediated shock, there is an intrinsic limit on the maximum energy to which particles can be accelerated. This maximum energy is determined from the requirement that particles must be isotropized in the downstream plasma frame before the mean field transports them far downstream, and falls considerably short of what is required to produce ultra-high-energy cosmic rays. To circumvent this limit, a highly disorganized field is required on larger scales. The growth of cosmic ray-induced instabilities on wavelengths much longer than the ion-plasma skin depth, both upstream and downstream of the shock, is considered. While these instabilities may play an important role in magnetic field amplification at relativistic shocks, on scales comparable to the gyroradius of the most energetic particles, the calculated growth rates have insufficient time to modify the scattering. Since strong modification is a necessary condition for particles in the downstream region to re-cross the shock, in the absence of an alternative scattering mechanism, these results imply that acceleration to higher energies is ruled out. If weakly magnetized ultra-relativistic shocks are disfavoured as high-energy particle accelerators in general, the search for potential sources of ultra-high-energy cosmic rays can be narrowed.

Operation X: Soviet Russia and the Spanish Civil War

This article offers a critical reassessment of the Soviet role in the Spanish Civil War, based on recent scholarship and declassified official documents. The author interrogates the broad historiographical consensus that reduces Soviet intervention in Spain to a sinister and nefarious force. Stalin's ignominious reputation vis-à-vis the Loyalist side is present in nearly all Western scholarship on the war, whether specialized studies by Nationalist sympathizers or Republicans in exile, or general treatments of European history written in England or America. It would be difficult to locate even a brief overview of the Civil War published outside of Russia that does not in some fashion demonize the Soviet dictator and the Soviet military assistance, code-named ‘Operation X’. The author argues that the basic error in the wide-ranging literature of this topic has always been to approach Stalin's position in Spain as one based on strength rather than weakness. If framed within the context of failure, Stalin's long-standing reputation as the villain of the Civil War may appear in a strikingly different light, and Soviets’ overall contribution to the Loyalist struggle therefore deserving a nuanced revision. The author also explores the multiple strands of the Soviet-Spanish relationship, which included not only military aid but also diplomatic, cultural and humanitarian facets.

General practitioners perceptions on advance care planning for patients living with dementia

BACKGROUND: Advance care planning (ACP) facilitates communication and understanding of preferences, nevertheless the use of ACPs in primary care is low. The uncertain course of dementia and the inability to communicate with the patient living with dementia are significant challenges for GPs to initiate discussions on goals of care.

METHODS: A cross-sectional survey, using a purposive, cluster sample of GPs across Northern Ireland with registered dementia patients was used. GPs at selected practices received the survey instrument and up to four mail contacts was implemented.

RESULTS: One hundred and thirty-three GPs (40.6%) participated in the survey, representing 60.9% of surveyed practices. While most respondents regarded dementia as a terminal disease (96.2%) only 37.6% felt that palliative care applied equally from the time of diagnosis to severe dementia. While most respondents thought that early discussions would facilitate decision-making during advanced dementia (61%), respondents were divided on whether ACP should be initiated at the time of diagnoses. While most respondents felt that GPs should take the initiative to introduce and encourage ACP, most survey participants acknowledged the need for improved knowledge to involve families in caring for patients with dementia at the end of life and that a standard format for ACP documentation was needed.

CONCLUSION: Optimal timing of ACP discussions should be determined by the readiness of the patient and family carer to face to face end of life. ACP discussions can be enhanced by educational strategies directed towards the patient and family carer that enable shared decision-making with their GP when considering options in future care.

Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based MSK and SEM Clinic for Managing Musculoskeletal symptoms in a GP

Musculoskeletal (MSK) complaints are common within primary care (1) (2) (3) but some General Practitioners (GPs)/family physicians do not feel comfortable managing these symptoms (3), preferring to refer onto hospital specialists or Integrated Clinical Assessment and Treatment Services (ICATs). Long waiting times for hospital outpatient reviews are a major cause of patient inconvenience and complaints (4). We therefore aimed to establish a GP-ran MSK and sport and exercise medicine (SEM) clinic based within a Belfast GP surgery that would contribute to a sustainable improvement in managing these common conditions within primary care as well as reducing waiting times for patients with these conditions to see a specialist. This shift from hospital-based to community-based management is in-keeping with recent policy changes within the UK health-system, including Transforming Your Care within Northern Ireland (NI) (5). The GP-ran MSK and SEM clinic was held monthly within a Belfast GP practice, staffed by one GP with a specialist interest in MSK and SEM conditions and its performance was reviewed over a three month period. Parameters audited included cases seen, orthopaedic and x-ray referral rates and secondary care referrals comparing the GP practice’s performance to the same time period in the previous year as well as patient satisfaction questionnaires.

Energy levels and radiative rates for transitions in Ti X

We report calculations of energy levels, radiative rates, oscillator strengths and line strengths for transitions among the lowest 345 levels of Ti X. These include 146 levels of the n 3 configurations and 86 of 3s ²4ℓ, 3s²5ℓ and 3s3p4ℓ, plus some of the 3s²6ℓ, 3p²4ℓ and 3s3p5ℓ levels. The general-purpose relativistic atomic structure package and flexible atomic code are adopted for the calculations. Radiative rates, oscillator strengths and line strengths are provided for all electric dipole (E1), magnetic dipole (M1), electric quadrupole (E2) and magnetic quadrupole (M2) transitions among the 345 levels, although calculations have been performed for a much larger number of levels. Comparisons are made with existing results and the accuracy of the data is assessed. Additionally, lifetimes for all 345 levels are listed. Extensive comparisons of lifetimes are made for the lowest 40 levels, for which discrepancies with recent theoretical work are up to 30%. Discrepancies in lifetimes are even larger, up to a factor of four, for higher excited levels. Furthermore, the effect of large configuration interaction (CI) is found to be insignificant for both the energies and lifetimes for the lowest 40 levels of Ti X which belong to the 3s²3p, 3s3p², 3s²3d, 3p³ and 3s3p3d configurations. However, the contribution of CI is more appreciable for the energy levels and radiative rates among higher excited levels. Our listed energy levels are estimated to be accurate to better than 1% (within 0.1 Ryd), whereas results for other parameters are probably accurate to better than 20%. © 2013 The Royal Swedish Academy of Sciences.

Musculoskeletal (MSK) and Sport and Exercise Medicine (SEM) in General Practice (GP): A Novel GP-based clinic

The problem-Musculoskeletal (MSK) symptoms are common within primary care but some GPs are not comfortable managing these; waiting times for hospital appointments are a major cause of patients’ complaints. Current UK healthcare policies emphasise a need for more community-based management. We aimed to pilot an innovative general practice-based clinic to improve the management of MSK and Sport and Exercise Medicine (SEM) symptoms within general practice.

The approach-This project was conducted in an inner-city practice of approximately 9,000 patients and 5 GP partners. The practice commissioned a novel monthly 4-hour clinic staffed by one GP with a specialist interest in MSK and SEM conditions. Each patient was allocated a 20-minute appointment. All primary care staff within the practice could refer any patient for whom they considered hospital referral appropriate, with no specific exclusion criteria. Management plans included injection therapy, exercise prescription and onward referral. After three months (August-October 2014) numbers of consultations, sources of referral, reasons for referral and management outcomes were described; patient satisfaction was assessed by questionnaire, offered to 10 randomly selected patients by reception staff and self-completed by patients. Costs of the clinic were compared to current options.

Findings- All patients (14 males; 21 females; aged 35-77 years), were seen within four weeks of referral (one third of orthopaedic referrals in 2013 waited over 9 weeks for appointment). Most were referred from other GPs; some came from physiotherapy and podiatry. Shoulder problems were the most frequent reason for referral. The commonest management option was steroid injection, with most patients being given advice regarding exercise and analgesia; there were 3 onward referrals (2 physiotherapy; 1 rheumatology).

Comparing August-October data in 2014 and 2013, total, orthopaedic and rheumatology referrals were reduced by 147, 2 and 3, respectively; within the practice MSK presentations and physiotherapy and x-ray referrals were 60, 47 and 90 fewer, respectively.

The cost per attendance at the clinic was £61; initial orthopaedic-ICAT assessments cost £82 and a consultant appointment £213.

Satisfaction questionnaires were returned by all 10 selected participants and provided positive feedback, expressing preference for community-based, rather than hospital, management.

Consequence- Our pilot study indicates that this novel service model has potential for efficient and effective management of MSK and SEM complaints in primary care, reducing the need for hospital referral and the clinical burden on general practices. The innovation deserves further evaluation in a full-scale trial to determine its generalisability to other practice settings and populations.