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.

Secure Transmission in MIMO Wiretap Channels Using General-Order Transmit Antenna Selection with Outdated CSI

In this paper, we propose general-order transmit antenna selection to enhance the secrecy performance of multiple-input–multiple-output multieavesdropper channels with outdated channel state information (CSI) at the transmitter. To evaluate the effect of the outdated CSI on the secure transmission of the system, we investigate the secrecy performance for two practical scenarios, i.e., Scenarios I and II, where the eavesdropper's CSI is not available at the transmitter and is available at the transmitter, respectively. For Scenario I, we derive exact and asymptotic closed-form expressions for the secrecy outage probability in Nakagami- m fading channels. In addition, we also derive the probability of nonzero secrecy capacity and the \varepsilon -outage secrecy capacity, respectively. Simple asymptotic expressions for the secrecy outage probability reveal that the secrecy diversity order is reduced when the CSI is outdated at the transmitter, and it is independent of the number of antennas at each eavesdropper N_text\rm{E} , the fading parameter of the eavesdropper's channel m_text\rm{E} , and the number of eavesdroppers M . For Scenario II, we make a comprehensive analysis of the average secrecy capacity obtained by the system. Specifically, new closed-form expressions for the exact and asymptotic average secrecy capacity are derived, which are valid for general systems with an arbitrary number of antennas, number of eavesdroppers, and fading severity parameters. Resorting to these results, we also determine a high signal-to-noise ratio power offset to explicitly quantify the impact of the main c- annel and the eavesdropper's channel on the average secrecy capacity.

PESSTO monitoring of SN 2012hn: further heterogeneity among faint Type I supernovae

We present optical and infrared monitoring data of SN 2012hn collectedby the Public European Southern Observatory Spectroscopic Survey forTransient Objects. We show that SN 2012hn has a faint peak magnitude(MR ˜ -15.65) and shows no hydrogen and no clearevidence for helium in its spectral evolution. Instead, we detectprominent Ca II lines at all epochs, which relates this transient topreviously described `Ca-rich' or `gap' transients. However, thephotospheric spectra (from -3 to +32 d with respect to peak) of SN2012hn show a series of absorption lines which are unique and a redcontinuum that is likely intrinsic rather than due to extinction. Linesof Ti II and Cr II are visible. This may be a temperature effect, whichcould also explain the red photospheric colour. A nebular spectrum at+150 d shows prominent Ca II, O I, C I and possibly Mg I lines whichappear similar in strength to those displayed by core-collapsesupernovae (SNe). To add to the puzzle, SN 2012hn is located at aprojected distance of 6 kpc from an E/S0 host and is not close to anyobvious star-forming region. Overall SN 2012hn resembles a group offaint H-poor SNe that have been discovered recently and for which aconvincing and consistent physical explanation is still missing. Theyall appear to explode preferentially in remote locations offset from amassive host galaxy with deep limits on any dwarf host galaxies,favouring old progenitor systems. SN 2012hn adds heterogeneity to thissample of objects. We discuss potential explosion channels includingHe-shell detonations and double detonations of white dwarfs as well aspeculiar core-collapse SNe.

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.