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The Exarchate of Ravenna has usually been seen as peripheral to Carolingian Italy because of its ’alien’ character, stemming from its position as a province of the eastern empire up to 751. This chapter first argues that, while the area retained many distinctive ‘Roman’ institutions that were quite distinct from the those of the old Lombard kingdom, it is unhelpful to regard these as ‘Byzantine’, and that enduring links with Constantinople were limited. The chapter goes on to argue that the area came to play an increasing role in the political and ecclesiastical life of Carolingian Italy, for a number of reasons, including the archbishops’ conflicts with the papacy and the attractiveness of Ravenna’s heritage to rulers keen to enhance their claims to imperial authority. Also, by the late ninth century various factors led to the settlement in the Exarchate of several powerful families of Lombard and Frankish descent.
The first formal bone tool in the Central Altai of Russia was found in an Early Upper Palaeolithic assemblage at the Kara-Bom open-air site. Here the authors report the results of AMS dating, use-wear analysis, 3D-modelling and zooarchaeological and collagen fingerprinting analysis, which reveal important new insights into the osseous technology of the Kara-Bomian tradition.
The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
Environmental information from place-names has largely been overlooked by geoarchaeologists and fluvial geomorphologists in analyses of the depositional histories of rivers and floodplains. Here, new flood chronologies for the rivers Teme, Severn, and Wye are presented, modelled from stable river sections excavated at Broadwas, Buildwas, and Rotherwas. These are connected by the Old English term *wæsse, interpreted as ‘land by a meandering river which floods and drains quickly’. The results reveal that, in all three places, flooding during the early medieval period occurred more frequently between AD 350–700 than between AD 700–1100, but that over time each river's flooding regime became more complex including high magnitude single events. In the sampled locations, the fluvial dynamics of localized flood events had much in common, and almost certainly differed in nature from other sections of their rivers, refining our understanding of the precise nature of flooding which their names sought to communicate. This study shows how the toponymic record can be helpful in the long-term reconstruction of historic river activity and for our understanding of past human perceptions of riverine environments.
Mass gatherings are growing in frequency. Religious, or in this case, “mass” mass gatherings are also growing in complexity, requiring considerable effort from nations hosting a Papal Mass. Ireland hosted a papal mass in 1979 when the prospect of terrorism at such events was significantly lower. Large high-profile events such as a Papal Mass offer a platform via the media and social media to gain widespread coverage of adverse events. In 2018, a predicted 500,000 guests were scheduled to attend a Papal Mass gathering in Phoenix Park, Dublin, a bounded 1,700-hectare park in the center of Dublin.
To develop a medical plan estimating numbers of people requiring medical attention at a Papal Mass held in Ireland late August 2018, and compare same with actual numbers treated post-event. This study aims to reduce the medical impact of such an event on local receiving hospitals through plans that effectively manage medical- and trauma-related presentations on site.
A literature review of medical reports regarding medical care at Papal Mass gatherings worldwide found a range of predicted medical attendance from 21-61 per 10,000 attendees. On that basis we had prepared on-site facilities, facilities on travel routes and access point system for medical care for a crowd of 500,000 were selected.
One of 6 receiving hospitals in Dublin had an increase in average presentations on the day. Attendance was reduced significantly due to weather. 261 patients were treated on site, falling in line with lower rate predicted of 31 patients treated in hospital on site and 17 transports off-site.
A predictable number of patients presented for medical care. On-site medical services reduced transports to hospital. Reduced attendance ensured facilities were sufficient, but could have been under the pressure of the predicted attendance of 500,000.
Health and social care face growing and conflicting pressures: mounting complex needs of an ageing population, restricted funding and a workforce recruitment and retention crisis. In response, in the UK the NHS Long Term Plan promises increased investment and an emphasis on better ‘integrated’ care. We describe key aspects of integration that need addressing.
Declaration of interest
D.K.T. and S.S.S. are on the editorial board of the British Journal of Psychiatry and executives of the Academic Faculty at the Royal College of Psychiatrists. A.J.B.J., H.P. and Z.M. have roles at the Royal College of Psychiatrists that include evaluation of integrated care systems. A.J.B.J. is married to Dr Sarah Wollaston, Member of Parliament for Totnes and Chair of the Health Select Committee.
To examine variation in antibiotic coverage and detection of resistant pathogens in community-onset pneumonia.
A total of 128 hospitals in the Veterans Affairs health system.
Hospitalizations with a principal diagnosis of pneumonia from 2009 through 2010.
We examined proportions of hospitalizations with empiric antibiotic coverage for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PAER) and with initial detection in blood or respiratory cultures. We compared lowest- versus highest-decile hospitals, and we estimated adjusted probabilities (AP) for patient- and hospital-level factors predicting coverage and detection using hierarchical regression modeling.
Among 38,473 hospitalizations, empiric coverage varied widely across hospitals (MRSA lowest vs highest, 8.2% vs 42.0%; PAER lowest vs highest, 13.9% vs 44.4%). Detection rates also varied (MRSA lowest vs highest, 0.5% vs 3.6%; PAER lowest vs highest, 0.6% vs 3.7%). Whereas coverage was greatest among patients with recent hospitalizations (AP for anti-MRSA, 54%; AP for anti-PAER, 59%) and long-term care (AP for anti-MRSA, 60%; AP for anti-PAER, 66%), detection was greatest in patients with a previous history of a positive culture (AP for MRSA, 7.9%; AP for PAER, 11.9%) and in hospitals with a high prevalence of the organism in pneumonia (AP for MRSA, 3.9%; AP for PAER, 3.2%). Low hospital complexity and rural setting were strong negative predictors of coverage but not of detection.
Hospitals demonstrated widespread variation in both coverage and detection of MRSA and PAER, but probability of coverage correlated poorly with probability of detection. Factors associated with empiric coverage (eg, healthcare exposure) were different from those associated with detection (eg, microbiology history). Providing microbiology data during empiric antibiotic decision making could better align coverage to risk for resistant pathogens and could promote more judicious use of broad-spectrum antibiotics.
We study the abundance of the remnants of stars that reionized the Universe in galaxies in the present day Universe using the eagle cosmological hydrodynamical simulation. High mass galaxies contain most of these ‘reionizers’. The fractional number of galaxies that do not host reionizers increases with decreasing stellar mass, M⋆. For the galaxies that host reionizers, the fraction of mass of the galaxy in reionizers increases with decreasing M⋆, such that the fraction is low (~10−4) for high mass galaxies and can be as high as 0.1 in low mass galaxies, M⋆ ≤ 107 M⊙. In Milky-Way like galaxies, the distribution of reionizers is spatially more extended than that of normal stars.
The use of psychological treatments for patients presenting with physical health problems has a long history. A Persian physician used exploratory psychotherapy over 1200 years ago to successfully treat a patient's psoriasis, by linking it to conflict with his father (Shafi & Shafi, 1979). Alexander (1950) was one of the great pioneers of psychosomatic medicine of the 20th century. Although he recognised that the aetiology of disease was multifactorial, he speculated that in a number of diseases (including hypertension, rheumatoid arthritis, peptic ulcer and asthma) psychological factors might be of aetiological importance. The notion that psychological factors may be relevant to either the genesis or the progression of physical illness persists. We now know that there is a strong association between most chronic diseases and psychiatric disorder, especially depression (Katon & Sullivan, 1990). Increasing awareness of this has led to an upsurge in the literature assessing psychological interventions in this area.
Even though only a minority of patients with physical illnesses meet criteria for psychiatric disorder, psychologically determined consequences of physical illness are common, clinically significant and potentially treatable. Indeed, it has been argued that psychological skills are essential in the management of all physical disorders (Mayou, 2005). Psychological treatments are not only useful for patients who have psychiatric disorder in addition to physical illness but are also beneficial in patients without psychiatric disorder who have difficulties arising from problematic illness beliefs, illness behaviour or adjustment to illness. Not infrequently these distinctions overlap, such as non-epileptic attacks in a patient who has epilepsy, or breathlessness secondary to panic attacks in a patient with asthma.
Psychological therapy has been particularly neglected in older patients, who are most at risk of physical illness and often require longer periods of treatment. However, there is no evidence that they do not respond to psychological treatment and many may benefit (Evans, 2007). The focus of this chapter is on psychological treatments for patients who are physically ill and those who present with medically unexplained symptoms. It will not cover treatments in other areas of liaison psychiatry such as self-harm, substance misuse, eating disorders or perinatal psychiatry, which have been addressed in the relevant chapters in this book.
St Andrews was of tremendous significance in medieval Scotland. Its importance remains readily apparent in the buildings which cluster the rocky promontory jutting out into the North Sea: the towers and walls of cathedral, castle and university provide reminders of the status and wealth of the city in the Middle Ages. As a centre of earthly and spiritual government, as the place of veneration forScotland's patron saint and as an ancient seat of learning, St Andrews was the ecclesiastical capital of Scotland. This volume provides the first full study of this special and multi-faceted centre throughout its golden age. The fourteen chapters use St Andrews as a focus for the discussion of multiple aspects of medieval life in Scotland. They examine church, spirituality, urban society andlearning in a specific context from the seventh to the sixteenth century, allowing for the consideration of St Andrews alongside other great religious and political centres of medieval Europe.
Michael Brown is Professor of Medieval Scottish History, University of St Andrews; Katie Stevenson is Keeper of Scottish History and Archaeology, National Museums Scotland and Senior Lecturer in Late Medieval History, University of St Andrews.
Contributors: Michael Brown, Ian Campbell, David Ditchburn, Elizabeth Ewan, Richard Fawcett, Derek Hall, Matthew Hammond, Julian Luxford, Roger Mason, Norman Reid, Bess Rhodes, Catherine Smith, Katie Stevenson, Simon Taylor, Tom Turpie.