To send content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about sending content to .
To send content items to your Kindle, first ensure email@example.com
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about sending to your Kindle.
Note you can select to send to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
The Ediacaran tubular fossils Cloudina, Sinotubulites, and Conotubus are taxonomically revised with type materials. It is proposed that Aulophycus lucianoi Beurlen and Sommer, 1957, is not a senior synonym of Cloudina hartmannae Germs, 1972. Instead, most of its syntypes may be assigned to Sinotubulites or other taxa. Lectotypes of Sinotubulites baimatuoensis Chen et al., 1981, and Conotubus hemiannulatus Zhang and Lin in Lin et al., 1986, are designated from rediscovered syntypes. Sinotubulites baimatuoensis Chen et al., 1981, is reported from the Mooifontein Member of Nama Group at Aar Farm, Namibia. Cloudina waldei Hahn and Pflug, 1985, is assigned to Sinotubulites baimatuoensis, and thus its occurrence range is extended to Brazil. The lectotype of Conotubus hemiannulatus shows corrugations and annulations on the surface distinguishing it from Cloudina and other collared Ediacaran tubular fossils. Based on the taxonomic revision, we propose a Cloudina hartmannae Interval Zone for the terminal Ediacaran with the upper boundary defined by the first appearance datum of Protohertzina anabarica (i.e., the index fossil of the early Cambrian Anabarites trisulcatus-Protohertzina anabarica Assemblage Zone).
Group Name: Duke Center for Antimicrobial Stewardship and Infection Prevention
Background: Blood cultures are an essential diagnostic test, but over- and underutilization may cause harm. Methods: We analyzed blood culture utilization at 6 hospitals in the southeastern United States including 1 academic hospital (A) and 5 community hospitals (B–F) from May 2019 to April 2020. We measured blood culture utilization rate (BCUR) per 1,000 patient days and blood cultures per encounter. We counted blood cultures by laboratory accession number and measured utilization per 1,000 patient days and encounter. A likely contaminant was defined as 1 of 2 blood cultures collected in the same calendar day positive for a common skin commensal (CSC), as defined by the NHSN, and not identified from subsequent cultures. A likely pathogen was defined as a culture with a pathogen not on the CSC list or a CSC not meeting the contaminant definition. Hospital-level BCUR included samples for culture collected in the emergency department (ED) and inpatient areas divided by inpatient days. Results: The analysis included 117,897 blood cultures and 662,723 patient days with a median BCUR of 209.7 per hospital and median blood culture per encounter of 2 (Table 1). One community hospital (C) demonstrated a substantially higher BCUR than others. Cultures were frequently collected in the ED (54%; range, 36%–78%); most encounters with cultures in the ED were subsequently admitted to an inpatient unit (84%; range, 73%–89%). Higher BCURs were observed in intensive care and oncology units. The proportion of first blood cultures drawn after initiation of antibiotics was 6% (range, 3%–9%. Mondays had higher BCURs than other days of the week (Figure 1). The average BCUR by month was 176.1 (range, 164.3–181.4) with no seasonal patterns observed. Overall, 7.7% (range, 4.5%–9.1%) of blood cultures identified a likely pathogen and 2.1% (range, 1.3%–3.2%) identified a likely contaminant. The 3 hospitals with BCURs >200 also had contaminant rates >2% and >60% ED cultures. Conclusions: Blood culture utilization varied by hospital, unit, and day of the week. We observed higher rates of likely contaminants among hospitals with higher BCURs and ED culture rates. Comparisons may assist in identifying opportunities to optimize practice around blood-culture ordering and collection.
Little is known about how the Royal College of Emergency Medicine (RCEM) residency programs are selecting their residents. This creates uncertainty regarding alignment between current selection processes and known best practices. We seek to describe the current selection processes of Canadian RCEM programs.
An online survey was distributed to all RCEM program directors and assistant directors. The survey instrument included 22 questions and sought both qualitative and quantitative data from the following six domains: application file, letters of reference, elective selection, interview, rank order, and selection process evaluation.
We received responses from 13 of 14 programs for an aggregate response rate of 92.9%. A candidate's letters of reference were identified as the most important criterion from the paper application (38.5%). Having a high level of familiarity with the applicant was the most important characteristic of a reference letter author (46.2%). In determining rank order, 53.8% of programs weighed the interview more heavily than the paper application. Once final candidate scores are established following the interview stage, all program respondents indicated that further adjustment is made to the final rank order list. Only 1 of 13 program respondents reported ever having completed a formal evaluation of their selection process.
We have identified elements of the selection process that will inform recommendations for programs, students, and referees. We encourage programs to conduct regular reviews of their selection process going forward to be in alignment with best practices.
We performed a mixed-methods study to evaluate antimicrobial stewardship program (ASP) uptake and to assess variability of program implementation in Missouri hospitals. Despite increasing uptake of ASPs in Missouri, there is wide variability in both the scope and sophistication of these programs.
The Emergency Medicine (EM) Specialty Committee of the Royal College of Physicians and Surgeons of Canada (RCPSC) specifies that resuscitation entrustable professional activities (EPAs) can be assessed in the workplace and simulated environments. However, limited validity evidence for these assessments in either setting exists. We sought to determine if EPA ratings improve over time and whether an association exists between ratings in the workplace v. simulation environment.
All Foundations EPA1 (F1) assessments were collected for first-year residents (n = 9) in our program during the 2018–2019 academic year. This EPA focuses on initiating and assisting in the resuscitation of critically ill patients. EPA ratings obtained in the workplace and simulation environments were compared using Lin's concordance correlation coefficient (CCC). To determine whether ratings in the two environments differed as residents progressed through training, a within-subjects analysis of variance was conducted with training environment and month as independent variables.
We collected 104 workplace and 36 simulation assessments. No correlation was observed between mean EPA ratings in the two environments (CCC(8) = -0.01; p = 0.93). Ratings in both settings improved significantly over time (F(2,16) = 18.8; p < 0.001; η2 = 0.70), from 2.9 ± 1.2 in months 1–4 to 3.5 ± 0.2 in months 9–12. Workplace ratings (3.4 ± 0.1) were consistently higher than simulation ratings (2.9 ± 0.2) (F(2,16) = 7.2; p = 0.028; η2 = 0.47).
No correlation was observed between EPA F1 ratings in the workplace v. simulation environments. Further studies are needed to clarify the conflicting results of our study with others and build an evidence base for the validity of EPA assessments in simulated and workplace environments.
To utilise a community-based participatory approach in the design and implementation of an intervention targeting diet-related health problems on Navajo Nation.
A dual strategy approach of community needs/assets assessment and engagement of cross-sectorial partners in programme design with systematic cyclical feedback for programme modifications.
Navajo Nation, USA.
Navajo families with individuals meeting criteria for programme enrolment. Participant enrolment increased with iterative cycles.
The Navajo Fruit and Vegetable Prescription (FVRx) Programme.
A broad, community-driven and culturally relevant programme design has resulted in a programme able to maintain core programmatic principles, while also allowing for flexible adaptation to changing needs.
Cricothyrotomy is an intervention performed to salvage “can't intubate, can't ventilate” situations. Studies have shown poor accuracy with landmarking the cricothyroid membrane, particularly in female patients by surgeons and anesthesiologists. This study examines the perceived versus actual success rate of landmarking the cricothyroid membrane by resident and staff emergency physicians using obese and non-obese models.
Five male and female volunteers were models. Each model was placed supine, and a point-of-care ultrasound expert landmarked the borders of each cricothyroid membrane; 20 residents and 15 staff emergency physicians were given one attempt to landmark five models. Overall accuracy and accuracy stratified by sex and obesity status were calculated.
Overall landmarking accuracy amongst all participants was 58% (SD 18%). A difference in accuracy was found for obese males (88%) versus obese females (40%) (difference = 48%, 95% CI = 30–65%, p < 0.0001), and non-obese males (77%) versus non-obese females (46%) (difference = 31%, 95% CI = 12–51%, p = 0.004). There was no association between perceived difficulty and success (correlation = 0.07, 95% CI = −0.081–0.214, p = 0.37). Confidence levels overall were higher amongst staff physicians (3.0) than residents (2.7) (difference = 0.3, 95% CI = 0.1–0.6, p = 0.02), but there was no correlation between confidence in an attempt and its success (p = 0.33).
We found that physicians demonstrate significantly lower accuracy when landmarking cricothyroid membranes of females. Emergency physicians were unable to predict their own accuracy while landmarking, which can potentially lead to increased failed attempts and a longer time to secure the airway. Improved training techniques may reduce failed attempts and improve the time to secure the airway.
BIRDS IN THE EXETER BOOK RIDDLES are an important subject of wonder, the various and unique transformations of particular species described in a scheme of nearly one hundred riddles that marvel at nonhuman phenomena, both animate and inanimate. Anglo-Saxon riddles as a whole had serious, didactic purposes and, despite their unique characteristics, the Old English riddles’ clear connections to the Anglo-Latin examples make it likely that they also served some form of pedagogic role in a monastic environment. Certainly their formulaic injunctions, instructing that we frige ‘ask’ or saga ‘say’ hwæt ‘what’ or hu ‘how’ something is or comes to be, fit with the intellectual lines of inquiry evident in the Latin riddles. Superficially, then, birds feature on one level in the ‘catalogue of diversity’ to be pondered, guessed and classified by naming a solution. As scholars of the Exeter Riddles have long known, however, their unique form of vernacular riddling presents audiences with sophisticated, often divergent forms of learning and hermeneutics in their own right, and in this chapter I explore how birds’ peculiarities become part of the collection's self-reflexive pedagogic aims and strategies.
As in Chapter One, we are never far from the mysterious qualities of birds’ foreignness, and this compelling avian aspect will ultimately concern us more with how the Riddles’ strategies reveal ignorance as much as enlightenment. I see avian quiddities as particularly apt in this dialogic game, because the lives and behaviours of these proximate strangers exemplify well the distinctive interplay of the known and unknown in riddling discourses; in being both nameable and anonymous they suit riddles’ tendencies to obfuscate and disambiguate concurrently. Birds are a significant element in the miscellany, that is, because they enact a series of diverse transformations that redouble their participation in the Riddles’ preoccupations with wondering. As subjects of wonder, they naturally perform a bewildering range of perpetual sleights and shifts that transgress species and territory boundaries, making their diversity excellent riddle material. Within riddling frameworks, however, this unpredictable diversity achieves a heightened focus because it meets with further transformations imposed by metaphor and paradox.
THE BIRDS THAT FLY AND SING through my five chapters have enacted, provoked and evaded transformations. Metaphor – indeed, all forms of human translation – is repeatedly at stake, empowered and limited through its various and tangled involvements with the avian real. In Chapter One, birds mobilised a paradoxical metaphor, aiding those transfigurations most desired in orthodox Christian doctrine. In Chapter Two they mystified scholastic attempts to decode their diversity of kinds that ‘be not distinguyd in certayne’, escaping or thwarting human transformative designs upon the natural world. Elsewhere, they managed curious frictions between biological and cultural species traits with comic aplomb, manipulating and resisting their assigned roles in literary modes to reverse or redirect humanised taxonomies of species and voice. In the final chapter, we ended with the most substantial and dramatic of all avian transformations, simultaneously dispersive and integrative mutations that ‘bringen forth of briddes kinde’ (CA, IV.3119).
Studies of the sort I offer here run an unavoidable risk. Those who consciously and rigorously attempt to write about the nonhuman are paradoxically forced to recognise that they always do write about the human. As Erica Fudge comments, in these cases ‘we read humans writing about animals’, and (even if we do claim to address the animal purely as itself) we must process these writings through our own human faculties. To borrow the words of another writer on birds, there is a ‘sense in which a book like this on birds is really about ourselves’. I do not intend, however, that the title of this book should be misleading. I maintain that birds are, in fact, my proper focus because their materiality is always evident and deeply relevant. Their presence reveals intertwined human–avian histories and existences that can and do suggest an interdependence or compatibility that makes the bird integral, not marginal, to our self-conceptions. It would be entirely false, of course, to suggest that the birds I discuss are not symbolic, metaphoric or anthropomorphic, or that medieval people were not users of birds in the traditional sense.
IF THE VOCABULARY of medieval English is anything to go by, birds were a conspicuous and abundant presence in the lives of medieval people. In Old English alone, one might talk of a fughel-dæg ‘bird-day’; of being a fugel-bana ‘bird-killer’ gone fugelung ‘fowling’ with a fugel-net ‘bird-net’ somewhere fugel-wylle ‘abounding in birds’; or of a fugel-hælsere ‘bird-diviner’ observing fugel-cynn ‘birdkind’; or perhaps of feðer-cræt ‘feather-embroidering’ or a feðer-bed. Raucously and richly vocal, feathered and flying, birds impressed and enriched, sustained and enabled the bodily and cognitive experiences of daily living. As much as their mammalian fellows, birds were participants in rural and urban living in a time, as one historian goes so far as to say, in which ‘animals and humans shared space, food, famines, work, and weather conditions more intensely’ than any other historical age except human prehistory. As the Old English terms above suggest, birds were often of practical interest. The most proximate, everyday species were domestic poultry: chickens were an important and protected resource, enjoyed by almost every social stratum, and geese, a more labour-intensive poultry species, not only provided meat and eggs, but their feathers, plucked from living or dead birds, were a crucial resource for arrows and quills. Tamed birds of prey were highly prized among the nobility, nurtured and flown by falconers who knew intimately the birds’ idiosyncratic habits and moulting patterns. All these birds could occupy less prosaic roles, too. Raptors had powerful semiotic value as emblems on escutcheons, or through the projection of ‘shared’ courtly values in literary realms, and even the humble chicken could, in cockerel form, function as a symbol of Christian light and hope, or the hen feature as an encrypted marvel in an Old English riddle, or a reminder of God's divine wisdom in bestiary sources.
Recent interest in human-nonhuman relations has emphasised this eclecticism of animal meaning in pre-modern living, but particularly nonhuman physicality, reminding us that these creatures existed within a network of relations and interactions with human subjects who were well acquainted with the origins and husbandries of those natural sources that provided foods and technologies.
[Tell me now, you wretched creature: is there any other purpose to you, other than that you have a shrill voice? You mean nothing to any other being … What good do you do among mankind?]
Heruore hit is þat me þe shuneþ
An þe totorue & tobuneþ
[So it is that people shun you, and pelt and beat you to pieces.]
(The Owl and the Nightingale, 556–63 and 1165–6)
THE OWL's VITRIOLIC WORDS in the first epigraph above remind us of the central theme of this poem's ‘plaiding suþe stronge’ [very strong debate (12)] – an owl and a nightingale contend aggressively on the usefulness of their voices, apologists for their own, and lambasters of the other's. In one respect, this is a generic feature, a recognisable component from a number of the possible Latin or Anglo-Norman debate-poems which are likely sources for The Owl and the Nightingale: people, abstractions or creatures debate their individual merits, or those of another whom they represent. On this simple basis, Neil Cartlidge comments, the poem certainly qualifies as a debate-poem, and the adept treatment the author makes of so-called debate-poetry characteristics in itself may point out an important aim for a text whose exact purpose has famously baffled scholars: ‘it could reasonably be described both as a self-conscious summation, and a self-conscious surpassing, of received literary possibilities’. In this skilled ‘summation’, however, we are alerted to how those ‘received literary possibilities’ mesh with other medieval literary discourses in which being useful bears significance. The cut and thrust of disputatio, dealt with more simply or superficially in The Owl and the Nightingale's sources, does not exist as a frivolous display of wit, or even just as a comment on rhetoric itself, but to press debating the subject of nonhuman worth to much more provocative ends.
This indoors flying makes it seem absurd, Although it itches and nags and flutters and yearns, To postulate any other life than now.
(Louis MacNeice, ‘Dark Age Glosses’, 15–17)
What came first, the seabird's cry or the soul Imagined in the dawn cold when it cried?
(Seamus Heaney, ‘Small Fantasia for W.B.’, 3–4)
LOUIS MACNEICE's poem reminds us of how well endures one specific association of a very well-known sparrow with a central Anglo-Saxon ‘image-complex’: fire-lit hall and raging storm, transience and eternity. The purported moment in Bede's Historia ecclesiastica when one king and his people reject their pagan beliefs for a promised Christian eternity pivots on a fictional augury in which a flying bird is entwined with the morphosis and fate of the human soul. Bede's sparrow is allegorical: like man's journey from the unknown to human existence on earth, and then again to the unknown, the bird flies in from the cold, through the banqueting hall and back out again into the tempestuous night, subject to the ineluctable transience of mortal life. The passer, or spearwa in Old English, becomes responsible for a seminal moment in the history of the English people, assigned a significant rhetorical function in a pagan representation of life without Christ that simultaneously contemplates what that life might look like after conversion. It resonates with and consolidates a scriptural legacy which designates birds a special status in thinking through this key theological anxiety and inquiry, a legacy which locates birds as ideal creatures to articulate the Christian pilgrim journey by aligning avian flight with the metaphorical peregrinations of the faithful who must ‘soar to the unchangeable substance of God’. The bird appears in Saint Augustine's lengthy exegesis of Psalm 83, for instance, where it is compared to the human heart or soul. Psalm 124.7 includes the neodspearuwa ‘needful sparrow’ that Ælfric alludes to elsewhere: Ute sawl is ahred of grine swa swa spearwa ‘Our soul is freed from the snare just like the sparrow’.