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This article documents the Health Libraries for the National Standards (HeLiNS) research project. The project received the ALIA 2016 research award and was undertaken by a collaboration of the ALIA...

Bleeding from the appendix is a rare cause of lower gastrointestinal haemorrhage. Previous publications have noted diagnosis via colonoscopy or computed tomography angiogram and treatment via surgical or endoscopy. We report a case of large volume per rectal bleeding from the appendix, with diagnosis and treatment via angiography and coil insertion, which is the first of its kind reported in the literature.

Archaeologists investigating Middle Bronze to Early Iron Age periods (1600–900 b.c.) in southern Italy often explore linkages between emerging inequality and foreign trade connections, esta...

Context Exertional heatstroke is one of the leading causes of death in American football players. Precooling (PC) with whole-body cold-water immersion (CWI) may prevent severe hyperthermia and, possibly, exertional heatstroke. However, it is unknown how much PC delays severe hyperthermia when participants wear American football uniforms during exercise in the heat. Does PC alter the effectiveness of CWI once participants become hyperthermic or affect perceptual variables during exercise? Objectives We asked 3 questions: (1) Does PC affect how quickly participants become hyperthermic during exercise in the heat? (2) Does PC before exercise affect rectal temperature (Trec) cooling rates once participants become hyperthermic? (3) Does PC affect perceptual variables such as rating of perceived exertion (RPE), thermal sensation, and environmental symptoms questionnaire (ESQ) responses? Design Crossover study. Setting Laboratory. Patients or Other Participants Twelve physically active males (age = 24 ± 4 years, height = 181.8 ± 8.4 cm, mass = 79.9 ± 10.3 kg). Intervention(s) On PC days, participants completed 15 minutes of CWI (9.98°C ± 0.04°C). They donned American football uniforms and exercised in the heat (temperature = 39.1°C ± 0.3°C, relative humidity = 36% ± 2%) until Trec was 39.5°C. While wearing equipment, they then underwent CWI until Trec was 38°C. Control-day procedures were the same except for the PC intervention. Main Outcome Measure(s) Rectal temperature, heart rate, thermal sensation, RPE, and ESQ responses were measured throughout testing. The duration of cold-water immersion was used in conjunction with Trec to calculate cooling rates. Results Precooling allowed participants to exercise 17.6 ± 3.6 minutes longer before reaching 39.5°C (t11 = 17.0, P < .001). Precooling did not affect postexercise CWI Trec cooling rates (PC = 0.18°C/min ± 0.06°C/min, control = 0.20°C/min ± 0.09°C/min; t11 = 0.9, P = .17); ESQ responses (F2,24 = 1.3, P = .3); or RPE (F2,22 = 2.9, P = .07). Precooling temporarily lowered thermal sensation (F3,26 = 21.7, P < .001) and heart rate (F3,29 = 21.0, P < .001) during exercise. Conclusions Because PC delayed hyperthermia without negatively affecting perceptual variables or CWI effectiveness, clinicians may consider implementing PC along with other proven strategies for preventing heat illness (eg, acclimatization).

Patients lack answers to too many questions about their healthcare after Brexit. That is not good enough, says Jeremy Taylor

The Iron Age hill fort at Burrough Hill, Leicestershire, eastern England, lies in a lowland landscape of Mesozoic sedimentary rocks comprising mudstones with thin limestone units, sandstones and ironstones, which are blanketed by Pleistocene till. During the late Iron Age the hill fort was an important central place; permanent occupation probably began in Early–Middle Iron Age and continued into the Roman period. A variety of materials in archaeological contexts from the site, including clay rampart bonding and the clay linings of storage pits and floors, are found to yield characteristically mixed microfossil assemblages of Early to Late Jurassic ostracods and foraminifera, together with foraminifera from the Late Cretaceous. These provide a unique microfossil signature that indicate provenance from the local till. Microfossils can also be recovered from Middle to Late Iron Age potsherds at Burrough Hill, and these too suggest a local glacial source for the clay. Our analysis demonstrates the power of microfossils to provenance clay materials used for construction and manufactures at an Iron Age site, where a detailed baseline understanding of the local geology is firmly established.

Anastomotic leak after oesophagectomy is associated with poor outcomes. We report the successful utilization of venovenous extracorporeal membrane oxygenation in conjunction with tracheal stent to treat and heal multiple tracheal-neo-oesophageal fistulae following oesophagectomy.

Microfossils found in archaeological ceramics include representatives of kingdoms Fungi, Protista, Plantae, and Animalia and are composed of calcite, silica, or resistant organic compounds capable of withstanding firing. Methods by which microfossils are isolated for study vary considerably, but the best results involve the disaggregation of potsherds into their individual grains or by cutting petrological thin sections. Microfossils can be related directly to the age and depositional environment of the source materials (clays, temper, and slip) used in the manufacturing process, although the introduction of contaminants at the time of construction must also be recognized. When incorporated into an integrated analysis, the microfossils may demonstrate provenance; contribute to a better understanding of the local environment and landscape; identify transportation routes; contribute to an understanding of the technology used, including construction methods and firing; and elucidate the use to which the vessels were put.

Summary The towns of Roman Britain have been subject to a long tradition of empirical research and discussion, but far less attention has been paid to the landscape context in which they developed. This paper considers the implications of this caveat for our understanding of Roman urbanism and suggests that most previous approaches have internalized the study of towns as social institutions and have failed to give due weight to the role of local rural agency in influencing the character of urban development. In so doing, it is suggested that the potential role of other important and competing nodes of economic, political and religious life, such as forts, fortresses, vici and small towns as well as rural sanctuaries and other settlements, is also not given due consideration in discussing the distinctive character of urbanism in Roman Britain.

There has been a hesitancy in academic discussion of Roman Britain to address the potential significance of the identity and agency of rural communities in shaping the provincial landscape. This article seeks to address the reasons for this before delineating some avenues by which we might better investigate this issue. Through two case studies the importance of kinship, agricultural peers and occupational identity (being farmers) are recognised as potential drivers for the course of rural life in Roman Britain. In so doing the extent to which ‘being Roman’ was really a central concern of many agricultural communities is questioned.

A new antimicrobial stewardship program can be overwhelmed at the breadth of interventions and education required to conduct a successful program. The expression "low-hanging fruit," in reference to stewardship, refers to selecting the most obtainable targets rather than confronting more complicated management issues. These targets include intravenous-to-oral conversions, batching of intravenous antimicrobials, therapeutic substitutions, and formulary restriction. These strategies require fewer resources and less effort than other stewardship activities; however, they are applicable to a variety of healthcare settings, including limited-resource hospitals, and have demonstrated significant financial savings. Our stewardship program found that staged and systematic interventions that focus on obvious areas of need, that is, low hanging fruit, provided early successes in our expanded program with a substantial cumulative cost savings of $832,590.

This paper presents the results of a programme of research on an unusual group of prehistoric stone settings located on Exmoor, south-west England. Taking a variety of semi-geometric and apparently random forms, a total of 59 settings have been identified, with new discoveries taking place on a regular basis. These stone settings are remarkable for their diminutive size, with component stones often standing to heights of 100 mm or less, a factor which has led to their being termed ‘minilithic’. Through reference to the results of a programme of geophysical survey and small-scale excavation targeted upon a particularly rich cluster of settings around the upper reaches of Badgworthy Water, issues of morphology, dating, relationships, and the implications of the Exmoor miniliths for developing understandings monumentality are discussed.

OBJECTIVE To examine the presentation, management and outcomes of patients with renal angiomyolipoma (AML) over a period of 10 years, at St George's Hospital, London, UK. PATIENTS AND METHODS We assessed retrospectively 102 patients (median follow-up 4 years) at our centre; 70 had tuberous sclerosis complex (TSC; median tumour size 3.5 cm) and the other 32 were sporadic (median tumour size 1.2 cm). Data were gathered from several sources, including radiology and clinical genetics databases. The 77 patients with stable disease were followed up with surveillance imaging, and 25 received interventions, some more than one. Indications for intervention included spontaneous life-threatening haemorrhage, large AML (10-20 cm), pain and visceral compressive symptoms. RESULTS Selective arterial embolization (SAE) was performed in 19 patients; 10 received operative management and four had a radiofrequency ablation (RFA). SAE was effective in controlling haemorrhage from AMLs in the acute setting (six) but some patients required further intervention (four) and there was a significant complication rate. The reduction in tumour volume was only modest (28%). No complications occurred after surgery (median follow-up 5.5 years) or RFA (median follow-up 9 months). One patient was entered into a trial and treated with sirolimus (rapamycin). CONCLUSIONS The management of AML is both complex and challenging, especially in those with TSC, where tumours are usually larger and multiple. Although SAE was effective at controlling haemorrhage in the acute setting it was deemed to be of limited value in the longer term management of these tumours. Thus novel techniques such as focused ablation and pharmacological therapies including the use of anti-angiogenic molecules and mTOR inhibitors, which might prove to be safer and equally effective, should be further explored.

PurposeThe purpose of this paper is to examine the applicability of HACCP within the hospitality industry from the perspective of two qualified and experienced chefs. It is the second article in the second Worldwide Hospitality and Tourism Themes issue of the International Journal of Contemporary Hospitality Management presenting a new method of HACCP for the hospitality industry and proof of its utility.Design/methodology/approachA combination of academic literature and industry materials is used to examine the nature of the hospitality industry, the scale of food safety problems and previous attempts to solve them.FindingsThe paper argues that in its traditional form, and in the way that many external bodies have tried to impose it, HACCP does not work for the hospitality industry and has been anything other than a benefit. However, HACCP could be the very catalyst the industry needs to come to terms with the food safety issues of a changing world. To make the principles meaningful they must be developed for the industry by the industry itself. They cannot simply be transferred from other sectors and superimposed by external agencies.Originality/valueThis informed and detailed chefs' perspective on HACCP in the hospitality industry is the first of its kind. It will be valuable reading for industry bodies, academics, enforcers and governments working with HACCP in this industry.