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Among the ritual practices denigrated through explicit or implicit criticism levied by the biblical writers is the worship of a deity or deities on the rooftops – sometimes of royal architecture, and at other times on private houses. In the present study I interpret this practice using concepts derived from the cognitive science of religion (CSR) and cognitive linguistics. I summarize previous typologies of objects employed in the sacrificial cult of the ancient Southern Levant, confirming prior arguments for understanding shaft-type limestone altars as stylized models of architectural precursors. From a cognitive perspective, these stylized architectural models prompted offrants to run a conceptual blend that replaced the modest small-scale vegetable or incense offering of the offrant’s small-scale input space with the more sumptuous small-scale offering – or even large-scale animal sacrifice – of the monumental-scale input. This cognitive explanation provides explanation for Deuteronomistic and Priestly attempts to limit the practice, and occasions insight into the temporal aspects of “sacred space.”

Background: It has been suggested that sequential bilateral (SBL) TMS, combining high frequency, left dorsolateral prefrontal cortex (DLPFC) stimulation and low frequency, right DLPFC stimulation, is more effective than unilateral TMS. Objective: To contrast treatment outcomes of left unilateral (LUL) and SBL protocols. Methods: Registry data were collected at 111 practice sites. Of 10,099 patients, 3,871 comprised a modified intent-to-treat (mITT) sample, defined as a primary MDD diagnosis, age ≥18, and PHQ-9 completion before TMS and at least one PHQ-9 assessment after baseline. The mITT sample received high frequency (10 Hz) LUL TMS exclusively (N = 3,327) or SBL TMS in at least 90% of sessions (N = 544). Completers (N = 3,049) were responders or had received ≥20 sessions and had an end of acute treatment PHQ-9 assessment. To control for site effects, a Matched sample (N = 653) included Completers at sites that used both protocols. To control for selection bias, the SBL group was also compared to a Restricted LUL group, drawn from sites where no patient switched to SBL after substantial exposure to LUL TMS. Secondary analyses were conducted on CGI-S ratings. Results: The LUL group had superior outcomes compared to the SBL group for multiple PHQ-9 and CGI-S continuous and categorical measures in the mITT, Completer and Matched samples, including in the specified primary analyses. However, outcome differences were not observed when comparing the Restricted LUL and SBL groups. Within SBL protocols, the LUL-RUL order had superior outcomes compared to the RUL-LUL order in all CGI-S, but not PHQ-9, measures. Conclusions: While limited by the naturalistic design, there was no evidence that SBL TMS was superior to LUL TMS. The sequential order of RUL TMS followed by LUL TMS may have reduced efficacy compared to LUL TMS followed by RUL TMS.

Background/Aims Vasculitis has always relied on pattern recognition, biopsy and imaging to secure a diagnosis. Historically, giant cell arteritis diagnosis has relied too heavily on pattern recognition without scrutiny. The current guidelines recommend securing a diagnosis by either temporal artery biopsy (TAB) or imaging. Ultrasound (US) has been given parity with biopsy in European guidelines for cranial giant cell arteritis (cGCA) although in the USA experience is more limited. Large vessel vasculitis (LVV) may not present with cranial symptoms and is diagnosed by axillary US, MRA or preferably PET. The Clyde GCA Fast Track US Pathway was introduced in 2018 and follows EULAR imaging guidelines. In a health board with access to all diagnostic modalities, how is GCA being diagnosed in patients treated with tocilizumab? How is this changing over time? Methods 46 patients commenced on tocilizumab for GCA since 2017 had their diagnoses examined. Electronic records and US data were used to categorise diagnosis as a result of biopsy, MRA, PET, ultrasound or clinical diagnosis alone. Clinical diagnoses with neither imaging nor biopsy were reviewed in more depth. Results There were 37 women and 9 men; 33 cranial GCA and 13 LVV; 9 presenting with a relapsing pattern of disease and 37 with new presentations. Age range 59-91 (mean of 73 years). Only 3 of 46 patients had no additional proof of diagnosis. Diagnosis was secured by biopsy in 16 and imaging in 27 (14 US and 13 PET). Conclusion By 2022, cGCA was equally likely to be diagnosed by US as biopsy. The fast track US service provided support for patients, referrers and surgeons to determine if biopsy was needed to secure a diagnosis. Biopsy was most valuable in delayed presentations or if clinical suspicion was high but US negative. PET is the most useful imaging technique for diagnosing LVV; US of axillary arteries was only positive in a few cases and unable to cover the differential diagnosis. MRA was informative but not diagnostic. All GCA diagnoses should be based on good evidence to warrant the potential toxicity of steroids, tocilizumab and any future treatments for relapsing disease. Disclosure L.M.M. Hutton: None.

Background/Aims Giant cell arteritis (GCA) has been revolutionised by fast track pathways that ensure early secure diagnosis. The GiACTA study provided evidence for the beneficial role of tocilizumab in the treatment of GCA and encouraged us all to reconsider the role of corticosteroids. These data relate to real life experience of the use of tocilizumab, including current status of patients after completing the initial year of treatment. In Scotland, tocilizumab was initially used for patients with relapsing disease or steroid complications. However, since 2018, the Scottish Medicines Consortium has supported use from disease onset and it has become increasingly common to consider adding at diagnosis. Methods The case notes of 23 patients treated with tocilizumab were reviewed back to 2017. Patient demographics were collated including whether cranial (C) or large vessel vasculitis (LVV) variant. The diagnosis of GCA had to be confirmed by biopsy or imaging with GCA rheumatology clinic review. Any patients who discontinued tocilizumab prior to completing one year had the reason recorded. Duration on tocilizumab was intended to be one year. Data were reviewed to capture outcomes after treatment was withdrawn. Results 2 patients with non-relapsing disease discontinued tocilizumab within the first month due to early relative neutropenia (1.4). 5 of 21 patients who completed treatment have since had additional tocilizumab treatment. 1 patient with particularly severe relapsing disease and steroid complications remains on long term tapered tocilizumab monotherapy without attempt to stop (C and LVV). 4 patients (LVV=C) flared within 1-9 months (median 6 months) and resumed with steroids and subsequent tapers; all had commenced for relapsing disease. 1 patient (C), commenced on tocilizumab at diagnosis, opted for MTX when flared. 15 remaining patients are on no steroid, methotrexate or tocilizumab and are free of disease activity as yet, but undergoing monitoring for flare (12C 3 LVV variant). Conclusion Tocilizumab is effective, limits steroid exposure and is well-tolerated by patients. The most common reason for discontinuing tocilizumab was relative neutropenia (neutrophils 1-1.4). The majority of patients discontinued tocilizumab and have not yet flared off all treatment. Cranial variant was less associated with relapse after tocilizumab treatment versus LVV. New diagnoses appear less prone to relapse off tocilizumab than patients already known to have relapsing disease prior to using tocilizumab. Patients discontinuing tocilizumab benefit from ongoing monitoring to recognise the early stages of returning disease; this would need to be provided for at least one year. Patients discontinuing treatment, their GPs and carers need advice on routes to escalate concerns about returning symptoms. Fast track services need to provide a flare service in addition to a diagnosis pathway if there is to be safety, confidence and expert support for this patient group and primary care colleagues. Disclosure L.M.M. Hutton: Other; 2022 Roche educational grant to attend BSR.

Background Identifying opportunities to safely reduce antibiotic prescribing is necessary for prescribers and antibiotic stewardship teams to minimize unwarranted antibiotic use. We aimed to quantify excess antibiotic use in General Surgery. Methods We retrospectively audited the antibiotic prescribing for patients discharged from the General Surgery specialty in an acute hospital in the south-west of England between 01/08/21 and 31/08/21 using an audit tool developed by Public Health England. The appropriateness of prescribing was determined for each patient at three antibiotic decision time-points: at initiation, the pre-72h antibiotic review, and treatment duration. Two infection specialists and a general surgeon reviewed each patient. Indication and excess days of therapy (DOTs) were calculated at each decision time-point and expressed as a proportion of total DOTs. Results Eighty-six patients were prescribed 1162 DOTs; 192 (16.5%) excess DOTs were prescribed in 38 patients (44%), with zero excess days identified in the remaining 48 patients (56%). Seventy-five of 192 (39%) excess DOTs occurred at initiation; 55/192 (29%) after the pre-72hour antibiotic review; and 62/192 (32%) due to protracted antibiotic courses. There was concordance between the general surgeon and infection specialist for the majority of apportioned excess DOTs. However, the surgeon apportioned fewer excess DOTs 160/1162 (13.8%). Overall IV antibiotics accounted for 53.4% of total DOTs. Seventy-two of 86 (83.7%) patients received 620 intravenous DOTs; of these, 79 (12.7%) IV DOTS were unnecessary. Conclusions We have identified excess antibiotic prescribing in General surgery with comparable excess DOTs at all three time-points.

Introduction Surgical site infections (SSIs) are associated with increased morbidity and mortality. Deep SSI, or prosthetic joint infection (PJI), is associated with revision surgery involving longer operative times with higher infection rates, longer length of stay (LoS) and high costs in addition to the catastrophic effect on the patient. The surveillance of SSI is important for patient decision making, identification of outliers for support and maximising focussed improvement. This paper reports the findings of the second Getting it Right First Time (GIRFT) national SSI survey for orthopaedic and spinal surgery. Methods Data were submitted prospectively by 67 orthopaedic units and 22 spinal units between 1 May 2019 and 31 October 2019. For a patient to be included, they had to present with SSI within the study period and within 1 year of the index procedure. Results A total of 309 SSIs were reported from primary and revision, total hip, knee, shoulder, elbow and ankle replacements, and 58 SSIs were reported from lumbar spine single level discectomy or decompression, lumbar spine single-level instrumented posterior fusion, posterior cervical spine decompression and instrumented fusion and posterior correction of adolescent idiopathic scoliosis. SSIs rates have remained low compared with the 2017 survey. There were variations in SSI rates by procedure, with primary shoulder replacement reporting the lowest (0.4%) and revision shoulder replacement the highest (2.5%) rates. Conclusions The authors recommend that the elective surgical restart following the COVID-19 pandemic provides a unique opportunity for all units to implement a full SSI prevention bundle to minimise the risk of infection and improve patient outcomes.

Herbivory is a key ecological process that often determines the composition and abundance of plants. Estimates of herbivory in seagrass meadows are typically lower than those in other vegetated coastal ecosystems, but herbivory can be intense when large herbivorous vertebrates are abundant. We surveyed rates of herbivory on 2 species of tropical seagrasses (Thalassia hemprichii and Enhalus acoroides), the abundance of herbivorous vertebrates, and the diet of 2 abundant herbivorous vertebrates (the green turtle Chelonia mydas and the rabbitfish Siganus lineatus) in lagoons adjacent to remote islands off northwestern Australia. Rates of herbivory in some deployments of tethered seagrass were more than 1000 times higher than rates of production and were among the highest recorded. Consumption exceeded production in half the deployments (9 of 18). Remote underwater video revealed that S. lineatus was the most abundant herbivore. Stomachs of S. lineatus contained mostly seagrass, and models based on stable isotopes indicated that seagrass was the primary source of nutrition. Stomach contents of C. mydas were more variable, containing seagrass and macroalgae (although the sample size was low), but models based on stable isotopes indicated that seagrass was likely the primary source of nutrition. Multiple lines of evidence suggest that the high rates of herbivory on the seagrasses T. hemprichii and E. acoroides are mainly due to direct consumption by the abundant S. lineatus, and perhaps also C. mydas. Seagrass is the primary contributor to the nutrition of both species.

BackgroundLeptospirosis, caused by Leptospira bacteria, is a common zoonosis worldwide more prevalent in the tropics. Reservoir species and risk factors have been identified but surveys for environmental sources of leptospirosis are rare. Furthermore, understanding of environmental Leptospira containing pathogenic genes and possibly capable of causing disease is incomplete and could result in some pathogenic strains evading detection, thereby convoluting diagnosis, prevention, and epidemiology.Methodology/Principal FindingsWe collected environmental samples from 22 sites in Puerto Rico during three sampling periods over 14-months (Dec 2018-Feb 2020); 10 water and 10 soil samples were collected at each site. Samples were screened for pathogenic Leptospira DNA using the lipL32 PCR assay and positive samples were sequenced to assess genetic diversity. One urban site in San Juan was sampled three times over 14 months to assess persistence in soil; live leptospires were obtained during the last sampling period. Isolates were whole genome sequenced and LipL32 expression was assessed in vitro.We detected pathogenic Leptospira DNA at 15/22 sites; both soil and water were positive at 5/15 sites. We recovered lipL32 sequences from 83/86 positive samples (15/15 positive sites) and secY sequences from 32/86 (10/15 sites); multiple genotypes were identified at 12 sites. These sequences revealed significant diversity across samples, including four novel lipL32 phylogenetic clades. Most samples from the serially sampled site were lipL32 positive at each time point. We sequenced the genomes of six saprophytic and two pathogenic Leptospira isolates; the latter represent a novel pathogenic Leptospira species likely belonging to a new serogroup.Conclusions/SignificanceDiverse and novel pathogenic Leptospira are widespread in the environment in Puerto Rico. The disease potential of the novel lineages is unknown but several persisted for >1 year in soil, which could contaminate water. This work increases understanding of environmental Leptospira and should improve leptospirosis surveillance and diagnostics.Author SummaryLeptospirosis is a common zoonotic disease worldwide, but more prevalent in the tropics. Cases are more common following severe weather events, possibly due to flooding, which may more readily distribute soil and/or water contaminated with Leptospira spp., the disease agents. Human cases increased following the 2017 hurricanes that ravaged Puerto Rico (Maria and Irma), prompting environmental sampling of soil and water to assess the presence, abundance, and persistence of pathogenic leptospires in these environments. The goal was to better understand these potential reservoirs of human and animal disease. Divergent and novel groups of pathogenic Leptospira were abundant and widespread in soil and water in Puerto Rico and sometimes persisted in these environments for >1 year. However, most groups we identified have not previously been described from humans and/or other animals, so the disease potential of these novel organisms is unknown. The results of this study reveal a tremendous amount of previously uncharacterized Leptospira diversity in soil and water in Puerto Rico, which could contribute to cryptic disease. The description and characterization of these novel types improves our understanding of the genus Leptospira, and will aid in the developent of improved diagnostics and preventative tools to advance public health outcomes.

Background Leptospirosis, caused by Leptospira bacteria, is a common zoonosis worldwide, especially in the tropics. Reservoir species and risk factors have been identified but surveys for environmental sources are rare. Furthermore, understanding of environmental Leptospira containing virulence associated genes and possibly capable of causing disease is incomplete, which may convolute leptospirosis diagnosis, prevention, and epidemiology. Methodology/Principal findings We collected environmental samples from 22 sites in Puerto Rico during three sampling periods over 14-months (Dec 2018-Feb 2020); 10 water and 10 soil samples were collected at each site. Samples were screened for DNA from potentially pathogenic Leptospira using the lipL32 PCR assay and positive samples were sequenced to assess genetic diversity. One urban site in San Juan was sampled three times over 14 months to assess persistence in soil; live leptospires were obtained during the last sampling period. Isolates were whole genome sequenced and LipL32 expression was assessed in vitro. We detected pathogenic Leptospira DNA at 15/22 sites; both soil and water were positive at 5/15 sites. We recovered lipL32 sequences from 83/86 positive samples (15/15 positive sites) and secY sequences from 32/86 (10/15 sites); multiple genotypes were identified at 12 sites. These sequences revealed significant diversity across samples, including four novel lipL32 phylogenetic clades within the pathogenic P1 group. Most samples from the serially sampled site were lipL32 positive at each time point. We sequenced the genomes of six saprophytic and two pathogenic Leptospira isolates; the latter represent a novel pathogenic Leptospira species likely belonging to a new serogroup. Conclusions/Significance Diverse and novel pathogenic Leptospira are widespread in the environment in Puerto Rico. The disease potential of these lineages is unknown but several were consistently detected for >1 year in soil, which could contaminate water. This work increases understanding of environmental Leptospira diversity and should improve leptospirosis surveillance and diagnostics.

Aim To provide an insight on current applications of immersive virtual reality (VR) on patients undergoing surgery and to project the potential uses of these applications on colorectal population. Methods A non-systematic literature search of PubMed using key subject “Virtual Reality and Surgery” to identify relative articles. On reviewing applications of VR in surgery we identified four main areas of interest: preoperative education, perioperative support, postoperative pain management and rehabilitation. Results VR technology showed promising results in all three stages of patient’s journey ; In pre-surgery, VR was used as a powerful educational tool for vascular patients. Intraoperatively, it showed promising results as a distraction method to relief stress and discomfort in patients undergoing colonoscopy and gynaecology procedures. Postoperatively, VR was utilized in pain management in orthopaedics, cardiothoracic populations with acceptable results. Moreover, physical rehabilitation showed a strong outlet of the technology due to its engaging properties. Conclusion VR has been showing applicable benefits in different stages of patient’s care undergoing surgery. With proper future development of Its applications, VR potentials in colorectal population could be numerous; education on stoma and type of surgery with help of 3D environment, distraction tool for colonoscopy screening and postoperative pain. In addition, VR could help with enhanced recovery inform of physical and mental rehabilitation. Future uses of VR in colorectal population could be a key in improving outcomes and overall satisfactions. However, formulated studies and validated applications should be tackled to apply the technology safely in the standard care of colorectal patients.

To measure and compare the total and normalised tibial nerve movements during forward bending in patients with and without failed back surgery syndrome (FBSS) and persistent leg pain following anatomically successful lumbar decompression surgery and demonstrated no psychological stress. Nerve pathomechanics may contribute to FBSS with persistent leg pain following anatomically successful lumbar decompression surgery. Tibial nerve movement during forward bending was measured in two groups of patients following anatomically successful lumbar decompression surgery. FBSS group (N = 37) consisted of patients with persistent leg pain following lumbar surgery, and non-FBSS (N = 37) were patients with no remaining leg pain following lumbar surgery. Total and normalised tibial nerve movement at the popliteal fossa was measured by a previously validated ultrasound imaging technique and compared between the two groups, and also between the painful and non-painful leg within the FBSS group. Both the mean total and normalised tibial nerve movement were significantly decreased in the FBSS group in both legs when compared to the non-FBSS group (P

Performing quantitative in situ spectroscopic analysis on minuscule sample volumes is a common difficulty in photochemistry. To address this challenge, we use a hollow-core photonic crystal fiber (HC-PCF) that guides light at the center of a microscale liquid channel and acts as an optofluidic microreactor with a reaction volume of less than 35 nL. The system was used to demonstrate in situ optical detection of photoreduction processes that are key components of many photocatalytic reaction schemes. The photoreduction of viologens (XV2+) to the radical XV•+ in a homogeneous mixture with carbon nanodot (CND) light absorbers is studied for a range of different carbon dots and viologens. Time-resolved absorption spectra, measured over several UV irradiation cycles, are interpreted with a quantitative kinetic model to determine photoreduction and photobleaching rate constants. The powerful combination of time-resolved, low-volume absorption spectroscopy and kinetic modeling highlights the potential of optofluidic microreactors as a highly sensitive, quantitative, and rapid screening platform for novel photocatalysts and flow chemistry in general.

The distribution of Burkholderia pseudomallei in the Caribbean is poorly understood. We isolated B. pseudomallei from US Virgin Islands soil. The soil isolate was genetically similar to other isolates from the Caribbean, suggesting that B. pseudomallei might have been introduced to the islands multiple times through severe weather events.

We describe here two previously unpublished funerary busts from Palmyra and now in the collection of the Nelson-Atkins Museum of Art, Kansas City, Mo. (inv. nos. 73-50 and 48-13). We trace the history of the busts’ ownership, engaging in a theoretical discussion of some issues involved in publishing unprovenanced artifacts. We describe each object briefly, giving accounts of the iconography and epigraphic data of each. Although we judge both objects likely to be authentic, we suggest that the inscription of NA no. 73-50 is likely authentic, whereas the inscription of NA no. 48-13 is most likely a forgery. We also provide a detailed onomastic analysis of NA no. 73-50.

Three Palmyrene funerary busts are part of the collections of the Harvard Semitic Museum. This article discusses the epitaphs, the portraits, and their stylistic features, summarizes the funerary b...

Any general or regional anaesthetic technique must always be tailored to both the individual patient and the operation, taking into account the potential benefits and risks. The contribution of the individual anaesthetist in managing the RA (or GA) technique effectively and safely in order to achieve a good outcome must not be underestimated. Nevertheless, evidence does suggest that RA confers some outcome benefits beyond reducing acute pain. These include a reduction in chronic pain after some procedures, less PONV, and a clear reduction in pulmonary complications. RA has also been linked with a reduction in cancer recurrence, blood transfusion, SSI, intensive care unit admissions, and even a small reduction in mortality in some cases, but these data must be treated more cautiously. When CNB is used alone rather than in combination with GA, the benefits are often greater. Logically, utilising PNBs without GA and therefore avoiding CNB-mediated hypotension may offer the most benefit, yet the potential outcome benefits of PNBs are the area least studied.

We report the first clinical-radiological-genetic-molecular-pathological study of a kindred with c.823-10G>T MAPT intronic variant (rs63749974) associated with frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17). We describe the clinical spectrum within this family and emphasize the association between MAPT gene variants and motor neuron disease. This report of a second family with FTDP-17 associated with c.823-10G>T MAPT variant strongly supports pathogenicity of the variant and confirms it is a 4-repeat (4R) tauopathy. This intronic point mutation, probably strengthens the polypyrimidine tract and alters the splicing of exon 10 (10 nucleotides into intron 9) close to the 3' splice site.

Changes in land use, such as mountaintop removal mining with valley fills (MTR-VF), often results in headwater streams with elevated specific conductivity (SC). Stream salamanders appear to be particularly sensitive to elevated SC, as previous studies have shown occupancy and abundance decline consistently among all species and life stages as SC increases. Yet, the proximate mechanism responsible for the population declines in streams with elevated SC have eluded researchers. We sampled salamander assemblages across a continuous SC gradient (30–1966 μS/cm) in southeastern Kentucky and examined the diet of larval and adult salamanders to determine if the ratio of aquatic to terrestrial prey (autochthony), total prey volume, aquatic prey importance (Ix), and body condition are influenced by SC. Further, we asked if threshold points for each diet component were present along a gradient of SC. Larval salamanders experienced a 12–fold decline in autochthony at 153 μS/cm, a 4.2–fold decline in total prey volume at 100 μS/cm, a 2.2-fold decline in aquatic Ix at 135 μS/cm, and a rapid decline in body condition as SC increased. Adult salamanders experienced a 3–fold decline in autochthony at 382 μS/cm, no change in prey volumes, a 2-fold decline in aquatic Ix at 163 μS/cm, and a decline in body condition as SC increased. Our results indicate that SC indirectly affects stream salamander populations by changing the composition of diet, which suggests that food availability is a proximate mechanism that leads to reduced population occupancy, abundance, and persistence in streams with elevated SC.

The article presents a conceptual model of effective school leadership which is based on the experience and knowledge gained from research work done with high-performing principals in the Jamaican school system. The basic and underlying premise is that to understand how leadership works, it is essential to explore the dimensions, components, and elements which shape and inform the behavior of the leaders. The article also presents the conceptual framework for the model and elaborates on the six dimensions which are the basis for analyzing and synthesizing leadership practice. The model would be useful as a diagnostic tool, and a guide for recruiting and developing training programs for principals.

Birds breeding on ocean beaches are threatened globally, often requiring significant investments in species conservation and habitat management. Conservation actions typically encompass spatial and temporal threat reductions and protection of eggs and broods. Still, populations decline or recover only slowly, calling for fresh approaches in beach-bird conservation. Because energetic demands are critically high during the nesting and chick rearing phases, and chick survival is particularly low, supplementing prey to breeding birds and their offspring is theoretically attractive as a means to complement more traditional conservation measures. Prey for plovers and similar species on ocean beaches consists of invertebrates (e.g. small crustaceans, insects) many of which feed on stranded masses of plant material (e.g. kelp and seagrass) and use this ‘wrack’ as habitat. We added wrack to the upper beach where plovers nest and their chicks forage to test whether algal subsidies promote the abundance and diversity of their invertebrate prey. Adding wrack to the upper beach significantly increased the abundance and diversity of invertebrate prey items. At wrack subsidies greater than 50% of surface cover invertebrate assemblages became highly distinct compared with those that received smaller additions of wrack. Substantial (2–4 fold) increases in the abundance amphipods and isopods that are principal prey items for plovers drove these shifts. This proof-of-concept study demonstrates the feasibility of food provisioning for birds on ocean shores. Whilst novel, it is practicable, inexpensive and does not introduce further restrictions or man-made structures. Thus, it can meaningfully add to the broader arsenal of conservation tools for threatened species that are wholly reliant on sandy beaches as breeding and foraging habitats.