Stable isotopes reveal dietary shifts associated with social change in Hellenistic, Roman and Late Antique Knossos

Knossos was an important city on Crete and within Mediterranean networks in terms of trade and political status, though its status differed throughout the Hellenistic, Roman and Late Antique periods. This paper uses stable carbon and nitrogen isotope analysis to consider whether people at Knossos had differential diets due to the social, political, cultural, and economic changes across this time frame, factoring in age, sex and social status. Samples of human bone were selected to represent this range of time periods and variables. In this initial study, a small but insignificant increase in δ13C values was observed between the Hellenistic and Roman periods and there was a significant increase in δ15N values for the Late Antique period. No relationship between δ13C or δ15N and age was observed and while the female and male means were similar, the females had wider ranging values. No significant differences were detected by social status as represented by tomb type but there were small sample sizes for several of the tomb types. The results indicated a C3 terrestrial diet with meat or other animal products included for most individuals. The slight increase in δ13C values in the Roman period may represent either the introduction of a small amount of C4 plant or marine food, or very low trophic level marine foods into some Roman diets. The higher δ13C and, in particular, δ15N values observed in the Late Antique samples, suggests an increased consumption of seafood, potentially linked to Christian dietary practices or advances in fishing technologies and preservation techniques. The wider spread values of females compared to males, indicating a more varied diet, could have resulted from differential participation in religious institutions connected to food or may have been caused by greater nutritional stress in females in relation to pregnancy and reproductive issues. This study does not show a pattern of higher animal protein consumption in times of economic and cultural growth and prosperity but differences were detected between the different time periods in connection with the concurrent socio-economic changes

Isotopic analysis of faunal material from South Uist, Western Isles, Scotland

This paper reports on the results from stable isotope analysis of faunal bone collagen from a number of Iron Age and later sites on the island of South Uist, in the Western Isles, Scotland. This preliminary investigation into the isotopic signatures of the fauna is part of a larger project to model the interaction between humans, animals, and the broader environment in the Western Isles. The results demonstrate that the island fauna data fall within the range of expected results for the UK, with the terrestrial herbivorous diets of cattle and sheep confi rmed. The isotopic composition for pigs suggests that some of these animals had an omnivorous diet, whilst a single red deer value might be suggestive of the consumption of marine foods, such as by grazing on seaweed. However, further analysis is needed in order to verify this anomalous isotopic ratio

Changing environment at the Late Upper Palaeolithic ite of Lynx Cave, North Wales

Lynx Cave is one of a handful of locations in North Wales that provide evidence of Late Upper Palaeolithic huntergatherers at the end of the last ice-age. With the region being recolonized at a time of rapid environmental change there is a need to develop on-site palaeoenvironmental records that are directly linked to the archaeology in order to further understanding of the environments and landscapes that these hunter-gatherer groups experienced. Through carbon (δ13C), nitrogen (δ15N) and sulphur (δ34S) stable isotope analysis of animal bones we explore the environmental conditions during the human occupation of Lynx Cave. Analysis of the data indicates the faunal isotope results cluster into three distinct groupings, which when considered in light of the species composition, radiocarbon dates, sample layer provenance and known temporal patterns in herbivore isotope data from Northern Europe, are likely to relate to GI-1cba (the Allerød period) around 13,700-13,000 cal BP, GI-1cba/GS-1 (the Late Allerød/ early Younger Dryas period) around 13,100-12,800 cal BP, and the Bronze Age. The isotope data indicates that the Late Upper Palaeolithic or Late Palaeolithic occupations occurred in an open landscape in which soils were undergoing changing hydrological conditions linked to ice sheet melt and permafrost thaw process and subsequent recovery. The evidence of butchery marks on the faunal remains from both Late Glacial isotope clusters, along with the disparate radiocarbon dates and the presence of three hearths, support the idea of very short-term episodic use of the cave over an extended time period

Radiocarbon chronology and environmental context of Last Glacial Maximum human occupation in Switzerland

Central Europe during the Last Glacial Maximum (LGM) was dominated by polar desert and steppe-tundra biomes. Despite this, a human presence during this time period is evident at several locations across the region, including in Switzerland, less than 50 km from the Alpine ice sheet margin. It has been hypothesised that such human activity may have been restricted to brief periods of climatic warming within the LGM, but chronological information from many of these sites are currently too poorly resolved to corroborate this. Here we present a revised chronology of LGM human occupation in Switzerland. AMS radiocarbon dating of cut-marked reindeer (Rangifer tarandus) bones from the sites of Kastelhöhle-Nord and Y-Höhle indicates human occupation of Switzerland was most likely restricted to between 23,400 and 22,800 cal. BP. This timeframe corresponds to Greenland Interstadial 2, a brief warming phase, supporting the hypothesis that human presence was facilitated by favourable climatic episodes. Carbon, nitrogen and sulphur stable isotope analysis of the fauna provides palaeoenvironmental information for this time period. These findings contribute to our understanding of human activity in ice-marginal environments and have implications for understanding cultural connections across central Europe during the LGM

Late Pleistocene/Early Holocene Migratory Behavior of Ungulates Using Isotopic Analysis of Tooth Enamel and Its Effects on Forager Mobility.

Zooarchaeological and paleoecological investigations have traditionally been unable to reconstruct the ethology of herd animals, which likely had a significant influence on the mobility and subsistence strategies of prehistoric humans. In this paper, we reconstruct the migratory behavior of red deer (Cervus elaphus) and caprids at the Pleistocene-Holocene transition in the northeastern Adriatic region using stable oxygen isotope analysis of tooth enamel. The data show a significant change in δ18O values from the Pleistocene into the Holocene, as well as isotopic variation between taxa, the case study sites, and through time. We then discuss the implications of seasonal faunal availability as determining factors in human mobility patterns

Iso-Wetlands: unlocking wetland ecologies and agriculture in prehistory through sulfur isotopes

Iso-Wetlands is a new, NERC-funded collaborative research project involving researchers at UCL Institute of Archaeology, the University of Leeds and the UK Centre for Ecology and Hydrology. The project is developing sulfur isotope analysis of archaeological plants and animals as a new tool for exploring hydrological conditions under which agricultural production was taking place. This development has the potential to improve understanding of water management strategies in the past, particularly in relation to seasonal floodwater agriculture and wetland agriculture (for example, rice paddy systems). The project will open wider possibilities for the use of sulfur isotopes in archaeology and ecology to examine wetland habitat use by both people and animals

Quality improvement priorities for safer out-of-hours palliative care: Lessons from a mixed-methods analysis of a national incident-reporting database

Background: Patients receiving palliative care are often at increased risk of unsafe care with the out-of-hours setting presenting particular challenges. The identification of improved ways of delivering palliative care outside working hours is a priority area for policymakers. Aim: To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary-care services outside normal working hours. Design: A mixed-methods cross-sectional analysis of patient safety incident reports from the National Reporting and Learning System. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Setting/participants: A total of 1072 patient safety incident reports involving patients receiving sub-optimal palliative care via the out-of-hours primary-care services. Results: Incidents included issues with: medications (n = 613); access to timely care (n = 123); information transfer (n = 102), and/or non-medication-related treatment such as pressure ulcer relief or catheter care (n = 102). Almost two-thirds of reports (n = 695) described harm with outcomes such as increased pain, emotional, and psychological distress featuring highly. Commonly identified contributory factors to these incidents were a failure to follow protocol (n = 282), lack of skills/confidence of staff (n = 156), and patients requiring medication delivered via a syringe driver (n = 80). Conclusion: Healthcare systems with primary-care-led models of delivery must examine their practices to determine the prevalence of such safety issues (communication between providers; knowledge of commonly used, and access to, medications and equipment) and utilise improvement methods to achieve improvements in care. </jats:sec

Protocol for a feasibility study incorporating a randomised pilot trial with an embedded process evaluation and feasibility economic analysis of ThinkCancer!: a primary care intervention to expedite cancer diagnosis in Wales

Abstract Background Compared to the rest of Europe, the UK has relatively poor cancer outcomes, with late diagnosis and a slow referral process being major contributors. General practitioners (GPs) are often faced with patients presenting with a multitude of non-specific symptoms that could be cancer. Safety netting can be used to manage diagnostic uncertainty by ensuring patients with vague symptoms are appropriately monitored, which is now even more crucial due to the ongoing COVID-19 pandemic and its major impact on cancer referrals. The ThinkCancer! workshop is an educational behaviour change intervention aimed at the whole general practice team, designed to improve primary care approaches to ensure timely diagnosis of cancer. The workshop will consist of teaching and awareness sessions, the appointment of a Safety Netting Champion and the development of a bespoke Safety Netting Plan and has been adapted so it can be delivered remotely. This study aims to assess the feasibility of the ThinkCancer! intervention for a future definitive randomised controlled trial. Methods The ThinkCancer! study is a randomised, multisite feasibility trial, with an embedded process evaluation and feasibility economic analysis. Twenty-three to 30 general practices will be recruited across Wales, randomised in a ratio of 2:1 of intervention versus control who will follow usual care. The workshop will be delivered by a GP educator and will be adapted iteratively throughout the trial period. Baseline practice characteristics will be collected via questionnaire. We will also collect primary care intervals (PCI), 2-week wait (2WW) referral rates, conversion rates and detection rates at baseline and 6 months post-randomisation. Participant feedback, researcher reflections and economic costings will be collected following each workshop. A process evaluation will assess implementation using an adapted Normalisation Measure Development (NoMAD) questionnaire and qualitative interviews. An economic feasibility analysis will inform a future economic evaluation. Discussion This study will allow us to test and further develop a novel evidenced-based complex intervention aimed at general practice teams to expedite the diagnosis of cancer in primary care. The results from this study will inform the future design of a full-scale definitive phase III trial. Trial registration ClinicalTrials.gov NCT04823559. </jats:sec

Nitrogen palaeo-isoscapes: changing spatial gradients of faunal δ15N in late Pleistocene and early Holocene Europe

Nitrogen isotope ratio analysis (δ15N) of animal tissue is widely used in archaeology and palaeoecology to investigate diet and ecological niche. Data interpretations require an understanding of nitrogen isotope compositions at the base of the food web (baseline δ15N). Significant variation in animal δ15N has been recognised at various spatiotemporal scales and related to changes both in baseline δ15N, linked to environmental and climatic influence on the terrestrial nitrogen cycle, and animal ecology. Isoscapes (models of isotope spatial variation) have proved a useful tool for investigating spatial variability in biogeochemical cycles in present-day marine and terrestrial ecosystems, but so far, their application to palaeo-data has been more limited. Here, we present time-sliced nitrogen isoscapes for late Pleistocene and early Holocene Europe (c. 50,000 to 10,000 years BP) using herbivore collagen δ15N data. This period covers the Last Glacial-Interglacial Transition, during which significant variation in the terrestrial nitrogen cycle occurred. We use generalized linear mixed modelling approaches for interpolation and test models which both include and exclude climate covariate data. Our results show clear changes in spatial gradients of δ15N through time. Prediction of the lowest faunal δ15N values in northern latitudes after, rather than during, the Last Glacial Maximum is consistent with the Late Glacial Nitrogen Excursion (LGNE). We find that including climatic covariate data does not significantly improve model performance. These findings have implications for investigating the drivers of the LGNE, which has been linked to increased landscape moisture and permafrost thaw, and for understanding changing isotopic baselines, which are fundamental for studies investigating diets, niche partitioning, and migration of higher trophic level animals

Analysis of applying a patient safety taxonomy to patient and clinician-reported incident reports during the COVID-19 pandemic: a mixed methods study

Background: The COVID-19 pandemic resulted in major disruption to healthcare delivery worldwide causing medical services to adapt their standard practices. Learning how these adaptations result in unintended patient harm is essential to mitigate against future incidents. Incident reporting and learning system data can be used to identify areas to improve patient safety. A classification system is required to make sense of such data to identify learning and priorities for further in-depth investigation. The Patient Safety (PISA) classification system was created for this purpose, but it is not known if classification systems are sufficient to capture novel safety concepts arising from crises like the pandemic. We aimed to review the application of the PISA classification system during the COVID-19 pandemic to appraise whether modifications were required to maintain its meaningful use for the pandemic context. Methods: We conducted a mixed-methods study integrating two phases in an exploratory, sequential design. This included a comparative secondary analysis of patient safety incident reports from two studies conducted during the first wave of the pandemic, where we coded patient-reported incidents from the UK and clinician-reported incidents from France. The findings were presented to a focus group of experts in classification systems and patient safety, and a thematic analysis was conducted on the resultant transcript. Results: We identified five key themes derived from the data analysis and expert group discussion. These included capitalising on the unique perspective of safety concerns from different groups, that existing frameworks do identify priority areas to investigate further, the objectives of a study shape the data interpretation, the pandemic spotlighted long-standing patient concerns, and the time period in which data are collected offers valuable context to aid explanation. The group consensus was that no COVID-19-specific codes were warranted, and the PISA classification system was fit for purpose. Conclusions: We have scrutinised the meaningful use of the PISA classification system’s application during a period of systemic healthcare constraint, the COVID-19 pandemic. Despite these constraints, we found the framework can be successfully applied to incident reports to enable deductive analysis, identify areas for further enquiry and thus support organisational learning. No new or amended codes were warranted. Organisations and investigators can use our findings when reviewing their own classification systems