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The discovery of mass burial sites is rare in Europe, particularly in rural areas. Recent excavations at Thornton Abbey in Lincolnshire have revealed a previously unknown catastrophic mass grave containing the remains of at least 48 men, women and children, with radiocarbon dating placing the event in the fourteenth century AD. The positive identification of Yersinia pestis in sampled skeletal remains suggests that the burial population died from the Black Death. This site represents the first Black Death mass grave found in Britain in a non-urban context, and provides unique evidence for the devastating impact of this epidemic on a small rural community.

The rising popularity of hobbyist metal detecting has provided early medieval scholars with various important new datasets, not least the concentrations of metalwork commonly known as ‘productive sites’. Awareness of these foci derives almost exclusively from archaeological evidence, yet they continue to be interpreted through a documentary lens, and are frequently labelled ‘monasteries’. Using the recently discovered site of Little Carlton, Lincolnshire, as a case study, it is argued that comprehension of metal-rich sites is significantly furthered by turning to archaeologically-orientated research agendas and terminologies. As a consequence, seventh- to ninth-century Little Carlton can be understood as one element of a high-status ‘meshwork’ within early medieval East Lindsey, in which elite power was articulated in the landscape through a number of contemporary centres. On site, archaeology indicates the presence of occupation, burial and craft working, but shows that highly symbolic indigenous practices were taking place too, including intentional deposition into a naturally-occurring pond. Evidence for activity either side of the seventh to ninth centuries also stresses the importance of long-term trajectories in shaping the character of places previously celebrated for their finds-rich phases alone.

The Order of St Gilbert of Sempringham was founded around 1130 and was notable both for its double houses, containing canons and nuns, and the claim of later historians that it was the only truly ‘English Order’. Rose Graham and Brian Golding have studied the history of the Gilbertines, however the archaeology of the order has never been comprehensively researched. Of the original 27 monastic houses, 13 have been destroyed or have had their original monastic plans obscured by later buildings. For the remaining 14 houses, there is good archaeological evidence surviving. Using this data, and especially the elements that enable the spatial reconstruction of each site, this thesis focuses on establishing the layout of the monastic buildings and precincts. The thesis takes a holistic approach to the study of the subject utilising a range of sources including data from excavation, geophysical survey, topographic survey and aerial photography. The thesis recreates the layouts of double and single houses in order to understand the relationship between the men and women of the Gilbertine order. It also identifies and addresses the transition from the Gilbertine double house to the prevalence of the single house following the death of St Gilbert c.1190 and the order’s subsequent decline. The study argues that the Gilbertine order formulated a number of distinctly Gilbertine forms of monastic layout, usually related to their distinctive role of accommodating both men and women, which are mostly visible on the sites of double houses in the first instance. This distinctive style was continued to a less extent in the foundation of later single houses through the recurrent placement of cloisters to the north of the priory church.

FEW PEOPLE now remember that the Russian aristocracy before the Revolution was the richest and most powerful in Europe. Though 18 members of the Imperial House and hundreds of the nobility perished, the great Russian families were by no means wiped out, and thousands of refugees managed to escape from Russia in and after 1917.

Objective To determine the nature of the association between renal dysfunction and outcomes following transcatheter aortic valve implantation (TAVI) in all cases performed in the UK between 2007 and 2012. Methods The UK TAVI registry was established to report outcomes on all TAVI procedures performed within the UK. Data were collected prospectively on 3980 patients from 1 January 2007 until 31 December 2012. Results In total, 205 patients (5.5%) died during their admission. Moderate to advanced chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <45 mL/min/1.73 m2) was significantly associated with increased mortality, even after adjustment for risk factors (OR 1.45, 95% CI 1.03 to 2.05; p=0.04). For every 10 mL/min/1.73 m2 decrease in eGFR, in-hospital mortality increased by 8.2% (95% CI 1.1% to 14.7%; p=0.03). In total 1119 patients (30.2%) died during the follow-up period (median 543 days). Moderate to advanced CKD (eGFR <45 mL/min/1.73 m2) was significantly associated with increased mortality, even after adjustment for risk factors (OR 1.36, 95% CI 1.17 to 1.58; p<0.001). For every 10 mL/min/1.73 m2 decrease in eGFR, cumulative mortality increased by 4.4% (95% CI 1.2% to 7.5%; p=0.007). Preoperative kidney function and the need for preoperative dialysis treatment discriminated between patients who died and survived. However, predictive power was poor with none of the c-statistics being >0.6. Conclusions Pre-procedural renal dysfunction is associated, in a graded fashion independently of dialysis status, with worse outcomes, including mortality in patients undergoing TAVI.

Background Hypertension and proteinuria are critically involved in the progression of chronic kidney disease. Despite treatment with renin angiotensin system inhibition, kidney function declines in many patients. Aldosterone excess is a risk factor for progression of kidney disease. Hyperkalaemia is a concern with the use of mineralocorticoid receptor antagonists. We aimed to determine whether the renal protective benefits of mineralocorticoid antagonists outweigh the risk of hyperkalaemia associated with this treatment in patients with chronic kidney disease. Methods We conducted a meta-analysis investigating renoprotective effects and risk of hyperkalaemia in trials of mineralocorticoid receptor antagonists in chronic kidney disease. Trials were identified from MEDLINE (1966–2014), EMBASE (1947–2014) and the Cochrane Clinical Trials Database. Unpublished summary data were obtained from investigators. We included randomised controlled trials, and the first period of randomised cross over trials lasting ≥4 weeks in adults. Results Nineteen trials (21 study groups, 1 646 patients) were included. In random effects meta-analysis, addition of mineralocorticoid receptor antagonists to renin angiotensin system inhibition resulted in a reduction from baseline in systolic blood pressure (−5.7 [−9.0, −2.3] mmHg), diastolic blood pressure (−1.7 [−3.4, −0.1] mmHg) and glomerular filtration rate (−3.2 [−5.4, −1.0] mL/min/1.73 m 2 ). Mineralocorticoid receptor antagonism reduced weighted mean protein/albumin excretion by 38.7 % but with a threefold higher relative risk of withdrawing from the trial due to hyperkalaemia (3.21, [1.19, 8.71]). Death, cardiovascular events and hard renal end points were not reported in sufficient numbers to analyse. Conclusions Mineralocorticoid receptor antagonism reduces blood pressure and urinary protein/albumin excretion with a quantifiable risk of hyperkalaemia above predefined study upper limit.

In women with late preterm pre-eclampsia, the optimal time to initiate delivery is unclear because limitation of maternal disease progression needs to be balanced against infant complications. The aim of this trial was to determine whether planned earlier initiation of delivery reduces maternal adverse outcomes without substantial worsening of neonatal or infant outcomes, compared with expectant management (usual care) in women with late preterm pre-eclampsia. In this parallel-group, non-masked, multicentre, randomised controlled trial done in 46 maternity units across England and Wales, we compared planned delivery versus expectant management (usual care) with individual randomisation in women with late preterm pre-eclampsia from 34 to less than 37 weeks' gestation and a singleton or dichorionic diamniotic twin pregnancy. The co-primary maternal outcome was a composite of maternal morbidity or recorded systolic blood pressure of at least 160 mm Hg with a superiority hypothesis. The co-primary perinatal outcome was a composite of perinatal deaths or neonatal unit admission up to infant hospital discharge with a non-inferiority hypothesis (non-inferiority margin of 10% difference in incidence). Analyses were by intention to treat, together with a per-protocol analysis for the perinatal outcome. The trial was prospectively registered with the ISRCTN registry, ISRCTN01879376. The trial is closed to recruitment but follow-up is ongoing. Between Sept 29, 2014, and Dec 10, 2018, 901 women were recruited. 450 women (448 women and 471 infants analysed) were allocated to planned delivery and 451 women (451 women and 475 infants analysed) to expectant management. The incidence of the co-primary maternal outcome was significantly lower in the planned delivery group (289 [65%] women) compared with the expectant management group (338 [75%] women; adjusted relative risk 0·86, 95% CI 0·79–0·94; p=0·0005). The incidence of the co-primary perinatal outcome by intention to treat was significantly higher in the planned delivery group (196 [42%] infants) compared with the expectant management group (159 [34%] infants; 1·26, 1·08–1·47; p=0·0034). The results from the per-protocol analysis were similar. There were nine serious adverse events in the planned delivery group and 12 in the expectant management group. There is strong evidence to suggest that planned delivery reduces maternal morbidity and severe hypertension compared with expectant management, with more neonatal unit admissions related to prematurity but no indicators of greater neonatal morbidity. This trade-off should be discussed with women with late preterm pre-eclampsia to allow shared decision making on timing of delivery. National Institute for Health Research Health Technology Assessment Programme.

ObjectiveExisting clinical prediction models (CPM) for short-term mortality after transcatheter aortic valve implantation (TAVI) have limited applicability in the UK due to moderate predictive performance and inconsistent recording practices across registries. The aim of this study was to derive a UK-TAVI CPM to predict 30-day mortality risk for benchmarking purposes.MethodsA two-step modelling strategy was undertaken: first, data from the UK-TAVI Registry between 2009 and 2014 were used to develop a multivariable logistic regression CPM using backwards stepwise regression. Second, model-updating techniques were applied using the 2013–2014 data, thereby leveraging new approaches to include frailty and to ensure the model was reflective of contemporary practice. Internal validation was performed by bootstrapping to estimate in-sample optimism-corrected performance.ResultsBetween 2009 and 2014, up to 6339 patients were included across 34 centres in the UK-TAVI Registry (mean age, 81.3; 2927 female (46.2%)). The observed 30-day mortality rate was 5.14%. The final UK-TAVI CPM included 15 risk factors, which included two variables associated with frailty. After correction for in-sample optimism, the model was well calibrated, with a calibration intercept of 0.02 (95% CI −0.17 to 0.20) and calibration slope of 0.79 (95% CI 0.55 to 1.03). The area under the receiver operating characteristic curve, after adjustment for in-sample optimism, was 0.66.ConclusionThe UK-TAVI CPM demonstrated strong calibration and moderate discrimination in UK-TAVI patients. This model shows potential for benchmarking, but even the inclusion of frailty did not overcome the need for more wide-ranging data and other outcomes might usefully be explored.