West (Morse, 133–62). When Lewis’ 5-feet-tall Death of Cleopatra (of Carrara marble) entered Memorial Hall at the Centennial Exposition in Philadelphia in 1876, having (un)crossed the Atlantic (like Lewis herself, repeatedly), its ‘visual dominance’ caused it to be ‘cited in both black and white U.S. newspapers as the most impressive piece’ (153), literally (re)making history. On paper, too, the artist’s struggle with the past and ‘its reception in a European tradition of Empire’ (38) creates new middle passages, ‘always at sea’ (30), always bound to connect, through varied forms of radical composition (by Derek Walcott and Marlene NourbeSe Philip: Greenwood, 29–56; Aimé Césaire: Lecznar, 197–222; Bernadine Evaristo: Walters, 223–39; Díaz: McConnell, 241–65): from creolised Latin cross-examining ‘the anguish that is English in colonial societies’ (Philip, cited at 39) to ctionalising Romano-British history, joining the Caribbean Sea to the English Channel, Martinique to Londinium — as did/does the Atlantic. The radicalised verse of Walcott and Philip articulates ‘the tale that cannot and yet must be told’ (31) — that of the Middle Passage; it ‘re-enacts the violence of the treatment of the slaves on board’ (40–1), always mediating, linguistically and historically, to express Caribbean experiences in (a) language(s) whose imperium is thus destabilised. The fantastic and the real, too, in drama, novel, novelette, of Césaire, Evaristo, Díaz, join forces to (re)tell ‘the interconnected histories of human beings across the Atlantic’ (225) — many of which, like Trinidadian-born Dr Henry Alexander Saturnin Hartley (Ronnick, 119–32), author of Classical Translations (1889 — the rst by anyone of African descent in the western hemisphere), pioneered those very Black Atlantic classicisms long before that concept’s recent (re)invention. This ‘Black Atlantic in action’ (250) — artists, intellectuals, academic navigators — create ‘alternative pasts and futures (to) suggest an imagined route away from the shadow of slavery and colonialism’ (244). Agreed that cargo, crew and itineraries can (and must) expand: taking on board more non-Anglophone freight (79); diverting from the western Atlantic routes and northern crossings (where is Africa? To be enlisted besides, not appropriated by, its American diaspora, which dominates the present voyage); team-shipping with non-Classicists who know their modern historical ropes (across the cultural and linguistic spectrum). And — Ahoy! — docking around the globe (also beyond the Black Aegean of Goff and Simpson’s (2007) Crossroads of the Black Aegean) is no abandoning ship, no jettisoning of particularity: ‘the consequences of centuries of inequity’ (276) have held coloured folk over the barrel just about everywhere. All hands are needed on deck, in the Atlantic, the Aegean and beyond. Díaz dared to wonder if his time-and-place-melting Life of Oscar Wao ‘ain’t a zafa of sorts’ (248) — the counterspell to the fukú, the curse ‘from Africa, carried in the screams of the enslaved’ (247), embodied in his own moving ‘back and forth between New Jersey and Santo Domingo’, like Penelope’s shuttle (250), or Lewis (and her Queen), a version of Padilla Peralta’s ‘black Dominican classicism [...] to decolonize the imaginary’ (116). The curse only stops when the Middle (of that) Passage has (be)come (to) the end, when the Hydra is the past of our futures. The tension of engaging the Classics against the Classics to turn the corner is an undercurrent throughout. Can ‘Classics’ really be ‘for all’ (Rankine, 267–89)? A ‘universal intuition’ (120)? Or are the black crew on board the Classicisms in the Black Atlantic, as their non-coloured mates in the Black Atlantic, caught between the white supremacist devil (appearing at times in shades of black, not only on Hispaniola) and the deep classicising sea, doomed to shuttle back and forth, like Sisyphus rolled his stone? Zafa!

Abstract An unusual circular funerary monument in the National Archaeological Museum in Perugia (inv. no. 634) depicts a remarkable, multifigured narrative combining generic and unique scenes of Etruscan funerary ritual. Despite its singular character, this Archaic-period monument has never been the focus of an in-depth study. The monument features a frieze with two distinct scenes, each composed around a central focal point. On one side appears a prothesis scene in which a corpse occupies the central space with figures aligned on each side of the funerary bed. On the opposite side, figures are arranged on both sides of an altar featuring a burning fire, a scene without comparison in Etruscan funerary iconography. Though many of the figures have parallels within Etruscan imagery in both gesture and in attribute, much about this monument from its morphology to its pendant scenes is exceptional. Prothesis scenes, which appear almost exclusively in the Chiusi area and only during the Archaic period, are typically combined with images of funerary banqueting, dancing, and/or lamentation scenes. The pairing here with the altar/fire image raises interesting interpretive questions about the constitutive effect of these two events and how these may have been read and comprehended by the ancient viewer. Formally, the scenes invite connection and comparison, perhaps even to convey a symbolic and/or temporal relationship between these two events. The prothesis may have preceded and necessitated some sort of ritual purification by fire. Alternatively, the fire may reference a type of sacrifice part of funerary ritual. Neither, however, was part of the iconographic tradition. In attempting to these scenes, this paper uses a proxemics-based approach (a model used frequently in New World archaeology), to understand how the formal and physical characteristics of the monument reflect aspects of ancient visuality that is, the interplay between viewer, perception, and space. The figuration, composition, and morphology of this monument suggest that these scenes were intended less as narratives to be read and more as evocations of a ritual landscape whose broad contours could be perceived and understood with even a cursory engagement. These scenes are the visual evocation of ritual performance and environments. Though unusual in many aspects, the Perugia monument may have more far-reaching implications for ancient viewership.

This paper considers recent discoveries at the site of Cetamura del Chianti and contextualizes them within the thriving economy at the site, revealing a strong Etruscan identity and continuity in northern Etruria in the Late Etruscan period. Excavations at the artisans’ quarter provide evidence of a vigorous and diversified industrial production intertwined with the adjacent sanctuary, a Late Etruscan complex with evidence of significant ritual activity during the second and first centuries B.C.E.

In this article, prothesis imagery on relief monuments from Archaic Chiusi is examined. The lying in state of the corpse, a scene initially adopted from Attic models in the Archaic period, appears frequently among the Chiusine corpus. Unlike Attic prothesis imagery, the prothesis scene at Chiusi shows significant variation in gender roles, gestures, and notions of pollution. Additionally, the frequent inclusion of children within the reliefs may reflect a high degree of social visibility and participation among all age groups in the mourning ritual in Etruria.

ROMAN CHILDREN - J. Mander Portraits of Children on Roman Funerary Monuments. Pp. xvi + 397, ills. Cambridge: Cambridge University Press, 2013. Cased, £80, US$130. ISBN: 978-1-107-00102-2. - Volume 63 Issue 2

Objective To identify the factors that can predict physicians’ use of electronic prescribing. Design All primary care physicians who practised in a single geographic region in Quebec were invited to use a free, advanced, research-based electronic prescribing and drug management system. This natural experiment was studied with an expansion of the Technology Acceptance Model (TAM), which was used to explain early adopters’ use of this electronic prescribing technology. Setting Quebec city region. Participants A total of 61 primary care physicians who practised in a single geographic region where there was no electronic prescribing. Main outcome measures Actual use of electronic prescribing; physicians’ perceptions of and intentions to use electronic prescribing; physician and practice characteristics. Results During the 9-month study period, 61 primary care physicians located in 26 practice sites used electronic prescribing to write 15 160 electronic prescriptions for 18 604 patients. Physician electronic prescribing rates varied considerably, from a low of 0 to a high of 75 per 100 patient visits, with a mean utilization rate of 30 per 100 patient visits. Overall, 34% of the variance in the use of electronic prescribing was explained by the expanded TAM. Computer experience (P = .001), physicians’ information-acquisition style (P = .01), and mean medication use in the practice (P = .02) were significant predictors. Other TAM factors that generally predict new technology adoption (eg, intention to use, perceived ease of use, and perceived usefulness) were not predictive in this study. Conclusion The adoption of electronic prescribing was a highly challenging task, even among early adopters. The insight that this pilot study provides into the determinants of the adoption of electronic prescribing suggests that novel physician-related factors (eg, information-acquisition style) and practice-related variables (eg, prevalence of medication use) influence the adoption of electronic prescribing. Editor’s kEy points • Although electronic prescribing can improve the quality and safety of patient care, its widespread adoption is largely lagging in North America. • Three groups of variables were defined as having a potential effect on the use of electronic prescribing: physicians’ perceptions of and intentions to use the new information system, physician characteristics, and practice setting characteristics. Within those variables, significant predictors of early adopters’ use of electronic prescribing were computer experience (P = .001), informationacquisition style (P = .01), and mean medication use in the practice (P = .02). • Knowledge of physicians’ informationacquisition styles (ie, pragmatist, receptive, seeker, or traditionalist approaches) is important, as the successful integration of electronic prescribing into the day-today practice of physicians will require a better understanding of how to present new information in electronic modes to enhance adoption and change physician practice patterns.

Objective To identify the factors that can predict physicians' use of electronic prescribing.Design All primary care physicians who practised in a single geographic region in Quebec were invited to use a free, advanced, research-based electronic prescribing and drug management system. This natural experiment was studied with an expansion of the Technology Acceptance Model (TAM), which was used to explain early adopters' use of this electronic prescribing technology.Setting Quebec city region.Participants A total of 61 primary care physicians who practised in a single geographic region where there was no electronic prescribing.Main outcome measures Actual use of electronic prescribing; physicians' perceptions of and intentions to use electronic prescribing; physician and practice characteristics.Results During the 9-month study period, 61 primary care physicians located in 26 practice sites used electronic prescribing to write 15 160 electronic prescriptions for 18 604 patients. Physician electronic prescribing rates varied considerably, from a low of 0 to a high of 75 per 100 patient visits, with a mean utilization rate of 30 per 100 patient visits. Overall, 34% of the variance in the use of electronic prescribing was explained by the expanded TAM. Computer experience (P = .001), physicians' information-acquisition style (P = .01), and mean medication use in the practice (P = .02) were significant predictors. Other TAM factors that generally predict new technology adoption (eg, intention to use, perceived ease of use, and perceived usefulness) were not predictive in this study.Conclusion The adoption of electronic prescribing was a highly challenging task, even among early adopters. The insight that this pilot study provides into the determinants of the adoption of electronic prescribing suggests that novel physician-related factors (eg, information-acquisition style) and practice-related variables (eg, prevalence of medication use) influence the adoption of electronic prescribing.

BACKGROUND:Public pressure has increasingly emphasized the need to ensure the continuing quality of care provided by health professionals over their careers. Health profession's regulatory authorities, mandated to be publicly accountable for safe and effective care, are revising their quality assurance programs to focus on regular evaluations of practitioner performance. New methods for routine screening of performance are required and the use of administrative data for measuring performance on quality of care indicators has been suggested as one attractive option. Preliminary studies have shown that community pharmacy claims databases contain the information required to operationalize quality of care indicators. The purpose of this project was to determine the feasibility of routine use of information from these databases by regulatory authorities to screen the quality of care provided at community pharmacies.METHODS:Information from the Canadian province of Quebec's medication insurance program provided data on prescriptions dispensed in 2002 by more than 5000 pharmacists in 1799 community pharmacies. Pharmacy-specific performance rates were calculated on four quality of care indicators: two safety indicators (dispensing of contra-indicated benzodiazepines to seniors and dispensing of nonselective beta-blockers to patients with respiratory disease) and two effectiveness indicators (dispensing asthma or hypertension medications to non-compliant patients). Descriptive statistics were used to summarize performance.RESULTS:Reliable estimates of performance could be obtained for more than 90% of pharmacies. The average rate of dispensing was 4.3% (range 0 - 42.5%) for contra-indicated benzodiazepines, 15.2% (range 0 - 100%) for nonselective beta-blockers to respiratory patients, 10.7% (range 0 - 70%) for hypertension medications to noncompliant patients, and 43.3% (0 - 91.6%) for short-acting beta-agonists in over-use situations. There were modest correlations in performance across the four indicators. Nine pharmacies (0.5%) performed in the lowest quartile in all four of the indicators, and 5.3% (n = 95) performed in the lowest quartile on three of four indicators.CONCLUSIONS:Routinely collected pharmacy claims data can be used to monitor indicators of the quality of care provided in community pharmacies, and may be useful in future to identify underperforming pharmacists, measure the impact of policy changes and determine predictors of best practices.

Background Asthma is a prevalent and costly disease resulting in reduced quality of life for a large proportion of individuals. Effective patient self-management is critical for improving health outcomes. However, key aspects of self-management such as self-monitoring of behaviours and symptoms, coupled with regular feedback from the health care team, are rarely addressed or integrated into ongoing care. Health information technology (HIT) provides unique opportunities to facilitate this by providing a means for two way communication and exchange of information between the patient and care team, and access to their health information, presented in personalized ways that can alert them when there is a need for action. The objective of this study is to evaluate the acceptability and efficacy of using a web-based self-management system, My Asthma Portal (MAP), linked to a case-management system on asthma control, and asthma health-related quality of life. Methods The trial is a parallel multi-centered 2-arm pilot randomized controlled trial. Participants are randomly assigned to one of two conditions: a) MAP and usual care; or b) usual care alone. Individuals will be included if they are between 18 and 70, have a confirmed asthma diagnosis, and their asthma is classified as not well controlled by their physician. Asthma control will be evaluated by calculating the amount of fast acting beta agonists recorded as dispensed in the provincial drug database, and asthma quality of life using the Mini Asthma Related Quality of Life Questionnaire. Power calculations indicated a needed total sample size of 80 subjects. Data are collected at baseline, 3, 6, and 9 months post randomization. Recruitment started in March 2010 and the inclusion of patients in the trial in June 2010. Discussion Self-management support from the care team is critical for improving chronic disease outcomes. Given the high volume of patients and time constraints during clinical visits, primary care physicians have limited time to teach and reinforce use of proven self-management strategies. HIT has the potential to provide clinicians and a large number of patients with tools to support health behaviour change. Trial Registration Current Controlled Trials ISRCTN34326236 .

1 . The focus of the UNCA/NYU-Florence excavations is a Roman farmhouse located in an alluvial plain known as the Sesto/Bientina Marsh southeast of the city of Lucca (fig. 1). The building, known locally as 'Palazzaccio', is one of more than one hundred ancient Roman farms in the plain of Lucca uniquely preserved by catastrophic flooding of the Serchio (ancient Auser) river. The flooding, which began in the 4 th

BACKGROUND:Adherence with antihypertensive and lipid-lowering therapy is poor, resulting in an almost 2-fold increase in hospitalization. Treatment side effects, cost, and complexity are common reasons for nonadherence, and physicians are often unaware of these potentially modifiable problems.OBJECTIVE:To determine if a cardiovascular medication tracking and nonadherence alert system, incorporated into a computerized health record system, would increase drug profile review by primary care physicians, increase the likelihood of therapy change, and improve adherence with antihypertensive and lipid-lowering drugs.METHODS:There were 2293 primary care patients prescribed lipid-lowering or antihypertensive drugs who were randomized to the adherence tracking and alert system or active medication list alone to determine if the intervention increased drug profile review, changes in cardiovascular drug treatment, and refill adherence in the first 6 months. An intention to treat analysis was conducted using generalized estimating equations to account for clustering within physician.RESULTS:Overall, medication adherence was below 80% for 36.3% of patients using lipid-lowering drugs and 40.8% of patients using antihypertensives at the start of the trial. There was a significant increase in drug profile review in the intervention compared to the control group (44.5% v. 35.5%; P < 0.001), a nonsignificant increase in drug discontinuations due to side effects (2.3% v. 2.0%; P = 0.61), and a reduction in therapy increases (28.5% v. 29.1%; P = 0.86). There was no significant change in refill adherence after 6 months of follow-up.CONCLUSION:An adherence tracking and alert system increases drug review but not therapy changes or adherence in prevalent users of cardiovascular drug treatment. Targeting incident users where adverse treatment effects are more common and combining adherence tracking and alert tools with motivational interventions provided by multidisciplinary primary care teams may improve the effectiveness of the intervention.

Background: Health problem lists are a key component of electronic health records and are instrumental in the development of decision-support systems that encourage best practices and optimal patient safety. Most health problem lists require initial clinical information to be entered manually and few integrate information across care providers and institutions. This study assesses the accuracy of a novel approach to create an inter-institutional automated health problem list in a computerized medical record (MOXXI) that integrates three sources of information for an individual patient: diagnostic codes from medical services claims from all treating physicians, therapeutic indications from electronic prescriptions, and single-indication drugs.Methods: Data for this study were obtained from 121 general practitioners and all medical services provided for 22,248 of their patients. At the opening of a patient's file, all health problems detected through medical service utilization or single-indication drug use were flagged to the physician in the MOXXI system. Each new arising health problem were presented as 'potential' and physicians were prompted to specify if the health problem was valid (Y) or not (N) or if they preferred to reassess its validity at a later time.Results: A total of 263,527 health problems, representing 891 unique problems, were identified for the group of 22,248 patients. Medical services claims contributed to the majority of problems identified (77%), followed by therapeutic indications from electronic prescriptions (14%), and single-indication drugs (9%). Physicians actively chose to assess 41.7% (n = 106,950) of health problems. Overall, 73% of the problems assessed were considered valid; 42% originated from medical service diagnostic codes, 11% from single indication drugs, and 47% from prescription indications. Twelve percent of problems identified through other treating physicians were considered valid compared to 28% identified through study physician claims.Conclusion: Automation of an inter-institutional problem list added over half of all validated problems to the health problem list of which 12% were generated by conditions treated by other physicians. Automating the integration of existing information sources provides timely access to accurate and relevant health problem information. It may also accelerate the uptake and use of electronic medical record systems.

Objectives: Prescribing alerts generated by computerized drug decision support (CDDS) may prevent drug-related morbidity. However, the vast majority of alerts are ignored because of clinical irrelevance. The ability to customize commercial alert systems should improve physician acceptance because the physician can select the circumstances and types of drug alerts that are viewed. We tested the effectiveness of two approaches to medication alert customization to reduce prevalence of prescribing problems: on-physician-demand versus computer-triggered decision support. Physicians in each study condition were able to preset levels that triggered alerts. Design: This was a cluster trial with 28 primary care physicians randomized to either automated or on-demand CDDS in the MOXXI drug management system for 3,449 of their patients seen over the next 6 months.Measurements: The CDDS generated alerts for prescribing problems that could be customized by severity level. Prescribing problems included dosing errors, drug-drug, age, allergy, and disease interactions. Physicians randomized to on-demand activated the drug review when they considered it clinically relevant, whereas physicians randomized to computer-triggered decision support viewed all alerts for electronic prescriptions in accordance with the severity level they selected for both prevalent and incident problems. Data from administrative claims and MOXXI were used to measure the difference in the prevalence of prescribing problems at the end of follow-up.Results: During follow-up, 50% of the physicians receiving computer-triggered alerts modified the alert threshold (n = 7), and 21% of the physicians in the alert-on-demand group modified the alert level (n = 3). In the on-demand group 4,445 prescribing problems were identified, 41 (0.9%) were seen by requested drug review, and in 31 problems (75.6%) the prescription was revised. In comparison, 668 (10.3%) of the 6,505 prescribing problems in the computer-triggered group were seen, and 81 (12.1%) were revised. The majority of alerts were ignored because the benefit was judged greater than the risk, the interaction was known, or the interaction was considered clinically not important (computer-triggered: 75.8% of 585 ignored alerts; on-demand: 90% of 10 ignored alerts). At the end of follow-up, there was a significant reduction in therapeutic duplication problems in the computer-triggered group (odds ratio 0.55; p = 0.02) but no difference in the overall prevalence of prescribing problems.Conclusion: Customization of computer-triggered alert systems is more useful in detecting and resolving prescribing problems than on-demand review, but neither approach was effective in reducing prescribing problems. New strategies are needed to maximize the use of drug decision support systems to reduce drug-related morbidity.