Vaso-occlusive episodes (VOE) are the most common complication resulting from sickle cell disease (SCD) in adults. VOEs are caused by ischemic tissue injury as a result of occlusion of microvascular beds from abnormal sickle shaped red blood cells (RBCs). Individuals with SCD display a host of complications associated with micro and occasionally macro vascular occlusion, including stroke, leg ulcers, spontaneous miscarriage, and renal insufficiency. The acute pain crisis is the most common reason patients with SCD seek medical care in emergency departments (EDs). Due to the recurrent nature of acute pain crises, possible inadequate knowledge of health care providers about the disease, and the intensity of treatment needed, patients with VOEs may be undermedicated in the ED. This can lead to low patient satisfaction, low provider satisfaction, and increased cost of care. Through the use of an ED observation unit (OU) or clinical pathway, patients experiencing VOEs can be effectively managed to improve outcomes, improve satisfaction, and decrease cost of care.

Introduction

The saltmarshes of the Georgia, USA, Atlantic coast are expansive and highly productive. The marshes form the intertidal ecosystem 5–10 km wide extending from the barrier-island chain to the mainland. The predominant macrophyte of the marshes is smooth cordgrass (Spartina alterniflora Loisel.). Cross-marsh average annual production of smooth cordgrass shoots in Georgia has been measured at approximately 1.3 kg m− 2 of marsh (Newell, 2001a, from Dai & Wiegert, 1996). Like most grasses, smooth cordgrass does not abscise its leaf blades; they remain attached to the leaf sheath after senescence and death (Newell, 1993, and references therein). As new blades are produced at the apex of shoots, the bottom blades senesce and die, until the whole shoot dies after flowering. Therefore, a large crop of standing-dead litter is available to microbes for decomposition for much of the year (for leaf blades alone, up to 538 g dry mass m− 2) (Newell et al., 1998).

Because smooth cordgrass is produced in an intertidal marsh, one might suspect that tidal flooding would be a major wetting phenomenon for the standing-dead cordgrass leaves. However, the grass shoots extend above the flooding-tidal level most of the time: it is estimated that most of the dead-blade mass is wetted by tides only about 10% of the time on an annual-average basis (Newell et al., 1998).

The first half of the sixteenth century witnessed the tentative beginnings of direct political relations between Ireland and France in the form of a French dimension to the intrigues of the Anglo-Irish Geraldine dynasty. During this period, leading members of the Geraldine family of Desmond and Kildare mounted campaigns in opposition to the English crown and in the process sought the assistance of François I (1494–1547). James Fitzgerald, tenth earl of Desmond (d. 1529), was the first Irish magnate to engage in serious intrigue with the French crown in the early 1520s. In 1540 his kinsman, Gerald Fitzgerald, heir to the earldom of Kildare then in abeyance following his half-brother's rebellion (1534–5), sought temporary asylum in France. His status as a leading Anglo-Irish magnate and as a figurehead of Ireland's first nation-wide coalition gained him an hospitable reception at the hands of the French authorities and ensured his safe passage through France into Flanders while exerting a modest strain on Anglo-French relations. In the longer term, it gave rise to his being invested with a pivotal role in French war propaganda during the 1540s. This deliberately contrived scaremongering was effective in playing upon one of the greatest fears of the Whitehall and Dublin administrations in relation to Ireland – a revival of the Geraldine interest, backed by the French and possibly the Scots. Through their intrigues the Fitzgeralds therefore furnished the French with legitimising causes for possible intervention in Ireland during the two Anglo-French wars in the 1520s and in the mid-1540s.

The opening years of the seventeenth century heralded a series of changes in politics in Ireland, France and on the international stage that brought to an end the episodic political engagement of the sixteenth century between Irish dissidents and the French for several decades to come. After the Spanish Armada, and throughout the 1590s, disaffected Irish lords consistently directed all their pleas for military aid at the Spanish and papal courts. However, a slight glimmer of hope for a possible French invasion of Ireland still survived so long as Hugh O'Neill, earl of Tyrone, and Hugh Roe O'Donnell of Tyrconnell led their campaign to forestall the Anglicisation of Ulster. Elizabeth I's decisive defeat of the joint Gaelic and Spanish forces led by O'Neill, O'Donnell and Don Juan del Águila at the battle of Kinsale in 1601, in the final challenge to the Tudor regime, and the departure from Ireland in 1607 of O'Neill and Rory O'Donnell (Hugh Roe's brother), the last of the greatest potentates of the Gaelic polity, effectively quashed the possibility of any further collusion between Irish rebels and the French. Henri IV's unwillingness to annoy James I, who concluded the Treaty of London with Spain in 1604, James's search for a Spanish or French bride and his resolution to concentrate on securing his position in England meanwhile proved decisive in ensuring the maintenance of stable amicable relations between the three monarchs in the first decade of the seventeenth century.

The historiography of Franco-Irish relations in the sixteenth and early seventeenth centuries has traditionally concentrated on commercial connections between the two countries and on the embryonic development of the Irish, and specifically the clerical, diaspora in France. Ireland's commercial ties with France in the late Middle Ages have been the subject of a substantial amount of specialised scholarly research that has broadly traced the principal trade routes, identified both Irish and French families involved in commercial networks and provided an insight into the practicalities of their business transactions. Arising from this exposition it is clear that Ireland had established trade links with the main ports of Normandy and those of the French Atlantic seaboard by the late fifteenth century. This trade survived the disruptions of legislative restrictions, war and piracy throughout the sixteenth century and increased in the early 1600s. While existing studies have examined Ireland's commerce with France in isolation, this study shows that when set within the wider context of sixteenth-century Franco-Irish relations, these connections, combined with Irish seafarers' familiarity with French ports, proved critical in facilitating the flight and safe harbouring of Ireland's political dissidents who sought asylum or assistance in France from 1540 onwards. Later they were to determine the destinations of the thousands of Irish migrants who fled to France during and in the immediate aftermath of the final contest in the Elizabethan conquest of Ireland, the Nine Years' War (1594–1603).

The flight of the Gaelic lords from Ulster, and the delicately balanced relationship between Henri IV, James I and Philip III in the early 1600s, effectively eliminated the remote prospect of a revival of Franco-Irish intrigue and closed a chapter on Ireland's short-lived political relations with France that was not re-opened until the 1640s. For almost sixty years, between the early 1520s and the early 1580s, the Irish had become embroiled in intrigue with the French for a variety of reasons. All the protagonists – the tenth earl of Desmond, Gerald Fitzgerald, Con O'Neill, Manus O'Donnell, O'Doherty, Cormac O'Connor, MacWilliam Burke, Shane O'Neill, Conor O'Brien, James Fitzmaurice, Brian MacGeoghegan andWilliam Nugent – were driven by essentially personal, dynastic or seigneurial motives. They sought French assistance to bolster their campaigns against the crown at times when they were experiencing particular difficulties in their immediate locales, and their rhetoric alone elevated their intensely localised disputes to the status of a ‘national’ cause. Some, such as James Fitzmaurice, sought French assistance to back their efforts to defend Catholicism in Ireland as part of their agenda for protecting their position and privileges in opposition to the advance of Anglicisation and Protestantism. Typically, when Gaelic lords such as Shane O'Neill and Manus O'Donnell were seeking better treatment from the English crown and the lord deputy and Irish council, they made political capital out of rumours of their alleged or real associations with the French in order to apply pressure on the English.

In early August 1540 Lord Leonard Grey's successor, Sir Anthony St Leger, arrived in Ireland to begin an eight-year term of office as lord deputy. This led to a change in the tenor of domestic and Anglo-Irish political relations which in turn profoundly shaped the character of Franco-Irish relations. During the early and mid-1540s the altered dynamic of Ireland's contacts with France resulted in a temporary aberration in their relations in two key respects. First, thanks to the success of St Leger's conciliatory policy in handling the most powerful Gaelic and Anglo-Irish lords, the early and mid-1540s witnessed none of the opportunistic contrivance with the French that had characterised previous decades. This was manifest in the refusal by both Anglo-Irish and Gaelic lords to respond to rumours of Gerald Fitzgerald leading a French invasion of Ireland that were little more than war propaganda deliberately circulated by Henry's French opponents in 1543–6 as one means of securing French victory over England. Second, in an unprecedented show of support for their newly-declared king, these lords mustered Gaelic soldiers for service in Henry's army in the Anglo-Scottish (1542–9) and Anglo-French (1543–6) wars at a time when his position and the security of the British Isles was particularly vulnerable.

St Leger's occupancy of the lord deputyship was critical in maintaining the fragile peace and stability that resulted in both Irish abstinence from involvement in intrigue with France and consequent minimal demands for financial, military and naval resources from the English privy council to fortify Ireland's defences.