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To identify interstage best practices associated with lower mortality, we studied National Pediatric Cardiology Quality Improvement Collaborative centres registry using a positive deviance approach.
Positive deviant and control centre team members were interviewed to identify potential interstage best practices. Subsequently, all collaborative centres were surveyed on the use of these practices to test their associations with centre mortality. Questionnaires were scored using Likert scales; the overall score was linearly transformed to a 0–100-point scale with higher scores indicating increased use of practices. Mortality was based on patients enrolled after a centre’s first year in the collaborative. Centre mortality rates were divided into tertiles. Survey scores for the low mortality tertile were compared with the other tertiles.
For this study, seven positive deviant and four control teams were interviewed. A total of 20 potential best practices were identified, including team composition, improvement practices, and parent involvement. Questionnaires were completed by 36/43 eligible centres, providing 1504 patients for analysis. Average survey score was 50.2 (SD 13.4). Average mortality was 6.1% (SD 4.1). There was no correlation between survey scores and mortality (r=0.14, p=0.41). The one practice associated with the low mortality tertile was frequency of discussion of interstage results: 58.3% of low mortality teams discussed results at least monthly versus 8.4% of the middle and high tertile centres (p=0.02).
Low-mortality centres more frequently discuss interstage results than high-mortality centres. Heightened awareness of outcomes may influence practice; however, further study is needed to understand the variation in outcomes across centres.
Although interstage mortality for infants with hypoplastic left heart syndrome has declined within the National Pediatric Cardiology Quality Improvement Collaborative, variation across centres persists. It remains unclear whether centres with lower interstage mortality have lower-risk patients or whether differences in care may explain this variation. We examined previously established risk factors across National Pediatric Cardiology Quality Improvement Collaborative centres with lower and higher interstage mortality rates.
Lower-mortality centres were defined as those with >25 consecutive interstage survivors. Higher-mortality centres were defined as those with cumulative interstage mortality rates >10%, which is a collaborative historic baseline rate. Baseline risk factors and perioperative characteristics were compared.
Seven lower-mortality centres were identified (n=331 patients) and had an interstage mortality rate of 2.7%, as compared with 13.3% in the four higher-mortality centres (n=173 patients, p<0.0001). Of all baseline risk factors examined, the only factor that differed between the lower- and higher-mortality centres was postnatal diagnosis (18.4 versus 31.8%, p=0.001). In multivariable analysis, there remained a significant mortality difference between the two groups of centres after adjusting for this variable: adjusted mortality rate was 2.8% in lower-mortality centres compared with 12.6% in higher-mortality centres, p=0.003. Secondary analyses identified multiple differences between groups in perioperative practices and other variables.
Variation in interstage mortality rates between these two groups of centres does not appear to be explained by differences in baseline risk factors. Further study is necessary to evaluate variation in care practices to identify targets for improvement efforts.
This paper examines management’s motives for rejecting takeover bids and the associated shareholder wealth effects. We develop measures of initial bid quality and find a significant negative correlation between the quality of a bid and rejection. The likelihood of higher follow-on offers decreases with bid quality and is greater when targets have classified boards and chief executive officers (CEOs) with significant personal wealth tied to the transaction. Target CEOs who fail to close high-quality offers experience a significant rate of forced turnover. Overall, the results support a price improvement motive for contested bids.
This work provides new insights into human responses to and perceptions of sea-level rise at a time when the landscapes of north-west Europe were radically changing. These issues are investigated through a case study focused on the Channel Islands. We report on the excavation of two sites, Canal du Squez in Jersey and Lihou (GU582) in Guernsey, and the study of museum collections across the Channel Islands. We argue that people were drawn to this area as a result of the dynamic environmental processes occurring and the opportunities these created. The evidence suggests that the area was a particular focus during the Middle Mesolithic, when Guernsey and Alderney were already islands and while Jersey was a peninsula of northern France. Insularisation does not appear to have created a barrier to occupation during either the Middle or Final Mesolithic, indicating the appearance of lifeways increasingly focused on maritime voyaging and marine resources from the second half of the 9th millennium BC onwards.
In this paper we give a formula for the
-theory of the
-algebra of a weakly left-resolving labelled space. This is done by realizing the
-algebra of a weakly left-resolving labelled space as the Cuntz–Pimsner algebra of a
-correspondence. As a corollary, we obtain a gauge-invariant uniqueness theorem for the
-algebra of any weakly left-resolving labelled space. In order to achieve this, we must modify the definition of the
-algebra of a weakly left-resolving labelled space. We also establish strong connections between the various classes of
-algebras that are associated with shift spaces and labelled graph algebras. Hence, by computing the
-theory of a labelled graph algebra, we are providing a common framework for computing the
-theory of graph algebras, ultragraph algebras, Exel–Laca algebras, Matsumoto algebras and the
-algebras of Carlsen. We provide an inductive limit approach for computing the
-groups of an important class of labelled graph algebras, and give examples.
At some point during the 1070s the archbishop of Canterbury, Lanfranc, wrote to Herfast (bishop of East Anglia 1070–84/5) in trenchant terms. Much of his letter criticized the bishop's lifestyle – ‘Give up the dicing (to mention nothing worse) and the world's amusements in which you are said to idle away the entire day’ – and the company he kept: ‘Banish the monk Hermann, whose life is notorious for its many faults, from your society and your household completely.’ Instead, Lanfranc told his bishop to read Scripture and above all to master the decrees of the Roman pontiffs and the canons of the holy councils, to ‘discover what you do not know’ and ‘ensure that you hold no opinion that is at variance with your mother church’. The significance of that advice finds context in the opening of the letter, which relates to the affairs of the abbey of Bury St Edmunds. After a conventional greeting, where Lanfranc wished Bishop Herfast might be humble in wisdom and of sober understanding, the archbishop began by observing that Berard, a cleric of Abbot Baldwin of Bury, had delivered a previous letter from the Archbishop to Bishop Herfast. He went on:
As [Berard] himself affirmed to me later, you made a coarse joke about it; you uttered cheap and unworthy remarks about me in the hearing of many; and you declared on oath that you would give me no assistance in that matter. There will be another time and another place to speak of those things. But my immediate instructions are these: that you lay no claim to the property of St Edmund unless you can give indisputable proof that it was claimed by your predecessors and that you discharge the aforesaid Berard without any fine or threat of punishment, until the case comes into our own court and can be rightly concluded according to canon law and our own ruling as judge.
There are three types of epilepsy: analempsia, epilempsia, and catalempsia. Analempsia has that name because it deprives the sacred parts of the head of sensation, and it arises either from neglect of the stomach, or from an excess of food or drink, or from drinking cold things, or from luxury … Epilempsia has that name from seizure of the mind and senses, and when they are besieged the body is also possessed, for it is a serious and slow affliction. Some call this sickness comitialis, others the holy affliction, and the Greeks call it geronoson … Catalempsia is epilepsy accompanied by fever … the sickness of cataleptics starts with the feet or lower legs. When they feel the advancing pain and catarrh, it comes from an excess of blood, or rather, choler ferments in the confines of the stomach, with no natural exit, whence it burdens the head and injures the senses.
This explanation of the causes and effects working within the human body is found in an eleventh-century medical text from Salerno, the Passionarius (‘Book of Diseases’) attributed to the physician Gariopontus. This medical text survives in sixty-five medieval manuscripts, one of which is now London, British Library, MS Royal 12. C. xxiv. Michael Gullick has identified the script of this manuscript as that of an early twelfth-century scribe of Bury St Edmunds, demonstrating that this text was known at Bury in the generation after the physician-abbot Baldwin.
The notion that the history of the abbey of Bury St Edmunds after the Norman Conquest was unusual is not new. William of Malmesbury in his Gesta pontificum described St Edmund as ‘the first of the saints of the country’. And in the Gesta regum he wrote that the saint's abbey was remarkable both for its capacity to attract patronage and to repulse tax-collectors:
By these arts he has so engaged the loyalty of all the inhabitants of Britain that anyone thinks it a privilege to enrich his monastery by even a penny. Even kings, the lords of other men, rejoice to call themselves his servants, and place their royal crown at his service, redeeming it at a great price if they wish to use it. The tax-collectors who run riot in other places, making no distinction between right and wrong, are on their knees before St Edmund, and stay their legal processes at his boundary-ditch, knowing from experience how many have suffered who have thought fit to persist.
A monk of the great Ile-de-France abbey of Saint-Denis, Abbot Baldwin of Bury St Edmunds (1065–97) was the one non-Englishman to be an abbot in England on the day that Harold lost the Battle of Hastings. He had first visited England well before his appointment to Bury in 1065 and been treated with great favour by King Edward.
The medieval persona of St Edmund, as far as it can be recovered, is generally recognised to have resided in Abbo of Fleury's Passio sancti Eadmundi. Written at the request of the monks of Ramsey at the end of the tenth century, this text was swiftly adopted by the Benedictine community at Bury, where it appears to have been recorded in a booklist from the 1040s, and from whose scribes three eleventh-century copies survive. The Passio was undoubtedly a creative stimulus for the local community, for it gave rise both to the famous cycle of illuminations in the twelfth-century illustrated libellus, now New York, Pierpont Morgan Library, MS M. 736, and to an important collection of eleventh-century chants for St Edmund's feast, which forms the basis of this chapter. Even Bury's late eleventh-century hagiographer Herman owed a debt to Abbo: in alluding to the story of the Passio, commenting on the general shortage of other available accounts, and apparently fashioning his own Miracula as a continuation of that narrative. One might be forgiven for assuming, therefore, that the St Edmund portrayed by Abbo's Passio – the humble, peace-loving figure characterised by Antonia Gransden as a model of Christian kingship – was the very same St Edmund known to the monks of Bury.
In comparison with the large number of manuscripts at Saint-Denis from the Carolingian period and the twelfth century, the sources for the eleventh century, the time of Abbot Baldwin of Bury St Edmunds, are meagre. This is one indication that the abbey suffered severe losses in the tenth century at the hands of the Normans. It lost many of its domains, the fabric of the church seems to have deteriorated greatly, and the performance of the liturgy seems to have become lax.
Abbot Suger, writing in the 1140s, saw the division of the Carolingian empire under the sons of the son of Louis the Pious, that is, Charles the Bald, as the major reason for Saint-Denis's losses. In addition to the problem the monks faced in recovering their illustrious past, the monastery encountered two major challenges to its prestige in the first half of the eleventh century. First of all, the monks at Saint Emmeram, Regensburg, claimed that they had the relics of St Denis. In response to this, the saint's body was exhumed in 1053, and a new feast, the Detection of Saint Denis, was celebrated on 9 June to commemorate this event. Secondly, the bishop of Paris challenged Saint-Denis's claims of exemption from episcopal control. So it is perhaps not surprising that the extant manuscripts and charters from the eleventh century reflect both of these topics: charters were forged to prove the monastery's independence from episcopal control, and manuscripts were created for its new liturgical celebrations.
An accurate picture of the architectural history of Abbot Baldwin's church began to emerge already in the middle of the nineteenth century, as for example with Graham Hills's study of 1865. The first person to make sense of the remains on the site as a whole was Arthur Whittingham, with the research he published in the early 1950s, and many aspects of the subject were investigated further at the conference of the British Archaeological Association of 1994, organized by Antonia Gransden. In the present essay I want to examine three things: the contrast between the Norman church and its Anglo-Saxon predecessors; how relations between the abbey and the diocese in the late eleventh century may be reflected in changes in the plan of the church; and the relationship between the plans of the abbey and the town.
The Contrast between the Norman Church and its Anglo-Saxon Predecessors
According to Abbo of Fleury, when St Edmund's body arrived in Beodricesworth (before c. 950), the faithful of the vill built a very large wooden church to receive it. Nothing is recorded of its shape. Cnut and Emma supported the building of a church which was begun about 1020 and consecrated in 1031 or 1032, the new work, according to Herman, being carried out in stone.