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The Fontan Outcomes Network was created to improve outcomes for children and adults with single ventricle CHD living with Fontan circulation. The network mission is to optimise longevity and quality of life by improving physical health, neurodevelopmental outcomes, resilience, and emotional health for these individuals and their families. This manuscript describes the systematic design of this new learning health network, including the initial steps in development of a national, lifespan registry, and pilot testing of data collection forms at 10 congenital heart centres.
To assess the impact of a newly developed Central-Line Insertion Site Assessment (CLISA) score on the incidence of local inflammation or infection for CLABSI prevention.
A pre- and postintervention, quasi-experimental quality improvement study.
Setting and participants:
Adult inpatients with central venous catheters (CVCs) hospitalized in an intensive care unit or oncology ward at a large academic medical center.
We evaluated CLISA score impact on insertion site inflammation and infection (CLISA score of 2 or 3) incidence in the baseline period (June 2014–January 2015) and the intervention period (April 2015–October 2017) using interrupted times series and generalized linear mixed-effects multivariable analyses. These were run separately for days-to-line removal from identification of a CLISA score of 2 or 3. CLISA score interrater reliability and photo quiz results were evaluated.
Among 6,957 CVCs assessed 40,846 times, percentage of lines with CLISA score of 2 or 3 in the baseline and intervention periods decreased by 78.2% (from 22.0% to 4.7%), with a significant immediate decrease in the time-series analysis (P < .001). According to the multivariable regression, the intervention was associated with lower percentage of lines with a CLISA score of 2 or 3, after adjusting for age, gender, CVC body location, and hospital unit (odds ratio, 0.15; 95% confidence interval, 0.06–0.34; P < .001). According to the multivariate regression, days to removal of lines with CLISA score of 2 or 3 was 3.19 days faster after the intervention (P < .001). Also, line dwell time decreased 37.1% from a mean of 14 days (standard deviation [SD], 10.6) to 8.8 days (SD, 9.0) (P < .001). Device utilization ratios decreased 9% from 0.64 (SD, 0.08) to 0.58 (SD, 0.06) (P = .039).
The CLISA score creates a common language for assessing line infection risk and successfully promotes high compliance with best practices in timely line removal.
In the United States alone, ∼14,000 children are hospitalised annually with acute heart failure. The science and art of caring for these patients continues to evolve. The International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was held on February 4 and 5, 2015. The 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute was funded through the Andrews/Daicoff Cardiovascular Program Endowment, a philanthropic collaboration between All Children’s Hospital and the Morsani College of Medicine at the University of South Florida (USF). Sponsored by All Children’s Hospital Andrews/Daicoff Cardiovascular Program, the International Pediatric Heart Failure Summit assembled leaders in clinical and scientific disciplines related to paediatric heart failure and created a multi-disciplinary “think-tank”. The purpose of this manuscript is to summarise the lessons from the 2015 International Pediatric Heart Failure Summit of Johns Hopkins All Children’s Heart Institute, to describe the “state of the art” of the treatment of paediatric cardiac failure, and to discuss future directions for research in the domain of paediatric cardiac failure.
Over the last six decades, the Supreme Court of India has created and re-created a right to property from very weak textual sources, despite constitutional declarations calling for social revolution, numerous amendments to reverse key judgments, and even, in 1978, the repeal of the core constitutional provisions guaranteeing a right to property. This article challenges the usual account of these developments. The primary contention is that the 1978 repeal is much less significant than it appears, due to the Court’s creative interpretation of other constitutional provisions. The Supreme Court has consistently advanced liberal models of constitutionalism and property, despite the influence of other models on the original constitutional design and later amendments. This article also examines whether the Court’s liberalism is compatible with the egalitarian values of the Constitution, and how its position will affect attempts to address social issues relating to the distribution of property in India.
Affective family processes are associated with the development of depression during adolescence. However, empirical description of these processes is generally based on examining affect at the individual or dyadic level. The purpose of this study was to examine triadic patterns of affect during parent–adolescent interactions in families with or without a depressed adolescent. We used state space grid analysis to characterize the state of all three actors simultaneously. Compared to healthy controls, triads with depressed adolescents displayed a wider range of affect, demonstrated less predictability of triadic affective sequences, spent more time in and returned more quickly to discrepant affective states, and spent less time in and returned more slowly to matched affective states, particularly while engaged in a problem-solving interaction. Furthermore, we identified seven unique triadic states in which triads with depressed adolescents spent significantly more time than triads with healthy controls. The present study enhances understanding of family affective processes related to depression by taking a more systemic approach and revealing triadic patterns that go beyond individual and dyadic analyses.
The correspondences between the names in the Scylding genealogy at the beginning of Beowulf and three names in the upper reaches of the genealogy of Æthelwulf in the Anglo-Saxon Chronicle, Beaw, Sceldwa and Sceaf, frequently appear in arguments for a late dating of Beowulf. But these arguments overlook many aspects of Æthelwulf's genealogy that disrupt their case for a late dating. As H. Munro Chadwick pointed out over a century ago, the forms Sceldwa and Beaw found in the Chronicle for Scyld and Beow are not West Saxon spellings, and the -wa suffix of Sceldwa and Tætwa suggests that these forms may be archaic. Thus spelling alone indicates that these names were probably copied from an older, non-West Saxon text. Furthermore, the very presence of these names in the royal pedigree is puzzling. On one level the presence of Scyld is easy to explain: Scyld and the Scyldings were famous in heroic legend, and his inclusion in Æthelwulf's pedigree provides reflected glory for the West Saxon dynasty and implies genealogical, political and cultural connections between the West Saxons and the Danes that could be useful for Alfred and his heirs to foster. But on another level his inclusion is rather surprising: according to genealogical conventions, the presence of Scyld implies that the West Saxon royal family is a cadet branch of the Scylding dynasty, and is thus potentially subordinate to Scandinavian rulers in England claiming direct descent from Scyld.
Since the date of the Beowulf manuscript is widely agreed upon, the very question which prompts this volume (and the conference it derives from, and even the 1980 conference with its 1981 proceedings volume) must assume that the date of the poem may not be the same as the date of the manuscript. It is certain that there must have been a moment of first inscription for the poem, and that the time and place of that moment remains a central point of interest for students of the poem. In this essay, I will bring new evidence to bear on this venerable question, and my argument shall be that Beowulf is metrically conservative according to a variety of independent metrical criteria. Further, I will suggest that that conservatism is so varied and consistent as to strongly indicate that the original version of Beowulf must be placed among the very earliest of the longer narrative Old English poems that survive, probably in the eighth century.
Of course, it remains true, I believe, that the moment of inscription is only one of the moments of interest which might engage modern scholars of the poem. As I argued in Authors, Audiences, and Old English Verse, our focus on authorship (and on moments of authorship) may sometimes cause us to lose sight of what can be gained by also considering audience, and I proposed there two later audiences for Beowulf, one located at Alfred's Wessex court in the late ninth century, and another, sometime around the turn of the eleventh century, perhaps in Canterbury, represented most clearly by the author of Maldon.
As the introduction to this collection makes clear, the various forms of linguistic and metrical evidence bearing on the dating of Beowulf point to a date of composition fairly early in the Anglo-Saxon period. In his article for The Dating of Beowulf in 1980, Thomas Cable proposed a rough guide to the metrical dating of poems using the incidence of type C, D, and E verses, which decline in frequency over the Anglo-Saxon period. Cable's criterion places Beowulf toward the beginning of a relative chronology. Since then, much additional metrical and linguistic evidence has been gathered that places Beowulf in the early to mid-eighth century. R.D. Fulk's A History of Old English Meter is the most substantial work of this kind, for it examines the presence of archaic metrical features through-out the corpus of Old English poetry and finds that Beowulf is by far the most archaic poem. Since that work, other scholars have written articles on individual metrical or linguistic features of the poetic corpus, which have corroborated the conclusions that Fulk so carefully reached.
Some scholars, however, remain dubious about the reliability of this type of evidence. At this point, the force of linguistic scholarship is too formidable to be undermined by the doubts raised by E.G. Stanley, who urged that the poem should not be dated by means of sundry linguistic oddities that could well be scribal error or just a few bad lines.
From the publication of the poem's editio princeps in 1815 to the emergence of the present collection two centuries later, few topics in Anglo-Saxon studies have generated as much speculation and scholarship as the dating of Beowulf. Marshaling disparate forms of evidence and argumentation, scholars have assigned dates to Beowulf that range from the seventh to the eleventh century. Various individuals have been unpersuasively identified as the author of Beowulf and dozens of kings, clerics, and contexts have been associated with the poem's genesis. Scholarship on the dating of Beowulf is markedly uneven in quality: alongside sober and thoughtful argumentation, there has been a great deal of improbable hypothesizing about the author of the poem or the milieu in which it was composed. Awareness of the qualitative differences in the scholarly literature is tacitly registered in the relative frequency with which publications are cited, but these differences have rarely received explicit discussion. This introduction to the dating of Beowulf controversy examines the changing standards of evidence, methodology, and argumentation that have attended this topic, particularly in the past thirty years. The dating of Beowulf has not been a static or monolithic subject, but has undergone considerable change in the disputes it connotes and the practices it encompasses. In the following account, emphasis will be given to the reasons for prevailing opinions rather than to the multiplicity of opinions as such.
Arguments about the date of Beowulf are more impassioned than the question seems to merit. Even so, the controversy has its uses. Beowulf is a great work, all agree, but it constitutes only a sliver of the poetic canon and is doubtless more important to Anglo-Saxon culture now than it was a thousand years ago. For all its glory, Beowulf provides no better an index to Anglo-Saxon poetry than Hamlet to Renaissance drama, which is to say that one can know both works well without knowing much about the corpus to which either belongs. It is to welcome and good effect, then, that several chapters in this volume link the date of Beowulf to the date of everything else, which, for purposes of this discussion, is the rest of Old English poetry.
At the Harvard conference, R.D. Fulk argued that the date of the poem's composition is less significant than the means used to hypothesize the date. The introduction to Fulk's Chapter 1 in this volume sums up an extended discussion regarding probability, proof, and linguistic evidence drawn from his History of Old English Meter. Fulk observes that the criteria for dating verse are not uniformly rigorous and that they have not been subjected to uniformly rigorous testing. Words can be counted and their forms analyzed, so that exceptions to linguistic and metrical criteria emerge quickly; in these cases, the relative probability of competing hypotheses can be readily gauged.
In a series of papers, Leonard Neidorf has argued that Germanic heroic legend circulated in Anglo-Saxon England predominantly in the seventh and eighth centuries, manifesting itself in Latin testimonia, vernacular poetry, visual art, royal genealogies, and personal names. These papers, together with conversations with their author, gave new impetus and purpose to a note I had been contemplating writing off and on for two or three of decades, a note on the other Heorot.
In two firmly historical passages Bede speaks of a place and a structure, the name of which is built on the word or name Heorot. And as unlikely as it seems, Beowulf scholarship has largely neglected to mention this potentially interesting fact. When I began research for this note, I thought that, against all probability, that neglect had been total; on the whole this initial belief has so far held true, with the unusual nineteenth-century exception of Daniel Henry Haigh, whose views I discuss below, together with brief modern allusions to Haigh. I cannot explain how this second Heorot has escaped the attention of Beowulf scholars – if it really has – and even the brashest scholar would be uneasy about too confidently asserting a negative, especially in such highly cultivated fields as Bede and Beowulf. I will at least affirm that this connection is not noticed in the encyclopedic recent edition of Klaeber or in the older commentaries known to me and so cannot, at the very least, be well known in our field.
Beowulf is a remarkable poem to have been written at any time. Around 3,200 lines of linguistically and metrically sophisticated poetry that sets “two moments in a great life,” in J.R.R. Tolkien's phrase, into a distant past and conveys a profound respect for the hero's actions while at the same time expressing a sense of the loss and futility of that world, is a remarkable achievement. A poem not of an age, but for all time. Which is not to say that it is undatable or that its date does not matter. Even without external evidence such as manuscripts and editions, we would recognize that well-known accounts of the deeds of three northern European heroes from around the year 500 – Beowulf, Arthur, and Hamlet – were written by their authors – our poet, Malory, and Shakespeare – at very different times, and recognizing their historical contexts is essential to any real appreciation of them. The reverse is also true. In the absence of precise evidence for a particular date of composition, understanding the meaning of the poem can help us to locate its likely place in history. My claim is that succession, or more precisely a change in the rules of succession brought about by the conversion of the Anglo-Saxons to Christianity, is a major theme in Beowulf. The poet explores a shift from an older “Germanic” system in which many members of a kin-group are eligible for the throne to a newer “Christian” one, which limits the contenders and favors the succession of sons.
The role of the Beowulf manuscript in scholarship dating the poem's composition has changed considerably in recent years. During the nineteenth and much of the twentieth century, discussions of the poem's date rarely embraced the manuscript as a source of relevant evidence. The omission is not unreasonable, since the presence of transcription errors throughout the manuscript reveals that it is a copy of a copy, written out perhaps at a vast remove from the authorial original. The text transmitted in a copy might contain indications that it had been committed to parchment at a much earlier date, but there is no guarantee that such indications will be present. Accordingly, the previous disregard for the manuscript in dating studies was not an inexplicable oversight, though it suddenly seemed to be such in 1981, when Kevin S. Kiernan argued that his examination of the manuscript revealed it to contain an authorial draft of an eleventh-century poem. Kiernan's hypothesis is rarely credited, and a series of subsequent studies have demonstrated that it is untenable, but the notoriety of his argument has created the impression that manuscript studies might support a later dating. This impression is registered in Nicholas Howe's belief that “from the type of evidence offered, one can predict a scholar's dating of Beowulf … the more closely one works with the language and metre, the more likely one is to date the poem early … the more closely one works with the manuscript, the more likely one is to date the poem late.”