Sideshadow views : narrative possibilities in Charles Dickens's late novels

Cet essai discute du rôle de l’hypothétique (ce qui ne peut être proposé que comme une hypothèse) dans les huit derniers romans de Charles Dickens et de la variété des moyens littéraires utilisés pour l’invoquer. Dans toute communication fondée sur le langage, les mots sont énoncés (et entendus) ou écrits (et lus), l’un après l’autre, dans l’ordre qu’exige la grammaire. La linéarité et l’ordre de telles séquences semblent refléter naturellement une temporalité et une causalité régissant les évènements représentés. En fait, ceci ne peut rendre compte que de leur nécessité et de leur chronologie. Je soutiens que les romans considérés recourent à des actions, des idées, des évènements, des perspectives, des voix, etc. hypothétiques, pour dépasser les limites imposées par le déterminisme apparemment inhérent aux structures narratives. Dans les mondes fictionnels de Dickens, le présent n’est pas la simple conséquence du passé et ce qui arrive n’est pas seulement la conséquence nécessaire d’une cause suffisante. Ce qui se produit est souvent sans nécessité et aurait aussi bien pu ne pas se produire. Un tel évènement, quand il n’était encore qu’une possibilité, a été en concurrence avec d’autres possibilités jusqu’à ce que la chance décide de l’actualiser. Cette réalité contingente -- avec sa « charge » éthique, épistémologique et ontologique -- ne peut être représentée par le discours linéaire et chronologique de la téléologie. La représentation de la contingence exige l’insertion du réel et du spéculatif dans un tissu narratif composé de développements et d’évènements actuels et virtuels. C’est pourquoi, dans les romans de Dickens, l’invisible peut être montré, le silence peut être éloquent et ce qui est en pleine vue peut demeurer secret. D’autres histoires possibles contribuent toujours à l’intrigue. À diverses jonctions du récit, les chemins non empruntés ii pourraient avoir mené ailleurs. Des directions hypothétiques et des mises en intrigues imprécises définissent l’histoire aussi puissamment que les développements poursuivis. Pour produire un monde de possibilités aussi complexe, Dickens, non seulement ne s’en remet pas à une supposée qualité mimétique du langage, mais il envisage aussi la réalité qu’il représente comme un fait naturellement littéraire. Il ne cache pas son art ; bien au contraire, avec une créativité et une fertilité étonnante, il déploie avec flamboyance son habileté à jouer avec le langage, avec une rhétorique luxuriante et avec une profusion d’intrigues potentielles. Tout ce qui constitue l’extravagante économie narrative de Dickens est exposé en permanence et est partie inhérente du plaisir procuré à ses lecteurs. En introduction, je discute du recours de Dickens à l’hypothétique dans son interaction avec un important conflit idéologique de son époque, la confrontation de la téléologie créationniste avec l’indéterminisme existentiel de la théorie de l’évolution de Darwin. Dans les trois chapitres suivants, j’adresse la fonction de l’hypothétique dans les incipit de David Copperfied, A Tale of Two Cities et The Mystery of Edwin Drood. J’examine ensuite comment, maintenant l’angoisse épistémique sur la réalité engendrée dans l’incipit, l’hypothétique se propage au travers du roman, soulevant les questions sans souvent y répondre. Je conclus que dans les huit derniers romans de Dickens -- et je suggère que cela est sans doute le cas pour le roman moderne en général -- le recours à l’hypothétique participe à l’acquisition d’une vérité littéraire, parce que, après tout, la littérature -- comme la science et la philosophie -- est une forme d’expérimentation avec la réalité.This essay discusses the role of the hypothetical – that which can be proposed only as a hypothesis -- in Charles Dickens’s last eight novels and the variety of literary means used to invoke it. In any language-based communication, words are uttered (and heard) or written (and read), one after the other, in the order that grammar demands. The linearity and order of such sequences seem to reflect naturally a temporality and a causality governing the represented events. In fact, this can only account for their necessity and their chronology. I argue that the novels under consideration make use of hypothetical and counterfactual actions, thoughts, events, perspectives, voices, etc., in order to overcome the limits imposed by the determinism apparently inherent to narrative structures. In Dickens’s fictional worlds, the present is not the simple consequence of the past and what happens is not only the necessary consequence of a sufficient cause. What happens is often without necessity and could as well not have happened. Such an event, when it was still only a possibility, competed with other unnecessary possibilities until chance decided its actualization. This contingent reality -- with its ethical, epistemological and ontological “payload” -- cannot be represented by the linear discourse of teleology. The representation of contingency demands the insertion of the real and the speculative in a narrative fabric woven out of virtual and actual developments and events. That is why, in Dickens’s novels, the unseen can be shown, silence can be eloquent, and what is in plain view can remain secret. Other possible stories always contribute to the plot. At various forks in the narrative, paths not taken could have led elsewhere. Hypothetical directions and indistinct emplotments define the narrative as powerfully as the developments that are pursued. iv To produce such a complex world of possibilities, Dickens not only refuses to rely upon a supposed mimetic quality of language, but he also contemplates the reality that he represents as a natural literary fact. He does not conceal his art. On the contrary, with an amazing fertility and inventiveness, he makes a lavish display of his capacity to play with language, with rhetorical flourish and with potential lines of emplotment. Everything that constitutes Dickens’s wild narrative economy is always on permanent display and is an inherent part of the pleasure procured for his readership. In the introduction, I discuss Dickens’s recourse to the hypothetical in its interaction with an important ideological conflict of his time -- the confrontation of the creationist teleology with the existential indeterminism of broadly Darwinian evolution theory. In the next three chapters, I address the function of the hypothetical in the incipits of David Copperfield, A Tale of Two Cities and The Mystery of Edwin Drood. I then examine how, by sustaining the epistemic anxiety generated in the incipit, the hypothetical propagates across the novel, raising questions without often answering them. I conclude that in Dickens’s last eight novels -- and, I suggest that this may also be the case in the modern novel in general -- the recourse to the hypothetical participates in the acquisition of a literary truth, because, after all, literature -- like science and philosophy -- is just another way to experiment with reality

Coccidioidomycosis (Valley Fever) Awareness

The overall purpose of this poster is to describe the fungal infection, Coccidioidomycosis, and bring awareness to this infection. The poster describes the history of the infection, pathophysiology, risk factors, and clinical presentation. Diagnosis, treatment, and complications of coccidioidomycosis are also addressed. The poster discusses the implications for nursing practice, information about the search for a vaccine, and comparisons of coccidioidomycosis and Covid-19. Finally, the conclusion discusses the key points within the poster and the importance of prompt and accurate diagnosis

Development of Evidence-Based Practice Anesthesia Guidelines for Brain-Dead Organ Donors

Organ donation is a gift of life for both donors and recipients that can come from living donors, donors after cardiac death, or brain-dead donors (BDDs). Treating the donors with optimal care throughout the entire donation process is crucial due to organ supply shortages. Organs from BDDs are a large contributor to the number of organs donated each year and require critical care from the time of admission, declaration of brain death, and throughout the organ procurement surgery. Although each BDD requires meticulous care for successful retrieval and donation, there is a lack of evidence-based practice (EBP) guidelines for anesthesia for BDDs during organ procurement surgery. This project encompasses the development, implementation, and evaluation plan of EBP anesthesia guidelines for BDDs. The problem was identified through an introduction to and background information regarding the organ donation process, from the declaration of brain death to organ procurement surgery, organ rejection, financial impact, and the significance of the problem to anesthesia. Next, a clinical person, intervention, comparison, outcomes, and time (PICOT) question was introduced which drove the objectives of the project and facilitated a thorough literature review. With the results from the literature search and recommendations from the Lifeline of Ohio Organ Procurement Agency (LOOP), guidelines for anesthesia for BDDs were created. The Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) Model was used to guide the development of and plan to implement the EBP anesthesia guidelines. Monitoring of outcomes will be completed by the QI department. Barriers, limitations, guideline improvement strategies, project timeline, and project budget are discussed, followed by a dissemination of the findings

Multimodale Computertomografie: moderne Bildgebung zur Erkennung von Schlaganfällen

Die moderne multimodale Computertomografie (CT) beinhaltet das Schichtröntgen des Gehirns (native CT), die Darstellung der hirnversorgenden Arterien (CT-Angiografie) und die Messung der Hirndurchblutung (CT-Perfusion). Mit Hilfe dieser Untersuchungstechnik kann bei Patienten mit akutem Schlaganfall rasch die Ursache der plötzlich eingesetzten Symptome beleuchtet werden: Liegt eine Gefäßobstruktion oder eine Blutung in das Gehirn vor? Wie ausgedehnt ist die Durchblutungsstörung und wie viel Hirngewebe ist bereits beschädigt bzw. vom Untergang bedroht? Anhand dieser Informationen kann sofort eine spezifische Therapie eingeleitet werden, die es ermöglicht, die Patienten vor dauerhafter schwerer Behinderung zu bewahren bzw. die Prognose schon früh abzuschätzen.Computed tomography (CT), including CT perfusion imaging and CT angiography, has the capacity to assess stroke pathology on a functional and morphological level and can thus provide important information about patients with acute stroke. It excludes brain haemorrhage, assesses the extent of perfusion deficit, the extent of ischemic damage, and the site and type of arterial obstruction. Ischemic brain tissue below the blood flow level of structural integrity takes up water immediately and causes a decrease in x-ray attenuation. Computed tomography thus has the specific advantage of being able to identify the brain tissue which is irreversibly injured. If CT can exclude major ischemic damage in acute stroke patients, reperfusion strategies may rescue brain function and prevent disability

Multimodale Computertomografie: moderne Bildgebung zur Erkennung von Schlaganfällen

Die moderne multimodale Computertomografie (CT) beinhaltet das Schichtröntgen des Gehirns (native CT), die Darstellung der hirnversorgenden Arterien (CT-Angiografie) und die Messung der Hirndurchblutung (CT-Perfusion). Mit Hilfe dieser Untersuchungstechnik kann bei Patienten mit akutem Schlaganfall rasch die Ursache der plötzlich eingesetzten Symptome beleuchtet werden: Liegt eine Gefäßobstruktion oder eine Blutung in das Gehirn vor? Wie ausgedehnt ist die Durchblutungsstörung und wie viel Hirngewebe ist bereits beschädigt bzw. vom Untergang bedroht? Anhand dieser Informationen kann sofort eine spezifische Therapie eingeleitet werden, die es ermöglicht, die Patienten vor dauerhafter schwerer Behinderung zu bewahren bzw. die Prognose schon früh abzuschätzen.Computed tomography (CT), including CT perfusion imaging and CT angiography, has the capacity to assess stroke pathology on a functional and morphological level and can thus provide important information about patients with acute stroke. It excludes brain haemorrhage, assesses the extent of perfusion deficit, the extent of ischemic damage, and the site and type of arterial obstruction. Ischemic brain tissue below the blood flow level of structural integrity takes up water immediately and causes a decrease in x-ray attenuation. Computed tomography thus has the specific advantage of being able to identify the brain tissue which is irreversibly injured. If CT can exclude major ischemic damage in acute stroke patients, reperfusion strategies may rescue brain function and prevent disability

Extent of hypoattenuation on CT angiography source images in Basilar Artery occlusion: prognostic value in the Basilar Artery International Cooperation Study

<p><b>Background and Purpose:</b> The posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) quantifies the extent of early ischemic changes in the posterior circulation with a 10-point grading system. We hypothesized that pc-ASPECTS applied to CT angiography source images predicts functional outcome of patients in the Basilar Artery International Cooperation Study (BASICS).</p> <p><b>Methods:</b> BASICS was a prospective, observational registry of consecutive patients with acute symptomatic basilar artery occlusion. Functional outcome was assessed at 1 month. We applied pc-ASPECTS to CT angiography source images of patients with CT angiography for confirmation of basilar artery occlusion. We calculated unadjusted and adjusted risk ratios (RRs) of pc-ASPECTS dichotomized at ≥8 versus <8. Primary outcome measure was favorable outcome (modified Rankin Scale scores 0–3). Secondary outcome measures were mortality and functional independence (modified Rankin Scale scores 0–2).</p> <p><b>Results:</b> Of 158 patients included, 78 patients had a CT angiography source images pc-ASPECTS ≥8. Patients with a pc-ASPECTS ≥8 more often had a favorable outcome than patients with a pc-ASPECTS <8 (crude RR, 1.7; 95% CI, 0.98–3.0). After adjustment for age, baseline National Institutes of Health Stroke Scale score, and thrombolysis, pc-ASPECTS ≥8 was not related to favorable outcome (RR, 1.3; 95% CI, 0.8–2.2), but it was related to reduced mortality (RR, 0.7; 95% CI, 0.5–0.98) and functional independence (RR, 2.0; 95% CI, 1.1–3.8). In post hoc analysis, pc-ASPECTS dichotomized at ≥6 versus <6 predicted a favorable outcome (adjusted RR, 3.1; 95% CI, 1.2–7.5).</p> <p><b>Conclusions:</b> pc-ASPECTS on CT angiography source images independently predicted death and functional independence at 1 month in the CT angiography subgroup of patients in the BASICS registry.</p&gt

A Large Web-Based Observer Reliability Study of Early Ischaemic Signs on Computed Tomography. The Acute Cerebral CT Evaluation of Stroke Study (ACCESS)

BACKGROUND: Early signs of ischaemic stroke on computerised tomography (CT) scanning are subtle but CT is the most widely available diagnostic test for stroke. Scoring methods that code for the extent of brain ischaemia may improve stroke diagnosis and quantification of the impact of ischaemia. METHODOLOGY AND PRINCIPAL FINDINGS: We showed CT scans from patients with acute ischaemic stroke (n = 32, with different patient characteristics and ischaemia signs) to doctors in stroke-related specialties world-wide over the web. CT scans were shown twice, randomly and blindly. Observers entered their scan readings, including early ischaemic signs by three scoring methods, into the web database. We compared observers' scorings to a reference standard neuroradiologist using area under receiver operator characteristic curve (AUC) analysis, Cronbach's alpha and logistic regression to determine the effect of scales, patient, scan and observer variables on detection of early ischaemic changes. Amongst 258 readers representing 33 nationalities and six specialties, the AUCs comparing readers with the reference standard detection of ischaemic signs were similar for all scales and both occasions. Being a neuroradiologist, slower scan reading, more pronounced ischaemic signs and later time to CT all improved detection of early ischaemic signs and agreement on the rating scales. Scan quality, stroke severity and number of years of training did not affect agreement. CONCLUSIONS: Large-scale observer reliability studies are possible using web-based tools and inform routine practice. Slower scan reading and use of CT infarct rating scales improve detection of acute ischaemic signs and should be encouraged to improve stroke diagnosis

3D ultrastructural organisation of calcium release units in the avian sarcoplasmic reticulum

Excitation-contraction coupling in vertebrate hearts is underpinned by calcium (Ca2+) release from Ca2+ release units (CRUs). CRUs are formed by clusters of channels called ryanodine receptors on the sarcoplasmic reticulum (SR) within the cardiomyocyte. Distances between CRUs influence the diffusion of Ca2+, thus influencing the rate and strength of excitation-contraction coupling. Avian myocytes lack T-tubules, thus Ca2+ from surface CRUs (peripheral couplings, PCs), must diffuse to internal CRU sites of the corbular SR (cSR) during centripetal propagation. Despite this, avian hearts achieve higher contractile rates and develop greater contractile strength than many mammalian hearts, which have T-tubules to provide simultaneous activation of the Ca2+ signal through the myocyte. We used 3D electron tomography to test the hypothesis that the intracellular distribution of CRUs in the avian heart permits faster and stronger contractions despite the absence T-tubules. Nearest edge-edge distances between PCs and cSR, and geometric information including surface area and volumes of individual cSR, were obtained for each cardiac chamber of the White Leghorn chicken. Computational modelling was then used to establish a relationship between CRUs distances and cell activation time in the avian heart. Our data suggest that cSR clustered close together along the Z-line is vital for rapid propagation of the Ca2+ signal from the cell periphery to the cell centre which would aid in the strong and fast contractions of the avian heart

Acute hypoxia-reoxygenation and vascular oxygen sensing in the chicken embryo.

Fetal/perinatal hypoxia is one of the most common causes of perinatal morbidity and mortality and is frequently accompannied by vascular dysfunction. However, the mechanisms involved have not been fully delineated. We hypothesized that exposure to acute hypoxia-reoxygenation induces alterations in vascular O2 sensing/signaling as well as in endothelial function in the chicken embryo pulmonary artery (PA), mesenteric artery (MA), femoral artery (FA), and ductus arteriosus (DA). Noninternally pipped 19-day embryos were exposed to 10% O2 for 30 min followed by reoxygenation with 21% O2 or 80% O2 Another group was constantly maintained at 21% O2 or at 21% O2 for 30 min and then exposed to 80% O2 Following treatment, responses of isolated blood vessels to hypoxia as well as endothelium-dependent (acetylcholine) and -independent (sodium nitroprusside and forskolin) relaxation were investigated in a wire myograph. Hypoxia increased venous blood lactate from 2.03 ± 0.18 to 15.98 ± 0.73 mmol/L (P < 0.001) and reduced hatchability to 0%. However, ex vivo hypoxic contraction of PA and MA, hypoxic relaxation of FA, and normoxic contraction of DA were not significantly different in any of the experimental groups. Relaxations induced by acetylcholine, sodium nitroprusside, and forskolin in PA, MA, FA, and DA rings were also similar in the four groups. In conclusion, exposure to acute hypoxia-reoxygenation did not affect vascular oxygen sensing or reactivity in the chicken embryo. This suggests that direct effects of acute hypoxia-reoxygenation on vascular function does not play a role in the pathophysiology of hypoxic cardiovascular injury in the perinatal period