This paper seeks to shed fresh light on the aesthetic and stylistic affiliations of Lycophron's Alexandra, approaching the poem from two distinct but complementary angles. First, it explores what can be gained by reading Lycophron's poem against the backdrop of Callimachus’ poetry. It contends that the Alexandra presents a radical and polemical departure from the Alexandrian's poetic programme, pointedly appropriating key Callimachean images while also countering Callimachus’ apparent dismissal of the ‘noisy’ tragic genre. Previous scholarship has noted links between the openings of the Aetia and of the Alexandra, but this article demonstrates that this relationship is only one part of a larger aesthetic divide between the two poets: by embracing the raucous acoustics of tragedy, Lycophron's poem offers a self-conscious and agonistic departure from Callimachus’ aesthetic preferences. Second, this article considers another way of conceiving the aesthetics of the poem beyond a Callimachean frame, highlighting how Lycophron pointedly engages with and evokes earlier Aristotelian literary criticism concerning the ‘frigid’ style: the Alexandra constructs its own independent literary history centred around the alleged name of its author, ‘Lycophron’. The article proposes that this traditional attribution is best understood as a pen name that signposts the poem's stylistic affiliations, aligning it not so much with the Ptolemaic playwright Lycophron of Chalcis but rather with Lycophron the sophist and a larger rhetorical tradition of stylistic frigidity. Ultimately, through these two approaches, the article highlights further aspects of the Alexandra's aesthetic diversity.

Background: Guidelines regarding asymptomatic bacteriuria (ASB) have consistently recommended against screening and treatment in most circumstances. However, screening of patients with spinal cord injury (SCI) is common practice and in some cases is a formal protocol at the organizational level. A previous study found that more than one-third of patients with ASB detected on routine screening cultures performed at annual visits in 2012 received antibiotics. However, the role of antibiotic stewardship has become more prominent over the last decade. We hypothesized that diagnostic and therapeutic stewardship efforts may be impacting the practice of annual urine-culture screening for SCI patients. We evaluated urine culture screening and treatment rates over a 10-year period. Methods: Patients with SCI seen in the VA Boston HCS for an annual exam in 2018 were eligible for inclusion and formed the baseline cohort for this study. Annual visits for the cohort over a 10-year period (January 1, 2009–December 31, 2018) were included in the analysis. Electronic data collection and manual chart review were utilized to capture outcomes of interest including urine culture, antibiotic prescriptions and indication within 15 days, and documentation of urinary or infectious symptoms. The main outcomes were (1) rate of urine cultures performed ±3 days of the visit, (2) rate of antibiotic treatment in asymptomatic patients, and (3) trend over time of urine culturing and treating. The χ2 test for trend was used to compare rates over time. Results: In total, 1,962 annual visits were made by the 344 unique patients over the 10-year period and were available for analysis. Among these, 639 (32.6%) visits had a urine culture performed within 3 days. The proportion of visits with a collected culture decreased from (109 of 127) 85.8% of visits in 2009 to (65 of 338) 19.2% of visits in 2018, P ≤ .001 (Fig. 1). In the treatment analysis, 39 visits were excluded for active symptoms, concern for uncontrolled infection, or prophylaxis as antibiotic indication. Among 600 remaining screening cultures, 328 had a bacterial pathogen or >100,000 mixed colonies consistent with ASB. Overall, 51 patients (17%) received antimicrobials. The rate of antibiotic treatment for ASB did not significantly decrease over time pP = 0.79 (Fig. 2). Conclusions: Over a 10-year period of annual SCI visits, the proportion of visits with a urine culture performed as routine screening significantly and consistently decreased. However, the rate of treatment for positive urine cultures remained consistent. These data support targeted diagnostic stewardship in this population to reduce unnecessary antibiotic use.

Funding: None

Disclosures: None

Background: The Core Elements of Outpatient Antibiotic Stewardship provide a framework to improve antibiotic use, but cost-effectiveness data on interventions to improve antibiotic use are limited. Beginning in September 2017, an antibiotic stewardship intervention was launched in within 10 outpatient Veterans Healthcare Administration clinics. The intervention was based on the Core Elements and used an academic detailing (AD) and an audit and feedback (AF) approach to encourage appropriate use of antibiotics. The objective of this analysis was to evaluate the cost-effectiveness of the intervention among patients with uncomplicated acute respiratory tract infections (ARI). Methods: We developed an economic simulation model from the VA’s perspective for patients presenting for an index outpatient clinic visit with an ARI (Fig. 1). Effectiveness was measured as quality-adjusted life-years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug reactions (ADRs), and healthcare utilization were obtained from the published literature. Probability parameters for antibiotic treatment, appropriateness of treatment, antibiotic ADRs, hospitalization, and return ARI visits were estimated using VA Corporate Data Warehouse data from a total of 22,137 patients in the 10 clinics during 2014–2019 before and after the intervention. Detailed cost data on the development of the AD and AF materials and electronically captured time and effort for the National AD Service activities by specific providers from a national ARI campaign were used as a proxy for the cost estimate of similar activities conducted in this intervention. We performed 1-way and probabilistic sensitivity analyses (PSAs) using 10,000 second-order Monte Carlo simulations on costs and utility values using their means and standard deviations. Results: The proportion of uncomplicated ARI visits with antibiotics prescribed (59% vs 40%) was lower and appropriate treatment was higher (24% vs 32%) after the intervention. The intervention was estimated to cost $110,846 (2018 USD) over a 2-year period. Compared to no intervention, the intervention had lower mean costs ($880 vs $517) and higher mean QALYs (0.837 vs 0.863) per patient because of reduced inappropriate treatment, ADRs, and subsequent healthcare utilization, including hospitalization. In threshold analyses, the antibiotic stewardship strategy was no longer dominant if intervention cost was >$64,415,000 or the number of patients cared for was <3,672. In the PSA, the antibiotic stewardship intervention was dominant in 100% of the 10,000 Monte Carlo iterations (Fig. 2). Conclusions: In every scenario, the VA outpatient AD and AF antibiotic stewardship intervention was a dominant strategy compared to no intervention.

Funding: None

Disclosures: None

Spatially and temporally unpredictable rainfall patterns presented food production challenges to small-scale agricultural communities, requiring multiple risk-mitigating strategies to increase food security. Although site-based investigations of the relationship between climate and agricultural production offer insights into how individual communities may have created long-term adaptations to manage risk, the inherent spatial variability of climate-driven risk makes a landscape-scale perspective valuable. In this article, we model risk by evaluating how the spatial structure of ancient climate conditions may have affected the reliability of three major strategies used to reduce risk: drawing upon social networks in time of need, hunting and gathering of wild resources, and storing surplus food. We then explore how climate-driven changes to this reliability may relate to archaeologically observed social transformations. We demonstrate the utility of this methodology by comparing the Salinas and Cibola regions in the prehispanic U.S. Southwest to understand the complex relationship among climate-driven threats to food security, risk-mitigation strategies, and social transformations. Our results suggest key differences in how communities buffered against risk in the Cibola and Salinas study regions, with the structure of precipitation influencing the range of strategies to which communities had access through time.

Adverse developmental outcomes for some children following institutional care are well established. Removal from institutional care and placement into families can promote recovery. However, little is known about how positive outcomes are sustained across adolescence among children with histories of severe deprivation. The present study examined the caregiving conditions that are associated with attaining and maintaining competent functioning (i.e., outcomes within typical levels) from middle childhood to adolescence following exposure to early institutional care. The participants included children with and without a history of institutional care who had competence assessed at ages 8, 12, and 16 years across seven domains: family relationships, peer relationships, academic performance, physical health, mental health, substance use (ages 12 and 16 years only), and risk-taking behavior. The participants were grouped based on whether they were always versus not always competent and never versus ever competent at ages 8 through 16 years. Adolescents with a history of institutional care were less likely to be consistently competent than those who were family reared. Among those who were exposed to early institutional rearing, maintaining competent functioning from 8 to 16 years was associated with spending less time in institutions and receiving higher-quality caregiving early in life. Ensuring high quality early caregiving may promote competent functioning following early deprivation.

Hill (Twin Research and Human Genetics, Vol. 21, 2018, 84–88) presented a critique of our recently published paper in Cell Reports entitled ‘Large-Scale Cognitive GWAS Meta-Analysis Reveals Tissue-Specific Neural Expression and Potential Nootropic Drug Targets’ (Lam et al., Cell Reports, Vol. 21, 2017, 2597–2613). Specifically, Hill offered several interrelated comments suggesting potential problems with our use of a new analytic method called Multi-Trait Analysis of GWAS (MTAG) (Turley et al., Nature Genetics, Vol. 50, 2018, 229–237). In this brief article, we respond to each of these concerns. Using empirical data, we conclude that our MTAG results do not suffer from ‘inflation in the FDR [false discovery rate]’, as suggested by Hill (Twin Research and Human Genetics, Vol. 21, 2018, 84–88), and are not ‘more relevant to the genetic contributions to education than they are to the genetic contributions to intelligence’.

Two arguments imply that Mahr & Csibra's (M&C's) functional theory is insufficient as an explanation of episodic memory: (1) The developmental course supports a different social cultural division of episodic and semantic memory, and (2) the existence of long-term autobiographical memory is not explained in the functional theory but can be seen in a broader cultural framework.

The entry into language via first words and, the acquisition of word meanings is considered from the perspective of publications in the Journal of Child Language over the past forty years. Problems in achieving word meanings include the disparate and sparse concepts available to the child from past prelanguage experience. Variability in beginning word learning and in its progress along a number of dimensions suggests the problems that children may encounter, as well as the strategies and styles they adopt to make progress. Social context and adult practices are vitally involved in the success of this process. Whereas much headway has been made over the past decades, much remains to be revealed through dynamic systems theory and developmental semiotic analyses, as well as laboratory research aimed at social context conditions.