Background: Inappropriate urine-culture ordering is associated with increased antibiotic prescribing in myriad care environments, including acute and long-term care. In primary care, where urinary tract infections (UTIs) are commonly encountered, the appropriateness of urine-culture ordering has not been well described. We examined the appropriateness of urine-culture ordering and factors associated with inappropriate urine-culture ordering in primary care. Methods: We conducted a secondary analysis of data from a previous prospective study that included patients aged ≥18 years presenting with provider-suspected UTI with an accompanying urine culture at 2 safety-net, primary-care clinics in Houston, Texas, between November 2018 and March 2020. Patients with complicated or uncomplicated UTI were included, but those with a urinary catheter and pregnant females were excluded. Urine cultures were considered appropriate if the patient had an evidence-based symptom of UTI (ie, dysuria, frequency, urgency, hematuria, fever, chills, costovertebral angle tenderness, suprapubic, pelvic, or flank pain, or nephrolithiasis) as a diagnostic code or listed in providers’ free-text documentation. Diagnostic codes for symptoms that were not evidence based were grouped into categories based on body system, visit type (eg, routine visit), or sign or symptom clusters. We evaluated the relationships among demographic and clinical factors, the clinic visited, and non–evidence-based diagnostic codes with inappropriately ordered cultures. Results: We examined 870 cultures from 807 patients. Overall, 61.5% of patients were Hispanic (61.5%) and 23% were African American or Black. Also, 70.6% were women; the mean age was 49.2 years (SD, 14.6); and the mean Elixhauser score was 1.9 (SD, 5.4). Among the 870 cultures, 210 (24%) were ordered inappropriately. Dysuria (n = 289), frequency (n = 129), and UTI or cystitis (n = 117) were the most common, evidence-based codes among appropriate cultures. In the adjusted model, the nonteaching clinic (aOR, 6.33) and diagnostic codes comprising the following categories were associated with inappropriate culturing: acute lower back pain (aOR, 5.42), cardiac-related visits (aOR, 2.41), urinary incontinence (aOR, 4.46), routine health visits (aOR, 3.66), urine characteristics (aOR, 14.32), voiding difficulties (aOR, 3.88), and well-woman visits with a gynecological exam or family planning aspect (aOR, 12.27) (all P < .05). Conclusions: This research highlights potential gaps or miscues in provider behavior related to urine culture ordering, and unveiled problematic culturing related to urine characteristics and to routine visits, especially of a gynecological nature. This information can be incorporated into diagnostic stewardship interventions to address misconceptions, and to further explore the reasoning or processes wherein urine cultures are ordered for routine visits.

Financial support: NIAID UM1AI104681

Disclosure: None

OBJECTIVES/GOALS: Childhood survivors of ALL are at considerable risk for late effects which are exacerbated by excess weight. The proposed study involves the adaption and evaluation of the first empirically supported intervention for childhood survivors of ALL that is consistent with all national recommendations for the treatment of childhood obesity. METHODS/STUDY POPULATION: The proposed intervention will be adapted from family-based behavioral weight loss treatment (FBT) a multicomponent intervention which targets diet, activity, behavioral skills, parenting, and social facilitation among children and their parents. The Framework for Reporting Adaptations and Modifications-Enhanced structure (FRAME), a dissemination and implementation framework, will guide the adaptation, allowing for the incorporation of feedback previously gathered from key stakeholders. A single-arm, non-randomized trial of the adapted intervention will then be conducted to evaluate its acceptability, feasibility, and preliminary indications of efficacy including measures of relative weight change and associated health-related behaviors among 40 childhood ALL survivors and their families. RESULTS/ANTICIPATED RESULTS: Self-reported feedback from families at the end of treatment (EoT) is anticipated to demonstrate that this intervention will be regarded as both acceptable and feasible. Other measures of feasibility will include attendance and retention rates, which are expected to reflect to those of previous FBT trials (92% and 85%, respectively). Preliminary indications of the efficacy of the adapted intervention will be investigated through the comparison of a series of measurements taken at both baseline and EoT. Changes in relative weight will be assessed and are expected to meet a previously established range of clinically meaningful reduction in child percent overweight of 9 units or more. Improvements in dietary intake, physical activity, and health related quality of life are also anticipated. DISCUSSION/SIGNIFICANCE: Knowledge gained from the implementation of the first evidence-based intervention adapted for childhood survivors of ALL will be critical to the justification of a larger-scale, randomized controlled trial and holds promise to effectively modify the risk for chronic disease among a vulnerable population.

Using a machine-learning model, we examined drivers of antibiotic prescribing for antibiotic-inappropriate acute respiratory illnesses in a large US claims data set. Antibiotics were prescribed in 11% of the 42 million visits in our sample. The model identified outpatient setting type, patient age mix, and state as top drivers of prescribing.

In this article I examine the editing and publishing of Ralph Ellison's Invisible Man by Albert Erskine. Over the course of the piece, I deploy letters, drafts, and other material drawn from both Ellison's archive in the Library of Congress and Erskine's own archive at the University of Virginia to unpack how Erskine, as a white editor at a powerful international publishing house, conceived of his role in shepherding to market and marketing what he saw as a major literary work by an African American author.

In March 2020, at the onset of the coronavirus disease 2019 (COVID-19) pandemic in the United States, the Southern California Extracorporeal Membrane Oxygenation (ECMO) Consortium was formed. The consortium included physicians and coordinators from the 4 ECMO centers in San Diego County. Guidelines were created to ensure that ECMO was delivered equitably and in a resource effective manner across the county during the pandemic. A biomedical ethicist reviewed the guidelines to ensure ECMO use would provide maximal community benefit of this limited resource. The San Diego County Health and Human Services Agency further incorporated the guidelines into its plans for the allocation of scarce resources. The consortium held weekly video conferences to review countywide ECMO capacity (including census and staffing), share data, and discuss clinical practices and difficult cases. Equipment exchanges between ECMO centers maximized regional capacity. From March 1 to November 30, 2020, consortium participants placed 97 patients on ECMO. No eligible patients were denied ECMO due to lack of resources or capacity. The Southern California ECMO Consortium may serve as a model for other communities seeking to optimize ECMO resources during the current COVID-19 or future pandemics.

Tim Groenland's The Art of Editing is an exciting new addition to the field of literary sociology, making a valuable contribution to a discipline which has seen a resurgence since the turn of the millennium. In his seminal early work in the field, John Sutherland traces the origins of this kind of publishing history to Robert Escarpit's Sociology of Literature (1958), which he describes as the beginning of “modern, serious work” in considering the effects of the literary marketplace on the fiction of a particular era. However, it is the first two decades of the twenty-first century that have seen the most significant growth in sociological studies of literary production, a trend that Alan Liu calls “the resurgent history of the book.” This is a “resurgence” that Liu argues has resulted in “restoring to view … vital nodes in the circuit” of literary production, including “editors, publishers, translators, booksellers,” and many others. This recent growth in scholarly interest in the production and circulation of literary texts includes other significant figures such as James F. English, Mark McGurl, John B. Thompson, Loren Glass, Paul Crosthwaite, and David D. Hall.

Tree-rings representing annual dates from live and deadwood Pinus flexilis at ten sites across the central Great Basin (~38°N) yielded a cumulative record across 4002 years (1983 BC–AD 2019). Individual site chronologies ranged in length from 861–4002 years; all were continuous over their sample depths. Correlations of growth with climate were positive for water relations and mostly negative for summer temperatures. Growth was generally correlated across sites, with the central Nevada stands most distinct. Although growth was low during the Late Holocene Dry Period, variability marked this interval, suggesting that it was not pervasively dry. All sites had low growth during the first half of the Medieval Climate Anomaly, high growth during the mid-interval pluvial, and low growth subsequently. Little synchrony occurred across sites for the early Little Ice Age. After AD 1650, growth was depressed until the early twentieth century. Growth at all sites declined markedly ca. AD 1985, was similar to the lowest growth period of the full records, and indicative of recent severe droughts. A small rebound in growth occurred after ca. AD 2010. A strong signal for Atlantic Multidecadal Oscillation (AMO) occurred in growth response at most sites. The persistence of all stands despite climate variability indicates high resilience of this species.

To successfully reduce overall invasive plant cover over time, an effective treatment plan must be established such that mortality exceeds new colonization and resprouting growth rates. However, few evaluations of the effects of long-term, consistent treatment at different intervals exist. We report the effects of treatment intensity on Old World climbing fern [Lygodium microphyllum (Cav.) R. Br.], Brazilian pepper (Schinus terebinthifolia Raddi), and punktree [Melaleuca quinquenervia (Cav.) S. F. Blake] as part of a large restoration project that has been underway for 6 yr in Telegraph Swamp at Babcock Ranch Preserve, a 27,520-hectare (68,000-acre) conservation area in Florida, USA. We found that at the end of the 6-yr period, for all three species, average live cover did not exceed 5% across all transects. In addition, dead foliar cover was higher than live cover for all three invasive plants, indicating progress toward restoration goals. We also found that percent live cover of L. microphyllum was significantly reduced only after four or more treatments were applied during the 6-yr period, as opposed to when three or fewer treatments were applied. Reductions in percent cover of live foliage were apparent only when the treatments were applied more often than biennially, as opposed to less often than biennially. Additionally, we found higher L. microphyllum cover in clear-cut and replanted cypress stands than in natural stands. Based on these findings, we conclude that treatments applied four or more times, or more often than biennially, were more effective at significantly reducing advanced invasions of L. microphyllum, S. terebinthifolia, and M. quinquenervia, especially where previous management activities or their effects may have increased the cover of invasive plants.

Cyclonic storms (often called hurricanes, typhoons, or cyclones) often cause population declines in vulnerable bird species, and the intensity of these storms appears to be increasing due to climate change. Prior studies have reported short-term impacts of hurricanes on avifauna, but few have examined long-term impacts. Over two decades (1993–2018), we periodically surveyed a subspecies of West Indian Woodpecker Melanerpes superciliaris nyeanus on San Salvador, a small island in The Bahamas, to determine its distribution on the island, habitat use, and effects of hurricanes on abundance and population size. We conducted passive and playback surveys, supplemented with mist-netting. Woodpeckers were found only in the northern part of San Salvador, despite extensive surveys throughout other accessible areas of the island. Birds occupied areas with taller coppice adjacent to sabal palm Sabal palmetto groves, which were used for nesting. After hurricanes with >160 kph winds passed over San Salvador, woodpecker densities declined to 35–40% of pre-hurricane densities, but generally recovered back to pre-hurricane densities within 2–3 years. Based on an estimated density of woodpeckers within a ~1,400 ha occupied area, we calculated a population size of approximately 240 individuals (CI = 68-408). However, the population declined to far lower numbers immediately following hurricanes. Under IUCN Red List criteria, M. s. nyeanus classifies as ‘Critically Endangered’, and could be especially sensitive to future hurricanes if they occur at a high enough frequency or intensity to prevent the population from rebounding. Given the small size, isolation, and vulnerability of this population, we recommend preservation of the core habitat, continued monitoring, and further research. Our study shows that small, threatened bird populations can be resilient to the effects of hurricanes, but increased intensity of hurricanes, in combination with other threats, may limit this resilience in the future.

Progress toward racial equality requires the engagement of the American state, centered in the presidency and the executive branch, and in fact is not possible without the state's direct and forceful intervention. The key to this transformation is what we call “Forceful Federalism,” a multidimensional understanding of the American state. Forceful Federalism has four essential dimensions: standard-setting, coercion, associationalism, and fiscal authority. These four processes rise and fall over time, each charting its own history and unfolding according to its own logic. These processes usually work against each other. But occasionally they align with each other so that the state can pursue and achieve even difficult and challenging policy aims in a focused way. We sketch the outlines of Forceful Federalism and demonstrate its explanatory power with a case study of Forceful Federalism in action: James Meredith's integration of the University of Mississippi in 1962. The Meredith case exemplifies the convergence of the four dimensions of Forceful Federalism and marks the first time the modern American state was thus mobilized on behalf of civil rights. The case offers suggestive evidence that Forceful Federalism was a necessary condition for the emergence of the Civil Rights State.

A total of 38 long-term care facilities within a region participated in a 3-month quality improvement initiative focused on environmental cleaning and disinfection. Significant improvements in daily and discharge cleaning were observed during the project period. Further study of the sustainability and clinical impact of this type of initiative is warranted.