Background: Historically, diagnosis of urinary tract infections (UTIs) has been divided into 3 categories based on symptoms and urine culture results: not UTI, asymptomatic bacteriuria (ASB), or UTI. However, some populations (eg, older adults, catheterized patients) may not present with signs or symptoms referrable to the urinary tract or have chronic lower urinary tract symptoms (LUTS), making the diagnosis of UTI challenging. We sought to understand the clinical presentation of patients who receive urine tests in a cohort of diverse hospitals. Methods: This retrospective descriptive cohort study included all adult noncatheterized inpatient and ED encounters with paired urinalysis and urine cultures (24 hours apart) from 5 community and academic hospitals in 3 states (NC, VA, GA) between January 1, 2017, and December 31, 2019. Trained abstractors collected clinical and demographic data using a 60-question REDCap survey. The study group met with multidisciplinary experts (ID, geriatrics, urology) to define the “continuum of UTI” (Table 1), which includes 2 new categories: (1) LUTS to capture patients with chronic lower urinary tract symptoms and (2) bacteriuria of unclear significance (BUS) to capture patients who do not clinically meet criteria for ASB or UTI (eg, older adults who present with delirium and bacteriuria). The newly defined categories were compared to current guideline-based categories. We further compared ASB, BUS, and UTI categories using a lower bacterial threshold of 1,000 colony-forming units. Results: In total, 220,531 encounters met study criteria. After using a random number generator and removing duplicates, 3,392 encounters were included. Based on current IDSA guidelines, the prevalence of ASB was 32.1% (n = 975), and prevalence of patients with “not UTI” was 1,614 (53%). Applying the expert panel’s new “continuum of UTI” definitions, the prevalence of “not UTI” patients decreased to 1,147 (37.7%), due to reassignment of 467 patients (15.3%)to LUTS. The prevalence of ASB decreased by 24% due to reassignment to BUS. Lowering the bacterial threshold had a slight impact on the number of definitive UTIs (14.9 vs 15.9%) (Table 1). Conclusions: Our rigorous review of laboratory and symptom data from a diverse population dataset revealed that diagnostic uncertainty exists when assessing patients with suspicion for UTI. We propose moving away from dichotomous approach of ASB versus UTI and using the “continuum of UTI” for stewardship conversations. This approach will allow us to develop nuanced deprescribing interventions for patients with LUTS or BUS (eg, watchful waiting, shorter course therapy) that account for the unique characteristics of these populations.

Disclosures: None

Most modern-day environmental issues are caused by the complex aggregation and interaction of numerous actions contributing to large-scale problems, from biodiversity loss to climate change. Environmental impact assessments (EIAs) consider how projects contribute to these cumulative environmental problems. This article firstly evaluates the theoretical importance of cumulative effects concepts for EIA. It reveals their potential to spotlight values embedded in decision making and to illuminate, as a lighthouse would, types of harm from broad-ranging, typically unregulated, activities. A large-scale global survey of national EIA laws and multilateral environmental agreements then shows that cumulative effects concepts are legally relevant for most national EIA frameworks. This prevalence suggests that better implementation of cumulative effects provisions may help EIA law to deliver more significant benefits than previously appreciated. Evaluating a sample of EIA provisions shows that cumulative effects concepts can contribute to different stages of an EIA, but that using these concepts across all EIA stages would maximize their potential to achieve the theoretical benefits identified. From theoretical and practical legal perspectives, cumulative effects concepts have significant latent potential – perhaps transformational potential – to address cumulative environmental change through EIA regimes at national and international levels. However, without better implementation, the latent potential of these laws to address cumulative environmental problems is likely to remain unrealized. By shedding light on the extent of national and international legal frameworks that adopt cumulative effects concepts, and their differences, this article highlights the significant learning potential between legal regimes to aid improved implementation.

Over the past 20 years, collaboration has become an essential aspect of archaeological practice in North America. In paying increased attention to the voices of descendant and local communities, archaeologists have become aware of the persistent injustices these often marginalized groups face. Building on growing calls for a responsive and engaged cultural heritage praxis, this forum article brings together a group of Native and non-Native scholars working at the nexus of history, ethnography, archaeology, and law in order to grapple with the role of archaeology in advancing social justice. Contributors to this article touch on a diverse range of critical issues facing Indigenous communities in the United States, including heritage law, decolonization, foodways, community-based participatory research, and pedagogy. Uniting these commentaries is a shared emphasis on research practices that promote Indigenous sovereignty and self-determination. In drawing these case studies together, we articulate a sovereignty-based model of social justice that facilitates Indigenous control over cultural heritage in ways that address their contemporary needs and goals.

Neuroimaging offers great potential to clinicians and researchers for a host of mental and physical conditions. The use of imaging has been trumpeted for forensic psychiatric and psychological evaluations to allow greater insight into the relationship between the brain and behavior. The results of imaging certainly can be used to inform clinical diagnoses; however, there continue to be limitations in using neuroimaging for insanity cases due to limited scientific backing for how neuroimaging can inform retrospective evaluations of mental state. In making this case, this paper reviews the history of the insanity defense and explains how the use of neuroimaging is not an effective way of improving the reliability of insanity defense evaluations.

Clinical trials continue to face significant challenges in participant recruitment and retention. The Recruitment Innovation Center (RIC), part of the Trial Innovation Network (TIN), has been funded by the National Center for Advancing Translational Sciences of the National Institutes of Health to develop innovative strategies and technologies to enhance participant engagement in all stages of multicenter clinical trials. In collaboration with investigator teams and liaisons at Clinical and Translational Science Award institutions, the RIC is charged with the mission to design, field-test, and refine novel resources in the context of individual clinical trials. These innovations are disseminated via newsletters, publications, a virtual toolbox on the TIN website, and RIC-hosted collaboration webinars. The RIC has designed, implemented, and promised customized recruitment support for 173 studies across many diverse disease areas. This support has incorporated site feasibility assessments, community input sessions, recruitment materials recommendations, social media campaigns, and an array of study-specific suggestions. The RIC’s goal is to evaluate the efficacy of these resources and provide access to all investigating teams, so that more trials can be completed on time, within budget, with diverse participation, and with enough accrual to power statistical analyses and make substantive contributions to the advancement of healthcare.

Background: As more US hospitals report antibiotic utilization to the CDC, standardized antimicrobial administration ratios (SAARs) derived from patient care unit-based antibiotic utilization data will increasingly be used to guide local antibiotic stewardship interventions. Location-based antibiotic utilization surveillance data are often utilized given the relative ease of ascertainment. However, aggregating antibiotic use data on a unit basis may have variable effects depending on the number of clinical teams providing care. In this study, we examined antibiotic utilization from units at a tertiary-care hospital to illustrate the potential challenges of using unit-based antibiotic utilization to change individual prescribing. Methods: We used inpatient pharmacy antibiotic use administration records at an adult tertiary-care academic medical center over a 6-month period from January 2019 through June 2019 to describe the geographic footprints and AU of medical, surgical, and critical care teams. All teams accounting for at least 1 patient day present on each unit during the study period were included in the analysis, as were all teams prescribing at least 1 antibiotic day of therapy (DOT). Results: The study population consisted of 24 units: 6 ICUs (25%) and 18 non-ICUs (75%). Over the study period, the average numbers of teams caring for patients in ICU and non-ICU wards were 10.2 (range, 3.2–16.9) and 13.7 (range, 10.4–18.9), respectively. Units were divided into 3 categories by the number of teams, accounting for ≥70% of total patient days present (Fig. 1): “homogenous” (≤3), “pauciteam” (4–7 teams), and “heterogeneous” (>7 teams). In total, 12 (50%) units were “pauciteam”; 7 (29%) were “homogeneous”; and 5 (21%) were “heterogeneous.” Units could also be classified as “homogenous,” “pauciteam,” or “heterogeneous” based on team-level antibiotic utilization or DOT for specific antibiotics. Different patterns emerged based on antibiotic restriction status. Classifying units based on vancomycin DOT (unrestricted) exhibited fewer “heterogeneous” units, whereas using meropenem DOT (restricted) revealed no “heterogeneous” units. Furthermore, the average number of units where individual clinical teams prescribed an antibiotic varied widely (range, 1.4–12.3 units per team). Conclusions: Unit-based antibiotic utilization data may encounter limitations in affecting prescriber behavior, particularly on units where a large number of clinical teams contribute to antibiotic utilization. Additionally, some services prescribing antibiotics across many hospital units may be minimally influenced by unit-level data. Team-based antibiotic utilization may allow for a more targeted metric to drive individual team prescribing.

Funding: None

Disclosures: None

The agricultural research and development institutions in most developing countries are poorly equipped to support the needs of millions of smallholder farmers that depend upon them. The research approaches taken by these systems explicitly or implicitly seek simple, one-size-fits-all solutions for problems and opportunities that are extremely diverse. Radical change is needed to facilitate the agroecological intensification of smallholder farming. We propose that large-scale participatory approaches, combined with innovations in information and communications technology (ICT), could enable the effective matching of diverse options to the wide spectrum of socio-ecological context that characterize smallholder agriculture. We consider the requirements, precedents and issues that might be involved in the development of farmer research networks (FRNs). Substantial institutional innovation will be needed to support FRNs, with shifts in roles and relationships amongst researchers, extension providers and farmers. Where farmers’ organizations have social capital and strong facilitation skills, such alignments may be most feasible. Novel information management capabilities will be required to introduce options and principles, enable characterization of contexts, manage data related to option-by-context interactions and enable farmers to visualize their findings in useful and intelligible ways. FRNs could lead to vastly greater capacity for technical innovation, which could in turn enable greater productivity and resilience, and enhance the quality of rural life.

Background: Cognitions are starting to receive more prominence as important when examining a number of factors including the topography of challenging behaviour. This study examined the relationships between maternal stress, challenging behaviour (aggressive and self-injurious behaviours) and parental cognitions and specifically whether maternal cognitions mediated the effect of challenging behaviour on parenting stress. Method: 46 mothers of children and young adults with ID completed questionnaires regarding their child's challenging behaviour, maternal cognitions and stress. Results: Significant correlations were found between challenging behaviour and maternal stress. The overall mediation models for aggression and self-injurious behaviour were significant. The Challenging Behaviour Perception Questionnaire: Consequences client subscale was the only independent significant mediator for both behaviours. Conclusions: Cognitions do play an important part in mediating the relationship between challenging behaviour and stress. Further research is needed to examine the similarities and differences between the mediation models for aggression and self-injurious behaviour.

The important roles of prediction and prior experience are well established in music research and fit well with Clark's concept of unified perception, cognition, and action arising from hierarchical, bidirectional predictive processing. However, in order to fully account for human musical intelligence, Clark needs to further consider the powerful and variable role of affect in relation to prediction error.