Journal articles on the topic 'Boston Visitors Center'

Abstract Background Many patients are avoiding essential care for fear of contracting Covid-19 in healthcare settings. However, the incidence of nosocomial Covid-19 infection in U.S. acute care hospitals is unknown. Methods We conducted an observational study of all patients admitted to Brigham and Women’s Hospital in Boston, Massachusetts between March 7 (when the first Covid-19 patient was admitted) and May 30, 2020. During this period, a comprehensive infection control program was implemented including dedicated Covid-19 units with airborne infection isolation rooms, personal protective equipment (PPE) in accordance with CDC recommendations, PPE donning and doffing monitors, universal masking, restriction of visitors, and liberal RT-PCR testing of symptomatic and asymptomatic patients. We reviewed the medical records of all patients who tested positive for SARS-CoV-2 by RT-PCR on hospital day 3 or later or within 14 days of hospital discharge to determine whether infection was community or hospital-acquired based on timing of RT-PCR tests, clinical course, and exposures. Results Over the 12-week period, 9,149 patients were admitted, in whom 7,394 SARS-CoV-2 RT-PCR tests were performed and 697 Covid-19 cases were confirmed, translating into a total 8,656 days of Covid-19-related care (Figure). The inpatient Covid-19 census peaked at 171 on April 21. Twelve of the 697 Covid-19 patients (1.7%) were first diagnosed by RT-PCR on hospital day 3 or later (median 4 days, range 3–15 days). Of these, only one was deemed hospital-acquired and was most likely acquired from his pre-symptomatic spouse who was visiting daily and diagnosed with Covid-19 before visitor restrictions were implemented. Amongst 8,370 non-Covid-19 patients discharged through June 17, 11 (0.1%) subsequently tested positive within 14 days (median time to diagnosis 6 days, range 1–14). Only one was deemed likely to have been hospital-acquired, albeit with no known exposures. Figure. Timeline of implementation of major infection control policies and cumulative number of hospitalized COVID-19 cases (total and hospital-onset) Conclusion Nosocomial Covid-19 infection was exceedingly rare during the height of the pandemic in a hospital with rigorous infection control measures. Our findings may inform practices in other institutions and provide reassurance to patients regarding the safety of receiving care in acute care hospitals. Disclosures All Authors: No reported disclosures

This essay will attempt to explain why it has taken so long for the city/state and public history organizations in Boston to begin to embrace the heritage of its Latino/a communities in public history projects. It will contextualize early attempts in the 1970s and 1980s to develop and promote Latino/a public history projects and exhibits and will discuss changes that have occurred in the 1990s. The second part of the essay will discuss how issues of representation, power, and participation have been addressed by two recent projects that have attempted to incorporate Latino/a history in Boston. The city of Boston has been selected as a case-study for a number of reasons. First, Boston is one of a few cities in the U.S. where public history projects have national repercussions. The combination of a high concentration of institutions of higher education, and the city's attractiveness to visitors fascinated by the U.S. colonial, maritime and independence history makes Boston a national leader in the field of public history. Second, the situation in Boston -- where increased hostility towards immigrants, affirmative action, and bilingualism - is representative of recent trends in urban centers throughout the U.S and allows for important comparisons. Finally, the selection of Boston is significant because it breaks from traditional studies that limit Latino/a history issues to cities that have a larger percentage of Latinos/as in its population such as Houston, Los Angeles, Miami, and New York. Within the small field of Latino/a public history including case studies of cities such as Boston is crucial because Boston is probably more representative of national trends than are the large cities mentioned earlier.

Abstract Background The COVID-19 pandemic has disrupted many health care activities. The impact of the pandemic on HIV primary care in a Boston community health center (CHC) that has specialized HIV, sexual and gender minority care is analyzed here. Methods The CHC has used the Centricity Practice SolutionTM electronic medical record (EMR) system since 1997. The current analyses used data abstracted from the EMR, testing for significant differences in HIV care utilization using the Student t-test for means and chi-square tests for proportions. Results There were 2,016 HIV+ patients among 25,606 patients (7.9%) engaged in primary care in 2019. In 2019, HIV+ patients had between 563 and 689 in-person visits per month. On average, monthly visits for HIV care increased (p< 0.0001) in the first two months of 2020 (mean=626, sd=60.1) compared to 2019 (mean=617, sd=40.6), but dropped to 370 and 36 in person visits by HIV+ patients in March and April 2020 respectively (mean=203, sd=236.2; p< 0.0001), when statewide stay-at-home policies were recommended. There were 263 telemedicine visits by HIV+ patients in March and 751 in April, 2020. When telemedicine and in-person visits were combined, mean number of visits per month by HIV+ patients were higher compared to the same two-month period in 2019 (p< .0001). The mean number of plasma HIV RNA viral load (VL) tests performed each month was 279 in 2019 (range 257–312, sd=18.3), versus 219 in March and 274 in April 2020 (mean=246.5, sd=38.9; p< 0.0001). Among those tested, monthly rates of virological suppression ranged from 71–81% in 2019, with 11–20% having VL < 100 copies/ml. Eighty percent had an undetectable VL as their last measurement in 2019; an additional 14% had last VL detectable but < 100 copies/ml. In March and April, 2020, the rates of VL suppression were 77% and 74% and 14% and 18% had VL detectable but < 100 copies/ml, respectively (p=0.209). Conclusion The COVID-19 pandemic has led to a significant decrease in in-person visits by HIV+ and other patients at a Boston CHC, but with a rapid migration to the use of telemedicine, patient engagement, as expressed by visits and VL suppression does not appear to be adversely affected Disclosures All Authors: No reported disclosures

PURPOSE Siloed electronic medical data limits utility and accessibility. At the Dana-Farber/Boston Children's Cancer and Blood Disorders Center, cross-institutional data were inconsistent and difficult to access. To unify data for clinical operations, administration, and research, we developed the Pediatric Patient Informatics Platform ( PPIP), an integrated datamart harmonizing multiple source systems across two institutions into a common technology. PATIENTS AND METHODS Starting in 2009, user requirements were gathered and data sources were prioritized. Project teams, including biostatisticians, database developers, and an external contractor, were formed. Read-access to source systems was established. The 3-layer PPIP architecture was developed: STAGING, a near-exact copy of source data; INTEGRATION, where data were reorganized into domains; and, CONSUMPTION, where data were optimized for rapid retrieval. The diverse systems were integrated into a common IBM Netezza technology. Data filters were defined to accurately capture the Center's patients, and derived data items were created for harmonization across sources. An interactive online query tool, PPIP360, was developed using Microstrategy Analytics. RESULTS Driven by scientific objectives, the PPIP datamart was created, including 33,674 patients, 2,983 protocols, and 3.6 million patient visits from 14 source databases, 164 source tables, and 2,622 source data items. The PPIP360 has 605 data items and 33 metrics across 11 reports and dashboards. Dana-Farber and Boston Children's established a legal data-sharing agreement. The PPIP has supported hundreds of faculty, staff, and projects, including planning clinical trials and informing strategic planning. CONCLUSION The PPIP has successfully harmonized and integrated diagnostic, demographic, laboratory, treatment, clinical outcome, pathology, transplant, meta-protocol, and –omics data, for efficient, daily operational and research activities at Dana-Farber/Boston Children's Cancer and Blood Disorders Center, and future external sharing.

There is growing emphasis on using patient-reported outcome measures to enhance clinical practice. This study was a retrospective review of scores on the Childhood Asthma Control Test (C-ACT) and the Pediatric Symptom Checklist-17 (PSC-17) at a pediatric primary care center in Boston, Massachusetts. A total of 218 patients were selected at random using billing codes for well-child (WC) care and asthma, excluding complex medical conditions. Cutoff scores were used to identify uncontrolled asthma (C-ACT ⩽19) and clinically significant psychosocial symptoms (+PSC-17). Multiple logistic regression was used to measure associations between C-ACT ⩽19 and +PSC-17, adjusting for covariates. In multivariable analysis, C-ACT ⩽19 at WC visits was associated with +PSC-17 at WC visits (adjusted odds ratio = 3.2 [95% confidence interval = 1.3-8.6]). C-ACT ⩽19 at non-WC visits was also associated with +PSC-17 at WC visits (adjusted odds ratio = 3.1 [95% confidence interval = 1.2-8.9]). Patient-reported outcome measures of asthma control and psychosocial symptoms were positively correlated in this sample.

ABSTRACT Background Low vitamin D status, assessed using serum 25-hydroxyvitamin D [25(OH)D] concentration, has been associated with depression, but research among minority populations, such as Puerto Ricans is limited. We examined the association between serum 25(OH)D and self-reported depressive symptomatology across 3 waves of follow-up in a cohort of Puerto Rican adults residing in Massachusetts. Objectives We evaluated the cross-sectional and longitudinal associations between serum 25(OH)D and self-reported depressive symptoms in the Boston Puerto Rican Health Study (BPRHS) cohort. Methods Participants of the BPRHS were evaluated for depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). Serum 25(OH)D was measured at baseline (n = 1434), year 2 (n = 1218), and year 5 (n = 914). We categorized serum 25(OH)D concentration as sufficient (≥20 ng/mL), insufficient (12 to <20 ng/mL), and deficient (<12 ng/mL). Multivariable linear regression was used for cross-sectional analyses at baseline, and repeated measures mixed effects modeling was used over 3 waves of follow-up for longitudinal analyses. We conducted sensitivity analyses in vitamin D supplement nonusers and participants with complete data on baseline serum 25(OH)D and CES-D at all 3 visits. Results Serum 25(OH)D concentration was not associated with CES-D score in cross-sectional analysis [β = −0.85; 95% CI: −2.80, 1.10 for deficient compared with sufficient 25(OH)D; P-trend = 0.59] or in longitudinal analyses over 5 y [β = −0.41; 95% CI: −1.95, 1.13 for deficient compared with sufficient 25(OH)D; P-trend = 0.93]. Results were similar in sensitivity analyses restricted to vitamin D supplement nonusers (n = 1371) and in analyses conducted in participants with complete measures of baseline serum 25(OH)D and CES-D score at all 3 visits (n = 887) [β = −0.12; 95% CI: −1.98, 1.74 for deficient compared with sufficient 25(OH)D; P-trend = 0.93]. Conclusions We did not observe a significant association between serum 25(OH)D and depressive symptomatology in the BPRHS cohort.

Background and Objectives.The prevalence of severe obesity in children has doubled in the past decade. The objective of this study is to identify the clinical documentation of obesity in young children with a BMI ≥ 99th percentile at two large tertiary care pediatric hospitals.Methods.We used a standardized algorithm utilizing data from electronic health records to identify children with severe early onset obesity (BMI ≥ 99th percentile at age <6 years). We extracted descriptive terms and ICD-9 codes to evaluate documentation of obesity at Boston Children’s Hospital and Cincinnati Children’s Hospital and Medical Center between 2007 and 2014.Results.A total of 9887 visit records of 2588 children with severe early onset obesity were identified. Based on predefined criteria for documentation of obesity, 21.5% of children (13.5% of visits) had positive documentation, which varied by institution. Documentation in children first seen under 2 years of age was lower than in older children (15% versus 26%). Documentation was significantly higher in girls (29% versus 17%,p<0.001), African American children (27% versus 19% in whites,p<0.001), and the obesity focused specialty clinics (70% versus 15% in primary care and 9% in other subspecialty clinics,p<0.001).Conclusions.There is significant opportunity for improvement in documentation of obesity in young children, even years after the 2007 AAP guidelines for management of obesity.

Objective Numerous attempts have been made to create a standardized “presenting problem” or “chief complaint” list to characterize the nature of an emergency department visit. Previous attempts have failed to gain widespread adoption as they were not freely shareable or did not contain the right level of specificity, structure, and clinical relevance to gain acceptance by the larger emergency medicine community. Using real-world data, we constructed a presenting problem list that addresses these challenges. Materials and Methods We prospectively captured the presenting problems for 180,424 consecutive emergency department patient visits at an urban, academic, Level I trauma center in the Boston metro area. No patients were excluded. We used a consensus process to iteratively derive our system using real-world data. We used the first 70% of consecutive visits to derive our ontology, followed by a 6-month washout period, and the remaining 30% for validation. All concepts were mapped to Systematized Nomenclature of Medicine–Clinical Terms (SNOMED CT). Results Our system consists of a polyhierarchical ontology containing 692 unique concepts, 2,118 synonyms, and 30,613 nonvisible descriptions to correct misspellings and nonstandard terminology. Our ontology successfully captured structured data for 95.9% of visits in our validation data set. Discussion and Conclusion We present the HierArchical Presenting Problem ontologY (HaPPy). This ontology was empirically derived and then iteratively validated by an expert consensus panel. HaPPy contains 692 presenting problem concepts, each concept being mapped to SNOMED CT. This freely sharable ontology can help to facilitate presenting problem-based quality metrics, research, and patient care.

Background Preoperative clinics have been shown to decrease operating room delays and cancellations. One mechanism for this positive economic impact is that medical issues are appropriately identified and necessary information is obtained, so that knowledge of the patients' status is complete before the day of surgery. In this study, the authors describe the identification and management of medical issues in the preoperative clinic. Methods All patients coming to the Preoperative Clinic during a 3-month period from November 1, 2003, through January 31, 2004, at the Brigham and Women's Hospital, Boston, Massachusetts, were studied. Data were collected as to the type of issue, information needed to resolve the issue, time to retrieve the information, cancellation and delay rates, and the effect on management. Results A total of 5,083 patients were seen in the preoperative clinic over the three-month period. A total of 647 patients had a total of 680 medical issues requiring further information or management. Of these issues, 565 were thought to require further information regarding known medical problems, and 115 were new medical problems first identified in the clinic. Most of the new problems required that a new test or consultation be done, whereas most of the old problems required retrieval of information existing from outside medical centers. New problems had a far greater probability of delay (10.7%) or cancellation (6.8%) than old problems (0.6% and 1.8%, respectively). Conclusions The preoperative evaluation can identify and resolve a number of medical issues that can impact efficient operating room resource use.

ABSTRACTBackground:Emerging genetic, ex-vivo, and clinical trial evidence indicates that calcium channel blockers (CCB) can improve mood and cognitive function. The objective of this study was to examine the effect of selective serotonin reuptake inhibitor (SSRI) therapy augmented with CCB on depression and cognitive decline in an elderly population with hypertension.Methods:Prospective study of 296 persons treated with SSRI and antihypertensive drugs. Baseline and two year clinic assessments were used to categorize participants as users of SSRI + CCB (n = 53) or users of SSRI + other antihypertensives (n = 243). Clinic visits were performed up to four times in a ten-year period to assess depression and cognitive function.Results:The sample mean age was 75.2 ± 5.47 years and 78% of participants were female. At two year follow-up there was a significant group by time interaction showing lower Center for Epidemiological Studies-Depression (CESD) scores in the SSRI + CCB group, F(1,291) = 4.13, p = 0.043, η2p = 0.014. Over ten-years follow-up, SSRI + CCB use was associated with improved general cognitive function (Mini-Mental State Examination: β = 0.97; 95% CI 0.14 to 1.81, p = 0.023) and immediate visual memory (Boston Visual Retention Test: β = 0.69; 95% CI 0.06 to 1.32, p = 0.033).Conclusion:The findings provide general population evidence that SSRI augmentation with CCB may improve depression and cognitive function.

Object Discovery of a syrinx in a child, without a readily identifiable proximate cause such as a Chiari malformation, tumor, or site of tethering, is often a cause of concern for families and a source of consternation for clinicians. There is a paucity of data describing the natural history of an idiopathic syrinx in the pediatric population. The authors present the combined data of 2 major pediatric neurosurgical centers to describe their experience with this condition. Methods Data were collected at Children's Hospital Boston and St. Louis Children's Hospital according to institutional review board–approved protocols and captured visits over a 2.5-year interval (October 2006–March 2009), with records reviewed if the patient had a preexisting diagnosis of syrinx. Patients were identified by ICD-9 codes derived from departmental databases. All pediatric patients (age < 19 years) in whom idiopathic syrinx had been diagnosed, as defined by MR imaging findings (dilated central canal in the spinal cord of ≥ 1 mm in axial dimension and extending over at least 2 vertebral levels), were included. Results Forty-eight patients met the criteria for idiopathic syrinx during this period, and in 32 of them detailed follow-up imaging was available. Discovery of a syrinx was incidental in 6 patients, whereas the others were referred for imaging because of the presence of pain, neurological symptoms, scoliosis, or skin markings. The average age at the first MR imaging session was 9.7 years, with a mean syrinx size of 4 mm (range 1.2–9.4 mm). The majority (52%) of patients had a thoracic syrinx, with the average lesion spanning 7.1 vertebral levels. The average follow-up was 23.8 months (range 2–64 months), and subgroups of patients with < 3 years and ≥ 3 years of follow-up were independently reviewed. Overall, symptoms improved in 34% and worsened in 9%; 57% of the patients remained asymptomatic or stable. Radiographically (in the subgroup of 32 patients with detailed follow-up imaging), syrinx size decreased in 25% of patients, increased in 12.5%, and remained unchanged in 62.5%, with no apparent correlation between change in syrinx size and clinical symptoms. Conclusions Clinically, children with an idiopathic syrinx remained asymptomatic, stable, or improved in 91% of cases. The majority of syringes (87.5%) remained stable or shrank over time, with no apparent correlation between changes in size and changes in symptoms. Although longer follow-up is needed, these data suggest that the natural history of an idiopathic syrinx in children is benign, and that repeated imaging may not be necessary.

Abstract BACKGROUND: Pregnant women with SCD have an increased risk of both maternal and fetal complications, including preeclampsia, venous thromboembolism, and cardiomyopathy, as well as an increased risk of intrauterine growth restriction, preterm birth, low birth weight, and fetal demise. While in general children with a history of intrauterine growth restriction are at risk for abnormal neurodevelopment as well as later obesity and metabolic syndrome, the long-term developmental outcomes of children without SCD but exposed to maternal SCD are unknown. Better data about the long-term developmental outcome for children of mothers with SCD will provide guidance about the utility of disease modifying therapy during pregnancy. The objective of this study is to explore outcomes for children born to mothers with SCD using data from the Boston Birth Cohort (BBC). METHODS: The BBC is a prospective birth cohort established in 1998 at the Boston Medical Center (BMC) that recruits preterm cases (born at less than 37 weeks gestation) and full term controls. The BBC enrolls predominantly urban, low-income minority mothers and their children 24-72 hours after delivery at the BMC and follows the children from birth up to age 21 years. Data is collected on maternal preconception medical conditions, pregnancy complications, and pregnancy exposures through structured interviews at the time of enrollment and medical record extraction. Data on child development is collected from medical records and structured interviews performed by trained study staff at their scheduled pediatric appointments. Approximately 38% of study participants self-identify as black/African American, 22% as Hispanic, 19% as Haitian, and 8.5% as white. From maternal electronic medical record data capturing 147,827 emergency room and outpatient visits contributed by 5,972 subjects, we identified all women with ICD-9-CM codes for sickle cell disease (282.60-64, 282.68, 282.69, 282.41, 282.42) and probable (two or more 282.62 codes) sickle cell anemia. We then linked maternal and child data on the basis of a unique family-level study ID. Information on child development was obtained from electronic medical record data, based on the presence of relevant ICD-9-CM hospital diagnosis codes from pediatric outpatient, inpatient, and emergency room visits. RESULTS: We identified 93 women who had at least one of the ICD-9 codes for SCD. For this report we have included only those forty-one women who were coded at least twice with a 282.62 diagnosis (Hemoglobin SS disease with crisis). Six (15%) had poor fetal growth during their pregnancy, while eight (20%) were diagnosed with preeclampsia or antepartum hypertension. Among these mothers with available questionnaire and medical record extraction data (n = 38), 7 (18%) delivered their children before 37 weeks gestation, and 6 (16%) had children weighing less than 2500 grams at birth. Twenty mothers had children who received pediatric care at the Boston Medical Center, with ages ranging from 2 to 9 years of age; one was diagnosed with SCA, while 19 are unaffected carriers. Among the 19 children without SCD with available follow-up data, 5 (26%) carried a diagnosis code of overweight/obesity; their mothers were seen for an average of 73 medical visits (SD 50) during their pregnancy. Five children, without any overlap with the children diagnosed with obesity, were diagnosed with failure to thrive; while not statistically significantly different, their mothers had fewer medical encounters (mean 55, SD 37). Five children were diagnosed with delayed milestones, two of whom were late preterm (35 and 33 weeks gestation); two of these children were diagnosed with obesity and two with failure to thrive. DISCUSSION: This exploratory, descriptive study represents the first data on long-term outcomes of children without SCD who were exposed to maternal SCD in utero . While we are limited by small sample size, finding that 26% of children born to mothers with SCD have developmental delay is a significant concern. This compares to the overall cohort where 12% of control children and 39% of preterm cases have been found to have developmental delay. Future studies will include medical record review of mothers to identify additional mothers with confirmed SCD in the cohort and exploration of additional predictors of these concerning outcomes. Figure Figure. Disclosures Lanzkron: Prolong: Research Funding; HRSA: Research Funding; Bayer: Research Funding; Global Blood Therapeutics: Research Funding; Pfizer: Research Funding; PCORI: Research Funding.

e13522 Background: Primary care physicians (PCPs) play a pivotal role during cancer diagnosis. Lack of access to primary care has been linked to worse outcomes including increased mortality in patients with cancer. Higher PCP continuity of care has been associated with lower likelihood of acute care services use among breast cancer survivors, however the impact of PCP utilization is not well studied in those newly diagnosed. This study examines the association between PCP visits and emergency department (ED) use and hospitalization in the year following diagnosis of breast cancer. Methods: Electronic medical records of women newly diagnosed with primary breast cancer from 2013 to 2019 at a single institution (Tufts Medical Center, Boston, Massachusetts) with an established PCP in the same system were retrospectively reviewed. Demographic (age at diagnosis, menopausal status, race/ethnicity), clinical (Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG) performance status, body mass index, mental health disorder, chronic pain syndrome), and tumor (histology, stage, grade, hormone receptor (HR) positivity, HER2 status) characteristics were extracted in addition to information on treatment modalities (if patient received surgery, radiation (RT), chemotherapy (CT), endocrine therapy (ET), ovarian suppression (OFS)). Univariate and multivariate logistic regression models were used to examine associations between frequency of PCP visits and ED use and hospitalizations within a year after diagnosis of breast cancer. Results: Of 182 women ages 33-93 (mean 60) years old, 131 (72%) were postmenopausal, 116 (64%) Caucasian; 176 (97%) had stages 1-3, and 157 (86%) had HR positivity. In the year following diagnosis, 178 (98%) received surgery, 127 (67%) RT, 142 (78%) ET, 19 (10%) OFS, 70 (39%) CT; 68 (37%) had ≤1 PCP visit, and 45 (25%) had 4-10 PCP visits. Increased PCP visits correlated with advancing age, increased BMI, greater mental health disorders and chronic pain syndromes, and increasing CCI and ECOG score. After adjusting for these confounders and tumor and treatment characteristics, logistic regressions showed that while frequency of PCP visits was not associated with hospitalizations (univariate: OR = 1.02, 95% CI [0.53, 1.62], p = 0.93; multivariate: OR = 0.35, 95% CI [0.05, 1.50], p = 0.184), increased PCP visits tended toward association with increased ED use (univariate: OR = 1.12, 95% CI [0.97,1.29], p = 0.124; multivariate: OR = 1.15, 95% CI [0.94, 1.41], p = 0.188), however did not demonstrate statistical significance. Conclusions: Primary care utilization was not associated with acute care services utilization in women newly diagnosed with breast cancer. Higher PCP utilization tended toward correlation with increased ED use. These findings may help in evaluating multidisciplinary care support in patients newly diagnosed with breast cancer.

INTRODUCTION Throughout the second half of the 20th Century, our nation's cities were marred by the onslaught of unsustainable suburbanization and the expansion of limited access highways that ripped through urban centers and divided communities within them. Paired with systematic disinvestment from redlining and white flight, these forces combined to create lasting physical, social and economic hardships in cities across the US. Over the last 20 years, cities have rebounded in America and new patterns of thought focused on livability, walkability and urban form have started to sprout: from the Big-Dig in Boston to Octavia Boulevard and the Embarcadero in San Francisco, cities are reassessing the value of highways that solely move automobiles through cities, and have started to focus on how these pieces of infrastructure impact the daily lives and economic interests of a their residents and visitors. In Oakland, California, through the efforts of ConnectOAKLAND, the city is taking up the mantle of this new pattern of thought and is beginning the planning process to reconnect West Oakland to Downtown by transforming an underutilized freeway (I-980) into a multi-modal transportation corridor that reestablishes the historic urban grid. The project's dual benefit will reconnect two of Oakland's historic neighborhoods while better connecting Oakland along with the entire East Bay to San Francisco, San Jose and Silicon Valley through the incorporation of a second transbay tunnel for Bay Area Rapid Transit (BART), commuter rail (Caltrain), and high speed rail (HSR). This article will explore the ConnectOAKLAND vision for I-980 as a case study for current and future patterns of highway removal, and as a part of the national movement to rethink the role of urban highways and holistically re-envision the US transportation infrastructure.

Abstract Objective Previous work has demonstrated that intra-individual cognitive variability (IICV) has predictive power similar to traditional Alzheimer’s disease (AD) biomarkers, such as CSF or hippocampal volume (HV) loss. Genetic factors, such as sex, have been identified as predictors of cognitive decline. Analysis of sex differences in IICV and other biomarkers may elucidate additional dimensions of this metric. Method Baseline neurocognitive test and neuroimaging data from 335 participants with ≥2 visits enrolled in the Wisconsin Alzheimer’s Disease Research Center Clinical Core were included. Z-scores were calculated comparing individual performance to group performance by test (Rey Auditory Verbal Learning Test (Learning and Delayed Recall), Trail Making Test (A and B), and either Boston Naming Test (BNT) or Multilingual Naming Test (MINT)). MINT scores were converted to BNT scores using the NACC Crosswalk Study. The standard deviation of z-scores across tests was calculated to determine IICV. Characteristics by sex were compared using Mann-Whitney and Fisher’s Exact tests. Spearman’s Rho was calculated to compare IICV and HV (relative to intercranial volume). Results At baseline (Table 1): (1) Males had more education than females; (2) females had both higher relative HV and IICV; and (3) in females, relative HV demonstrated a weak positive correlation with baseline IICV (Figure 1). Conclusions IICV has previously demonstrated potential as a cost-effective non-invasive marker of preclinical AD. In females, larger relative HV and its correlation with IICV may be due to differences in metabolic brain age or concurrent progression of HV and IICV through the AD process. Analyses of other biopsychosocial factors are needed.

55 Background: The National Comprehensive Cancer Network (NCCN) recommends active surveillance (AS) as the primary management option for patients with very low-risk prostate cancer (VLRPC) and an expected survival of <20 years. Factors associated with selection of AS are therefore of clinical importance. We hypothesized that care at a multidisciplinary clinic (MC), where multiple physicians simultaneously review each case, will be associated with increased rates of AS in men with VLRPC, including those with limited life expectancy. Methods: Of 630 patients with low-risk prostate cancer managed at one of three tertiary care centers in Boston, MA in 2009, 274 (43.5%) had VLRPC. Patients were either seen by one or more individual providers in sequential visits (N=178) or at an MC (N=96), in which concurrent consultation with two or more of the following specialties was obtained: urology, medical oncology, and radiation oncology. Results: Patients seen at an MC were more likely to select AS than those seen by individual providers (64% vs 30%, p<.001), an association which remained significant on multivariable logistic regression (OR=4.16, p<.001), see Table. When the analysis was limited to patients with an expected survival of <20 years based on the 2007 Social Security Life Table, this association remained highly significant (OR=5.19, p<.001). Conclusions: Multidisciplinary care is strongly associated with selection of AS, adherence to NCCN guidelines, and minimization of over-treatment in patients with VLRPC. [Table: see text]

Introduction Fostamatinib is a first in its class oral inhibitor of spleen tyrosine kinase (Syk) pathway for treatment of adults with immune thrombocytopenia (ITP) with insufficient response to previous treatment. Choice of treatment for relapsed ITP varies greatly according to clinician and patient preference. It is common for patients to switch between available thrombopoietin (TPO) agonists and now fostamatinib. Titration of these agents is often cumbersome and labor intensive; romiplostim in particular requires weekly visits with lab draws and consumes nurse, pharmacy and provider effort. Here we present real world experience with fostamatinib use in an academic medical center. Methods. We retrospectively identified four patients who were prescribed fostamatinib within the past nine months at Boston Medical Center Health System. All patients had a diagnosis of chronic ITP and were previously treated with corticosteroids, intravenous immunoglobulin (IVIG), and rituximab. With respect to previous TPO receptor use, two of four patients had received both eltrombopag and romiplostim. Patients were started on fostamatinib at a dose of 100 mg by mouth twice daily and titrated up to 150 mg by mouth twice daily if platelet counts were <50 10x9 /L after 4 weeks of therapy. All patients were seen by a pharmacist and provider for initiation of the drug and seen in clinic weekly for the first month on therapy to assess toxicity and efficacy. The duration of follow up for the patients is between 2 and 9 months on therapy. Results. Three of four patients initiated on fostamatinib had a baseline platelet count 100K or greater and the fourth patient had ITP refractory to multiple lines of therapy with a baseline platelet count of 7K at therapy initiation. Three patients sought alternative therapy given side effects from TPO agonists or inconvenience of romiplostim. Three patients had platelets counts >50K at 4 weeks and one patient had a platelet count <30K. Recent platelet counts of the two patients that have been on therapy for 7 and 8 months were 123K and 108K, respectively. The third patient that responded initially discontinued therapy due to lack of stable response. Both of the patients with stable responses were well controlled on previous therapy with romiplostim. One patient required rescue therapy with IVIG and romiplostim due to petechiae 15 days after therapy initiation but continued on therapy thereafter. Two patients that discontinued therapy had platelet counts of 10K and 88K upon discontinuation due to inadequate response and toxicity, respectively. One patient was romiplostim naïve and the other patient had not received romiplostim for four years prior. Two patients developed diarrhea that was managed with loperamide and one led to treatment discontinuation (in combination with insufficient response). One patient experienced hypertension that was managed accordingly. Conclusion. The ideal place in therapy for fostamatinib in ITP therapy is not yet clear. However, the availability as an oral option for patients with refractory disease is appealing. One of our patients required rescue therapy which should be considered when transitioning patients to fostamatinib from TPO agonists. Additionally, side effect management with anti-hypertensives and anti-diarrheal agents may be required to continue therapy. Effectiveness of romiplostim may predict responsiveness to fostamatinib, although additional data are needed. Table Disclosures Shah: Rigel Pharmaceutical: Consultancy, Speakers Bureau. Sarosiek:Acrotech: Research Funding. Sloan:Merck: Other: endpoint review commitee; Abbvie: Other: Endpoint Review Committee; Stemline: Consultancy.

Systemic amyloidoses are a group of progressive and life-threatening rare diseases. Patients often feel overwhelmed by the complexities of symptoms, treatment options, and management of their care team. The Amyloidosis Appointment Companion (AAC) was created to help patients identify their goals of care, changes in their condition, as well as the challenges they are facing and share these with their health care providers (HCPs). The AAC has been developed to create a synergy between patients and their clinicians as it relates to not only their health and wellbeing but their overall life goals, and to guide discussion and development of their treatment plan. Here we report on the findings of the first 70 patients to use the AAC at the Amyloidosis Center of Boston University Medical Center (BUMC). The Amyloidosis Research Consortium (ARC) in collaboration with Patient Discovery, a virtual healthcare platform, created the AAC, a digital tool to guide patients through a personalized, interactive survey in order to capture their current status, treatment goals and preferences, correct misperceptions, frame decisions, and promote adherence to treatment plans. The tool was beta tested at 5 amyloidosis centers to assess dissemination and clinical integration strategies, decision-making processes, and communication. The tool launched at BUMC in January 2020, after being integrated into the appointment process as part of both in person and virtual telehealth visits via the Amyloid Center Office and included in the appointment scheduling workflow. Data collected via the tool is securely shared with BUMC by patients and entered into their charts. Additional telehealth-specific features were added to the AAC when the BUMC clinic added virtual appointments in response to COVID-19. This is a report of the findings from the first 70 patients utilizing the tool over a five-month time period. There was a completion rate of 82%, well above the industry standard for patient surveys of 41%. The average user age was 65 years (range, 24 to 86), and 41% (n=29) of patients used the AAC on a mobile device. Patients reported the following subtypes of amyloidosis: Patients spent an average of 16.5 minutes using the AAC prior to their appointment and completed the following tasks: Completing Clinic Intake FormsPreparing for Telehealth AppointmentsReconciling MedicationsCapturing Treatment Satisfaction and PreferencesSharing Goals of CareReporting Symptoms and Side EffectsCharting LabsReviewing Educational VideosReporting on Quality of Life Measures Of these 70 patients, 60% (n=42) patients reported slight to moderate levels of anxiety or depression and 69% (n=48) pain and 59% (n=41) restricted mobility. Two main types of reported goals of care were identified: 1) short term, isolated goals (such as attending a specific life event) and 2) long term, lifestyle goals (such as regaining exercise tolerance or living independently). Individualized to their responses, patients prioritized a list of topics to discuss with their clinicians, the most common topics were: 1. Understanding treatment options, 2. Learning more about my disease, 3. Managing my symptoms and side effects, 4. Concern my disease is progressing. Three providers within the Amyloidosis Center at BUMC independently reported enhanced satisfaction with outcome of appointments as a result of patients having used the AAC. The data patients shared led to greater efficiency during telehealth appointments in particular with the time saved on medicine reconciliation and vital signs, allowing more time during the appointment to focus on delivering personalized care. The AAC demonstrated improved patient to physician communication particularly during a time of increased telehealth visits. The AAC is a patient and provider centered tool that facilitates patient communication and involvement in decision making, as well as helping providers understand their patients' preferences and goals of care. The tool improves appointment efficiency in particular, reducing significantly the time taken up in a telehealth visit for medication reconciliation, obtaining vitals and in some cases, technical support. The tool emphasizes patient engagement to improve patient-provider communication. Furthermore, insights from these data provide powerful information that may help improve development of assistance programs, clinical trials, and research. Figure Disclosures Shore: Patient Discovery Solutions, Inc.: Current Employment, Current equity holder in private company. Sodowick:Patient Discovery Solutions, Inc.: Current Employment, Current equity holder in private company. Mendelson:Patient Discovery Solutions: Consultancy. Sanchorawala:Proclara: Other: advisory board; Caleum: Other: advisory board; Regeneron: Other: advisory board; Oncopeptide: Research Funding; Caelum: Research Funding; Prothena: Research Funding; Celgene: Research Funding; Takeda: Research Funding; Janssen: Research Funding; Abbvie: Other: advisory board; UpToDate: Patents & Royalties.

Introduction: Coronavirus disease 2019 (COVID-19) has led to unprecedented modifications to healthcare delivery in the U.S. To preserve resources in preparation for a COVID-19 surge, Boston Medical Center (BMC) implemented workflows to decrease ambulatory in-person visits effective March 16th, 2020. Telemedicine was incorporated into clinical workflows and much preventive care, including Hepatitis C (HCV) testing, was not routinely performed. Objective: To explore the impact that the COVID-19 rapid restructuring response has had on HCV testing and identification hospital-wide and in ambulatory settings. Methods: BMC utilizes reflex confirmatory testing for HCV. When a sample is HCV Ab positive, it is automatically reflexed for confirmatory RNA and genotype testing. HCV test results for patients were collected daily. We compared unique patient tests for 3.5 month periods before and after March 16th, 2020. Descriptive statistics showed total tests and total new HCV RNA+ before versus after, both hospital-wide and in ambulatory clinics alone. Mean daily tests completed were compared. Results: Hospital-wide, total HCV testing decreased by 49.6%, and new HCV+ patient identification decreased by 42.1%. In ambulatory clinics, testing decreased by 71.9%, and new HCV+ identification decreased by 63.3%. Hospital-wide, mean daily tests decreased by 22.9 tests per day (95% CI: 17.9-28.0, P < .001), and mean daily new HCV+ identification decreased by 0.36 (95% CI: 0.20-0.53, P < .001). In ambulatory clinics, mean daily tests decreased by 22.1 tests per day (95% CI: 17.5-26.7, P < .001) and mean daily HCV+ decreased by 1.40 (95% CI: 1.03-1.76, P < .001). Conclusion: The COVID-19 systematic emergency response led to decreased HCV testing and identification, and in this regard telemedicine acts as a barrier to HCV care. Other public health initiatives must be monitored in the context of telemedicine workflows. Continued monitoring of HCV screening trends is vital, and adaptive approaches to work toward the goal of HCV elimination are needed.

99 Background: Black men have the highest incidence of prostate cancer (PCa) and are twice as likely to die of the disease than any other race/ethnic group in the United States. The recent controversy related to PCa screening may disproportionately impact black men who are already at greatest risk from the disease. This project sets out to develop culturally-competent educational and screening programs for men in high-risk populations so they can make an informed decision about PCa screening. Methods: A community-based education and screening program targeted towards black men living in an under-resourced community in Boston, MA was implemented. A mobile PCa screening van was initially employed and stationed at a local community health center (CHC) twice annually. Education about PCa screening was provided by a trained racially-concordant patient navigator (PN). Screening was available on the van by a primary care physician (PCP). In 2013, the pre-screening educational model was incorporated into the clinical practice of a single PCP practicing at the CHC. Every male patient over the age of 40 had an educational consultation about PCa screening with the PN before seeing their PCP. The patient would then discuss screening with the doctor and decide whether to proceed at that visit. Results: From 2004 to 2013, 20 van visits were conducted at the CHC. Two-hundred seven (207) men received PCa screening education; 179 (86.5%) elected to undergo screening. Of the men screened, 26 (14.5%) were referred for further testing as a result of their screening test. From January 2013 to September 2014, 121 men received PCa education; 100 men (82.6%) were screened. Ninety percent had both prostate-specific antigen testing and a digital rectal exam. Conclusions: These data suggest that formal PCa screening education prior to meeting with a physician is welcomed and may be a way to increase baseline screening in high risk populations. This provides an opportunity to develop an individualized prostate health management program based on individual risk profiles and to carefully monitor PSA fluctuations. The ultimate goal is to reduce unnecessary interventions while capturing PCa early in men at greatest risk.

61 Background: There are nearly 3 million breast cancer (BC) survivors in the US. Among the recently diagnosed, accrediting organizations (e.g., Commission on Cancer) now require SCPs at the completion of curative therapy. Within the Oncology Care Model, the preparation and delivery of SCPs is recognized as one of the 13 quality metrics. SCPs, combining treatment summaries (TS) and follow-up care plans (FUCPs), assist patients and providers in the delivery of high quality long-term care. BC presents a unique challenge, as the risk of recurrence extends decades past initial treatment; adjuvant risk reduction may extend up to 15 years. Periodic FUCPs provide a mechanism to review updated information and may allow providers to catch up with longer term BC survivors whose care was delivered prior to SCPs. We explored the role of phase-specific SCPs within the heterogeneous BC survivor population. Methods: Oncologists and nurse practitioners (NPs) from the Breast Health and Survivorship Programs at Tufts MC, an academic medical center in Boston, and New England Cancer Specialists, a community-based private oncology practice in Maine--together caring for more than 2,000 BC survivors--convened to develop and test phase-specific survivorship tools. Using an adapted ASCO template for BC, TS were completed at the end of initial therapy by trained NPs. FUCPs for initial, 5-year, and 10-year visits were designed with clinical input, literature reviews, and existing guidelines. Results: FUCPs were pilot tested and refined before incorporation into the electronic health record. Further testing is planned to identify barriers to effective survivorship care, particularly involving documentation of changes in recommendations and the transition from oncologist to primary care physician. Conclusions: SCPs are critical for providing quality health care to BC survivors, but a single SCP, written at the conclusion of curative treatment, might not be sufficient to address changing needs of individuals as they progress through survivorship. Thus, phase-specific SCPs enable providers to focus on salient aspects of care that may change over time. Despite growing recognition of the value of SCPs, implementation remains a challenge across cancer programs.

Abstract Introduction Early detection of joint problems and musculoskeletal (MSK) abnormities is a priority in hemophilia care worldwide; however, there is no standard approach to screening. The World Haemophilia Federation Hemophilia Joint Health Score (HJHS) is well validated but requires time-intensive evaluation by a MSK expert (e.g. physical therapist, PT). Joint screening popularized for the US Center for Disease Control Universal Data Collection (UDC) focuses on range of motion (ROM) assessment only but is quick and easy to implement with modest staff training of non-experts. The approach used at our center, here dubbed UDC-plus, combines ROM measurements with pain and functional evaluation. In 2012 our center found that HJHS was sensitive but non-specific (high false positive rate) and correlated poorly with need for MSK referral or imaging [Morrison et al, Haemophilia, 18 suppl. 3 p.120]. The aim of this study was to evaluate the utility of using HJHS in clinical practice to predict need for MSK referral within 5 years of initial assessment. We also evaluated the ability of UDC-plus to predict actionable MSK findings at 5 years. Methods This is a single center, retrospective, observational study. Patients diagnosed with hemophilia A or B of any severity, a HJHS assessment between 2009 and 2011 and a PT evaluation 5 years later (between 2014-2016) during annual comprehensive visits at Boston Children's Hospital were eligible for the study. HJHS includes evaluation of 6 joints (elbows, knees, ankles) with score range from 0 to 124 points, considered positive if greater than 0. UDC-plus score includes the same joints with score range from 0 to 3, considered positive when 2 or greater. Outcomes included need for MSK-related referral during the 5-year observation period. Clinical and demographic characteristics were summarized using descriptive statistics; logistic regression was used to determine whether baseline joint scores were prognostic of referral. Sensitivity and specificity of joint scores were calculated. Results Seventy-one male patients met inclusion. Median observation time was 5.7 years (range: 3.2-6.8); median baseline age was 10.3y (3-21). Thirty-six (51%) had severe, 8 (11%) moderate and 27 (38%) mild hemophilia; 92% of severe and 25% of moderate patients were on regular prophylaxis. Nine (13%) patients had at least one TJ, reflecting that even for young patients in the prophylaxis era (after 1996 at our center), TJs are not eliminated. An abnormal score was found in 47 (66%) patients; only 6 (13%) of them required referral for PT, orthopedic or radiologic assessments. Of patients with abnormal baseline HJHS without initial MSK referral, 17/41 (42%) required at least one referral by 5 years while only 4/41 (10%) had an MSK concern at the 5-year comprehensive visit (other concerns were transient). Of patients with a normal baseline HJHS, 11/24 (46%) required at least one referral by 5 years and 3/24 (12.5%) required a referral at 5 years. Baseline HJHS was not prognostic of need for referral at 5 years, Table 1. An abnormal UDC-plus score occurred at baseline in 38 (54%) patients, 6 of whom (16%) received a referral. The sensitivity and specificity for the UDC-plus score were slightly less sensitive but more specific than HJHS. Conclusion While high sensitivity of HJHS makes it useful in a research setting, the time requirement by an expert PT and its poor correlation with need for either acute or long-term clinical intervention (low specificity) render it less desirable for screening in routine hemophilia care. UDC-plus, has modest sensitivity for acute and 5-year referral prediction, but is correspondingly more specific. Hemophilia comprehensive clinics require a basic joint assessment, which is neither time- nor resource-intensive. These data suggest HJHS does not meet this need; however, a more concise examination focusing on ROM of key joints, pain and functional status may be an important foundation. The UDC-plus with revised scoring criteria may support routine integration into hemophilia care without compromising clinic flow or costs. Disclosures Neufeld: Novartis: Consultancy.

Abstract Introduction:Previous research has reported broad deficits in health-related quality of life (HRQoL) in patients with immunoglobulin light chain (AL) amyloidosis. While research also shows improvements in HRQoL following treatment with high-dose melphalan and stem cell transplantation (SCT), little is known about whether changes in HRQoL corresponding to a hematologic complete response (CR) are indicative of clinically meaningful changes in functioning and well-being. The purpose of this analysis is to examine patterns of change in HRQoL among AL amyloidosis patients by achievement of hematologic CR following targeted treatment of plasma cell dyscrasia. Methods: Patients with AL amyloidosis were asked to complete the SF-36v1 Health Survey (SF-36v1) during clinic visits at the Amyloidosis Center at Boston University between 1994 and 2014. A complete case analytic sample (n=177) was created based on the following eligibility criteria: 1) patients with an SF-36v1 observation within 30 days of their initial evaluation at the clinic; and 2) patients with an SF-36v1 observation within two years of their initial evaluation that also corresponded to a visit with a recorded CR status. The SF-36v1 assessed HRQoL across eight domains and two component summary measures: physical functioning (PF); role limitations due to physical health problems (RP); bodily pain (BP); general health (GH); vitality (VT); social functioning (SF); role limitations due to emotional health problems (RE); mental health (MH) and physical (PCS) and mental (MCS) component summaries. Higher SF-36v1 scores represented better functioning. Baseline characteristics of patients were compared by CR status using two-sample t-tests and chi-square tests for continuous and categorical variables, respectively. Paired t-tests were conducted to test for significant differences between baseline and follow-up SF-36v1 scores within each CR status group. Changes in SF-36v1 scores were compared to established minimal important changes (MICs) to determine whether the observed changes may be clinically meaningful to patients and clinicians. Finally, changes in SF-36v1 scores in relation to CR status were examined using generalized linear models controlling for CR status, baseline scores, and potential confounders. Results:Significant improvements in VT, MH, and MCS scores were observed among patients with CR within two years of their initial evaluation (adjusted p < 0.05 for all). The mean changes in VT and MCS among patients with CR also exceeded established MICs. Among patients without CR, significant improvements were observed for RP, VT, MH, and MCS; however these significant changes did not persist after adjusting for multiple comparisons. Significant associations between CR status and changes in SF-36v1 were observed for PF, GH, VT, and PCS (adjusted p <0.05 for all). For each of these scales, with the exception of VT, the mean scores increased among patients with CR and declined among patients without CR. Conclusion : Meaningful change in HRQoL was observed among AL amyloidosis patients with hematologic CR following treatment directed against plasma cell dyscrasia, specifically for aspects of mental well-being. Furthermore, changes in HRQoL differed significantly by CR status for several aspects of physical health. While previous studies in AL amyloidosis have highlighted significant deficits, particularly in physical health, these findings stress the importance of considering multi-dimensional aspects of HRQoL in this condition. While treatments may ultimately focus on improving physical functioning, achieving CR may have important changes to patients' mental health. Disclosures McCausland: Prothena Biosciences Inc: Research Funding. White:Prothena Biosciences Inc: Research Funding. Bayliss:Prothena Biosciences Inc: Research Funding. Guthrie:Prothena: Employment, Equity Ownership, Other: Leadership. Oliver:Prothena Biosciences, Inc.: Employment, Equity Ownership.

Background: An international survey we recently conducted indicated that, even today, adults with acute myeloid leukemia (AML) standardly remain hospitalized after completion of induction chemotherapy until resolution of cytopenias due to a high risk of infection and frequent need for transfusions. In contrast, over the last five years at our institution, hospital discharge immediately following completion of induction chemotherapy has become routine after a phase 2 trial evaluating an Early Hospital Discharge (EHD) strategy showed this approach to be safe and cost-effective. On the other hand, EHD is a nearly-universal practice following post-remission or "consolidation" therapy. Here, we sought to compare safety and healthcare resource utilization outcomes for patients who are discharged to the outpatient setting following intensive induction vs. consolidation chemotherapy. Methods: We retrospectively identified all adults aged ≥18 years with newly-diagnosed AML/high-grade myeloid neoplasms (≥10% blasts in peripheral blood/ bone marrow) who started AML-like intensive induction or consolidation chemotherapy ("7+3," high-dose cytarabine [HiDAC], or a regimen of similar/higher intensity) at our institution from 8/1/14 (completion of our phase 2 EHD study) to 7/31/18. EHD was defined as discharge from the hospital within 72 hours of completing chemotherapy (as done in our phase 2 study). Induction therapy was defined as the first course of intensive chemotherapy for untreated disease. Consolidation therapy was defined as intensive therapy if the marrow (and hematologic parameters) prior to starting treatment showed complete remission by standard International Working Group criteria. Patients with relapsed or primary refractory disease were excluded from this analysis. The study period began on the day of initial discharge and ended with count recovery, death, receipt of additional disease-directed therapy, transfer of care, or once 42 days elapsed. We collected baseline demographic and clinical characteristics, logistical information, and treatment regimen. Outcomes of interest including readmission timing/reasons, intensive care unit (ICU) admission, resource utilization (number of lab visits, provider visits, days of IV antimicrobial use, units of transfused red blood cell [RBC] and platelets) and survival. All analyses accounted for correlation between patients because 100 patients were in both the induction and consolidation datasets and 62 patients had more than 1 consolidation cycle in the dataset. Results: We identified 215 induction cycles and 225 consolidation cycles that met our criteria for EHD. As detailed in Table 1, induction EHD patients had worse baseline performance status and higher white blood cell counts than consolidation EHD patients. Consolidation patients spent more time on study (27.8 vs. 24.7 days) and spent a higher proportion of their study time as outpatients (mean of 79% vs. 71% of study time; p&lt;0.001), at least in part because of a lower readmission rate (mean of 0.8 vs. 1.1 readmissions; p&lt;0.001). There were no differences in the proportion of study days spent in the ICU (1.6% after induction vs 0.6% after consolidation; p=0.27). However, the early death rate (within 30 days of study day 1) was higher in the induction EHD group (4% vs. 1%; p=0.03). A higher proportion of study days were spent on IV antimicrobials in the induction group (37% vs. 32% days; p=0.06), and though absolute numbers were small, the induction cohort had more frequent physician (0.07 vs. 0.05; p&lt;0.001) and nurse/advanced practiced practitioner visits (0.09 vs. 0.08; p=0.02) per study day than the consolidation group, respectively. There were no differences in mean lab visits per outpatient study day (p=0.63), in mean number of red blood cell transfusions per study day (p=0.18) or mean number of platelet transfusions per study day (p=0.51). Conclusion: Although the early death rate, as would be expected given a baseline sicker population, was higher for EHD patients following induction compared to consolidation chemotherapy, there were no differences between the two groups in requirements for ICU care, laboratory monitoring, or transfusion need in the outpatient setting. This suggests that an EHD strategy following induction therapy may be safely and reasonably implemented at centers with infrastructure supporting EHD following standard consolidation therapy. Disclosures Halpern: Pfizer Pharmaceuticals: Research Funding; Bayer Pharmaceuticals: Research Funding. Othus:Glycomimetics: Other: Data Safety and Monitoring Committee; Celgene: Other: Data Safety and Monitoring Committee. Buckley:CTI BioPharma: Employment, Equity Ownership. Percival:Pfizer Inc.: Research Funding; Nohla Therapeutics: Research Funding; Genentech: Membership on an entity's Board of Directors or advisory committees. Becker:The France Foundation: Honoraria; AbbVie, Amgen, Bristol-Myers Squibb, Glycomimetics, Invivoscribe, JW Pharmaceuticals, Novartis, Trovagene: Research Funding; Accordant Health Services/Caremark: Consultancy. Scott:Novartis: Consultancy; Agios: Consultancy; Incyte: Consultancy; Celgene: Consultancy. Oehler:Pfizer Inc.: Research Funding; Blueprint Medicines: Consultancy; NCCN: Consultancy. Gernsheimer:Fuji film: Consultancy; Bioverativ: Consultancy; Dova pharmaceuticals: Consultancy; Novartis: Honoraria; Cellphire: Consultancy; Amgen: Consultancy, Honoraria; Rigel: Consultancy; Shionogi: Consultancy. Orozco:Actinium Pharmaceuticals: Research Funding. Cassaday:Amgen: Consultancy, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Incyte: Research Funding; Kite/Gilead: Research Funding; Merck: Research Funding; Seattle Genetics: Research Funding; Seattle Genetics: Other: Spouse's disclosure: employment, stock and other ownership interests. Shustov:Seattle Genetics, Inc.: Research Funding. Hartley:Pfizer Inc.: Employment, Equity Ownership. Welch:Pfizer Inc: Employment, Equity Ownership. Walter:Agios: Consultancy; Amgen: Consultancy; Amphivena Therapeutics: Consultancy, Equity Ownership; Aptevo Therapeutics: Consultancy, Research Funding; Argenx BVBA: Consultancy; Astellas: Consultancy; BioLineRx: Consultancy; BiVictriX: Consultancy; Boehringer Ingelheim: Consultancy; Boston Biomedical: Consultancy; Covagen: Consultancy; Daiichi Sankyo: Consultancy; Jazz Pharmaceuticals: Consultancy; Kite Pharma: Consultancy; New Link Genetics: Consultancy; Pfizer: Consultancy, Research Funding; Race Oncology: Consultancy; Seattle Genetics: Research Funding.

Drift: An IntroductionEntering into Drift is akin to entering—or becoming ensnared by—a hum. Projected across one wall, the work uses abstract visual forms to draw visitors into its meditational folds. Quadraphonic sound circulates in smooth, heavy pulses, like the steady rumble of a train running over deep-set tracks. A succession of vibrating lines occupy the screen, much like the horizontal static of a poorly-tuned television. Gradually, the ambient timbre darkens, the hum becomes more persistent and atmospheric undulations more frequent, until room and body expand with intensity. Throbbing vibrations connect ground to feet, roll along skin, finding their way into deep interiors until organs and sinew become subsumed by Drift’s thick, heart-gripping drone. The installation’s tight, affective grasp only becomes apparent upon the sudden release of this tension; the room lightens and hum eases as the screen whitens with faint patterns, like a window opening from a darkened room. Drift, by German artist Ulf Langheinrich, appeared in White Noise, an exhibition dedicated to abstract moving image art at the Australian Centre for the Moving Image in Melbourne (ACMI). At the time of this exhibition in 2005, I was undertaking a seven month study of ACMI’s Screen Gallery, also documenting the preceding exhibition, World without End. My research used the Gallery as a site to examine the shifting relationship between visitor experience, digital art and museums, as the space compelled unusual modalities of visitor interaction. Most notable were states of complete stillness. I aimed to investigate how art and technology might mediate visitor agency through such experiences; not only to understand how museum visitation is transforming in new and significant ways, but to also extrapolate a substantial account of an individual’s agency within this era of what Beck, Giddens and Lash have termed ‘reflexive modernisation’. However, existing studies of museum visitation are rarely informed by the subjective modalities of visitor encounter, but rather, detail how experiences are shaped by institutional practices (Bourdieu; Luhmann; Silverman; Falk; Falk and Dierking) or governmental agendas (Bennett; Hooper-Greenhill). A notable exception is Megan Hick’s phenomenological study of Sydney’s Powerhouse museum. Following this example, I developed a phenomenology of museum visitation that could privilege the visitor’s enunciation of experience, whilst also exploring how expressions of agency may be highly subjective, multifarious and nuanced. I used qualitative ethnographic techniques to gather phenomenological material. Firstly, I attended the Gallery on a fortnightly basis to conduct longitudinal participant observations. However, as observation offered no means to interpret quiet faces and still bodies I also undertook visitor interviews. I approached visitors immediately after their visitation, and attempted to capture a wide cross-sample of responses by recruiting on the basis of age, gender and reason for visitation. I undertook ten 45 minute interviews, enquiring into the factors influencing impressions of the Gallery, prior familiarity with museums, and opinions about media art and technology. This ethnographic material was central to my study, as the voices of visitors guided its thematic direction and ensuing analysis. As the first in-depth, qualitative analysis of visitation to the Screen Gallery, my study therefore makes an empirical contribution to existing visitor research by offering an original means of exploring issues of museum visitation and agency, and movement and stillness.For example, visitors often received Drift with complete stillness, lulled into a focused state of attention by the shiftings of light and sound. As interviewee Colleen reveals, this concentration arose because Drift resonated intimately, akin to a meditative encounter:There wasn’t any other emotion or feeling behind it other than feeling relieved and comfortable, and relaxed. It was almost meditative … I was actually trying not to think about anything! … I didn’t want it to be influenced by the morning’s happenings … I just thought ‘this is relaxing’.Colleen has described how stillness and movement are therefore modalities within a broad vocabulary of interaction. While theorists have long noted how the transition from painting to film marked a shift from still to more ‘active’ forms of contemplation (Benjamin), an unanticipated finding of my study reasserted stillness as a dominant modality of active reception. In this article I therefore ask how agency finds expression within states of stillness.I propose that stillness mediates a distinctive form of agency as it is laden with what Brian Massumi calls ‘potential movement.’ I explore this concept with reference to visitors’ experiences of History of a Day, a work in World Without End. I then draw upon Henri Lefebvre’s description of ‘eurrhythmic’ congruence to describe how stillness is characterised by a focused state of attention, reflecting a highly subjective form of agency. I conclude by describing how this spatial awareness enables individuals to realise their own creativity, and inspire new praxes for daily living.1. Stillness: A State of Potential MovementBy dedicating its exhibition space to time-based art, ACMI’s Screen Gallery has cultivated a new temporal paradigm for visitor participation. It mediates both stillness and movement. Visitors described how the task of negotiating multiple time-based screens in a singular space loosened the temporal boundaries of engagement. Visitors were frequently compelled to pause and wait, as there was an absence of ‘entry’ or ‘exit’ points for viewing a piece. This raises questions as to how slower, or ‘still’, forms of participation in the Gallery may elicit agency. If considering stillness as a state that exists as an inverse of movement, rather than a state lacking in movement, it becomes possible to locate agency within the process of maintaining stillness, and as a result, engender what Brian Massumi describes as ‘potential movement’.In his account of architect Lars Spuybroek’s wetGRID design, Massumi describes how Spuybroek compares the experience of viewing images with the spatial experience of moving through buildings. Spuybroek drew from the premise that while movement can be understood as “the actual content of architecture” (322), it is more difficult to draw correlations between the properties of movement and perception of still images. He developed the idea of potential movement to breach a commonality between the two, as paraphrased by Massumi: “potentials for movement are extracted from actual movement, then fed back into it via architecture. We normally think of abstraction as a distancing from the actual, but here potentials are being ‘abstracted into it’” (323). Spuybroek therefore inscribed the idea of ‘tendency’ in his work, an ‘affordance’ that manifests as “a possibility of convergence that unconsciously exerts a pull, drawing the body forward into a movement the body already feels itself performing before it actually stirs” (Gibson in Massumi 324). This idea suggests that the act of sitting and viewing an image, can be reconceived as a state laden with potential movement. As Massumi describes, “sitting still is the performance of a tendency towards movement … It is the pre-performance, in potential, of the movement and its function … It is in intensity” (324).Sitting can therefore be regarded an 'active' state, where 'tendency'—indeed intensity—charges stillness with a potential for movement, actualisation and change. Conventions that invite still forms of participation in an interactive museum are an opportunity to express one’s agency, as one cannot feel the full momentum of tendency if not having at first remained still. At one level, the process of waiting for a work to begin or end generates a potential for movement, as visitors must decide when they will move towards another work. However, the potential for agency is also articulated within a less performative, ‘internal’ shift that arises within stillness, when visitors eschew reflexive forms of interaction to maintain a focused state of attention.2. Focusing Attention in StillnessVisitors’ interaction with Simon Carrol and Martin Friedel's History of a Day (2004) demonstrated how such a focused attention arises. This work comprises five screens arranged in a pentagonal shape. Visitors engage with this work whilst moving or still, seating themselves on an ottoman set within the pentagon or viewing the work while walking around its outside perimeter. The work came to mediate a number of different types of still and playful encounters, as described by Sean:I was aware that there was other stuff going on around the gallery … could see that out the corner of your eye because there’s spaces in-between screens, but at the same time I wasn’t hurried … And Luke who was with me, he sat down and watched one particular screen, whereas I sort of moved around. When I got to the edge I could see two or three screens at once, so I was just trying to work out what the story was. On one hand, the ‘gaps’ between these screens could fragment visitors’ attention and mediate reflexive forms of perception. Sean described how he “moved around”, as he was drawn to these ‘gaps’ as he exchanged peripheries and centres of focus. However, the close arrangement of the five screens also created a veiled, intimate space that confined visitors’ attention within the spatial parameters of the work. Unlike Sean, Luke remained seated. His experience was conditioned by stillness. He sat observing a single screen and maintained a focused state of attention. By focusing their attention in this way, visitors become more receptive towards the affective experience of viewing art. For example, History of a Day flutters with time-lapse images, a soothing rhythm of night turning to day and to night again. On one hand, each screen has been allocated its own narrative, a temporal illustration of a day’s passing within natural and human-made landscapes. A fairground, for example, was shot at night and showed crowds arriving, swarming, alighting rides and departing. However, it is possible to yield to the projection’s visual and aural rhythm, and in doing so abstract the figurative signifier of each scene. Narrative logic recedes as the senses become flooded, and in turn slows the pace of reflexive perception. Without the imposition of a linear narrative the work’s images begin to unfold with a new slowness. The main ride comes to resemble the slowly beating wings of a moth in lamplight, arms lifting, rotating and dropping in the fairground floodlights. People, rides and the dark sky blend into a meditation on colour, rhythm and sound, a palette comprising the many moments that emerge and pass at a night carnival.This form of perception elicits an agency of complex, affective awareness. Sound artist Brian Eno’s account of the role of silence in ambient music provides a close analogy as to how experiences of stillness in the Screen Gallery become dynamic with enhanced affective awareness. He describes how silences—a ‘stillness’ in sound—actually draw attention to the aural experience that preceded it, as the “‘rests’ are invariably filled in by ‘echoes’ of previously heard fragments” (in Tamm 134). In other words, the experience of listening is heightened by silences, for they create a space of reflection that resonates with the impressions of sound passed. The Gallery is an ambient chamber that echoes with affective forms of experiential encounter rather than echoes of sound. The echoes of visitors’ encounters are also intensified by stillness. Stillness focuses attention, so visitors garner an affective awareness of their spatial environment. This awareness constitutes a distinctive form of agency within the museum, for it enables visitors to locate what Henri Lefebvre describes as a ‘rhythmic’ congruence between their subjective experience and conditions of external environment.3. Awareness of Rhythmic CongruenceIn his theory of rhythmnanalysis, Henri Lefebvre (16) describes how an awareness of ‘rhythmic’ congruity and incongruity can be used to inform a politics in daily life. He argues that practices of self-observation and spatial awareness can reveal how our internal and environmental rhythms are a part of a rhythmic landscape, and can be used as a political means for change. Lefebvre (20) delineates between ‘eurhythmia’ and ‘arrhythmia’ as the forms of rhythmic logic that describe states of congruity:What is certain is that harmony sometimes (often) exists: eurhythmia. The eu-rhythmic body, composed of diverse rhythms – each organ, each function, having its own – keeps them in a metastable equilibrium, which is always understood and often recovered, with the exception of disturbances (arrhythmia) that sooner of later becomes illness (the pathological state). But the surroundings of bodies, be they in nature or a social setting, are also bundles, bouquets, garlands of rhythms, to which it is necessary to listen in order to grasp the natural or produced ensembles. While Lefebvre uses these definitions to develop a Marxist critique of modernity, they also show how within the flexible temporal boundaries of stillness, visitors can express a form of agency by using their heightened affective awareness to locate eurhythmic and arrhythmic experiences. By becoming aware of the way we are conditioned by rhythms, we can begin to imprint new rhythms upon the patterns that govern cultural and social practices. Within the Screen Gallery, this rhythmic observation manifests as an attentiveness towards the temporal relationship between internal sensation and external environment.Congruence between internal and external rhythms was often described by visitors as a feeling of relaxation, even meditation. For example, Sean drew comparisons between still encounters with time-based art and his impression of quiet environments: “It’s like having background music while you’re falling asleep, or you turn the radio on so you haven’t caught the start of a song but you catch the end of it”. These associations imply a close environmental relationship between sound and body, where the rich aesthetic presence of art overrides the expectation of narrative continuity. Perhaps most telling is Sean’s analogy of falling asleep to background music, as it suggests that time-based art can maintain an ambient presence while not intruding upon natural bodily ‘rhythms’. It seems that a harmony between body and art environment allows a pull towards a state of relaxation akin to the drift of sleep, which, notably, is a point where both internal and external rhythms synchronise. Falling asleep is a crossing of thresholds into a space dominated by the activities of the unconscious. Occupying the Gallery and surrendering to a state of relaxation can therefore also be understood as crossing a threshold into a deeper, more internal realm of interaction with art.Affective awareness therefore enables visitors to cultivate a greater sensitivity towards their sensory responses. This is a highly-subjective agency, as it arises when visitors develop a keen awareness of the eurrhythmic alignment between the rhythm of external space, and their own, internal rhythm. Stillness therefore draws attention to the complexity of our own subjective experience, and the different ways we are conditioned by our environments. Yet most importantly, these experiences also generated self-reflection and a desire to creatively transform their circumstances. Matthew described how his encounter with art aroused creative inspiration: “I go there to experience something new. I would love to be able to do something like that… Maybe it’s something for me, where I wish I was doing something else in terms of my occupation.” Paul noted how expressive potential could be expanded by considering oneself an artist: “you can do it yourself as well, and I suppose that’s what draws people in to the whole thing”. Katrina suggested that aesthetic forms of interaction can challenge the conventional ways of thinking about and responding to our environment: “if it gets somebody to do something different, or, gets someone to do something in a different way maybe, expand their minds in that way, maybe that’s a use for it as well … give them something to think about, and they can see it again in a different light”. These comments show how stillness can enable a realisation of one’s own subjective, creative potential by countering the reflexive speed of the everyday.ConclusionMy study of ACMI’s Screen Gallery has shown how agency finds expression in stillness. The temporal elasticity created by artwork and institution allows visitors to appropriate time and space in a way that slows the pace of movement and focuses attention, in turn enhancing a visitor’s awareness of their presence and spatial environment. Stillness therefore heightens visitors’ awareness of sensation, sentience, the body’s occupation of time and space. This form of encounter elicits a feeling of congruence and awakens the spirit. This transformation was the mainstay of the political project set by Lefebvre, a statement on mobilising individuals to affect change by becoming more attentive towards incongruities between self and environment. In the Gallery it became possible, through immersion in an aesthetic, ambient space, for visitors to cultivate an intuition towards their own rhythms and those of surrounding environments. An important claim is to be staked on creating spaces for stillness in daily life, as opportunities for stillness are becoming increasingly scarce within the dynamics of spatial and temporal compression that characterise this era of globalisation and informationalisation. As Heidi describes, these moments given to daydreaming and reflection can become powerful conduits for realising one’s own potential:[It] gives you a new lease on life. And all the dreams you have – it’s possible … Sometimes you think ‘it’s all a bit out of reach, it’s too difficult,’ whereas you go and see something like that, and … it makes everything clear. And makes everything possible.ReferencesBeck, Ulrich, Anthony Giddens, and Scott Lash. Reflexive Modernization: Politics, Tradition and Aesthetics in the Modern Social Order. Cambridge, UK: Polity Press, 1994.Benjamin, Walter. “The Work of Art in the Age of Mechanical Reproduction.” Illuminations. Ed. Hannah Arendt. Great Britain: Fontana/Collins, 1977. 219-253.Bennett, Tony. “Museums and 'the People'.” The Museum Time-Machine: Putting Cultures on Display. London: Routledge, 1988. 63-85.———. “Putting Policy into Cultural Studies.” Cultural Studies. London: Routledge. 1992, 23-37.———. The Birth of the Museum: History, Theory, Politics. London: Routledge, 1995.———. “Consuming Culture, Measuring Access and Audience Development”. Culture and Policy 8.1 (1997): 89-113.———. “Culture and Policy” Culture:a Reformer's Science, St. Leonard's, NSW: Allen & Unwin, 1998. 189-213.———. “Culture and Governmentality.” In J.Z. Bratich, J. Packer & C. McCarthy, eds. Foucault, Cultural Studies and Governmentality. Albany: State U of New York P, 2003. 47-64.Bourdieu, Pierre. “The Economy of Practices.” Distinction: A Social Critique of the Judgement of Taste. Trans. Richard Nice. Cambridge: Harvard U P, 1984. 97-256.———. The Love of Art, Stanford: Stanford U P, 1991.Falk, John. “Museum Recollections.” Visitor Studies - 1988: Theory, Research and Practice. Jacksonville: Center for Social Design, 1988. 60-65.Falk, John, and Lynn Dierking. The Museum Experience. Washington, D.C.: Whalebooks, 1992.Hicks, Megan. "'A Whole New World': The Young Person's Experience of Visiting the Sydney Technological Museum." Museum and Society 3.2 (2005): 66-80. Hooper-Greenhill, Eilean. Museum and Gallery Education. London: Leicester U P, 1991.Lefebvre, Henri. “The Critique of the Thing.” Rhythmnanalysis: Space Time and Everyday Life. London: Continuum, 2004. 5-18.———. “The Rhythmanalyst: A Previsionary Project.” Rhythmanalysis: Space Time and Everyday Life. London: Continuum, 2004. 19-26.Luhmann, Niklas. Art as a Social System, Trans. Eva Knodt. Stanford: U of Stanford P, 2000.Massumi, Brian. “Building Experience: The Architecture of Perception.” NOX: Machining Architecture. London: Thames and Hudson, 2004. 322-331.Silverman, Lois. “Visitor Meaning Making in Museums for a New Age.” Curator 38 (1995): 161-170.Tamm, Eric. “The Ambient Sound.” Brian Eno: His Music and the Vertical Color of Sound. Boston: Faber and Faber, 1989. 131-150.

For more than 20 years, Dr. Florence Bourgeois, MD, MPH has held multiple positions at the intersection of pediatrics, therapeutics, regulatory science, health informatics and research integrity. A graduate of Yale University, Harvard School of Public Health and Washington University School of Medicine in St. Louis, Dr. Bourgeois’ record transcends academia and medicine. In addition to being a faculty member at Harvard Medical School and the Division of Emergency Medicine and the Computational Health Informatics Program (CHIP) at Boston Children’s Hospital, she is the Director of PedRx, which aims to advance the development and evidence-based use of novel therapeutics for children globally. As the Scientific Director of the Boston Children’s Hospital Biobank, Dr. Bourgeois’ efforts focus on expanding physicians’ capacity to conduct research in pediatric populations. As the Co-Director of the Harvard-MIT Center for Regulatory Science, Dr. Bourgeois also spearheads cross-disciplinary collaborations between academia, biotechnology and pharmaceutical companies, and regulatory agencies. She is the recipient of an Innovation in Regulatory Science Award from the Burroughs Wellcome Fund and has served as an Expert Visitor to the European Medicines Agency to analyze the EU’s pediatric drug legislation. As part of this interview, we examine the relationship between clinical trials and drug development in pediatrics as well as their ethical and social impacts.

Objective The aim of this study was to evaluate the initial impact of the COVID-19 pandemic on individuals with systemic lupus erythematosus (SLE). Methods Patients with SLE participating in a multi-center longitudinal cohort study in New York and Boston were invited to complete a supplemental web-based questionnaire in the summer of 2020. Participants completed standardized patient-reported outcome (PRO) measures and a combination of Likert scale and open-ended questions exploring the impact of the COVID-19 pandemic on their health and access to health care. Changes in PROs were evaluated with paired t-tests and frequencies of worsened symptoms were calculated. A thematic qualitative analysis was conducted on free text responses. Results Of 97 patients invited, 63 (65%) completed a supplemental questionnaire. Nearly 50% of respondents exhibited increases in anxiety (47.5%) and depression (48.3%) and over 40% scored worse in measures of pain interference, fatigue, and cognitive abilities. Respondents with pre-existing diagnoses of anxiety did not differ from other participants in PRO scores, but were more than three times as likely to report worsened health status. Patients denied difficulties accessing medications (85%) or medical care (84%) and over 50% participated in telehealth visits. Anxiety and increased health risks due to immunosuppression were recurring themes in free text responses. Conclusions SLE patients experienced a significant physical and emotional toll in the initial months of the COVID-19 pandemic. Comprehensive patient-centered care, including monitoring and addressing anxiety and health-related quality of life, is critical to improving health outcomes in this population during the ongoing health crisis.

Abstract Background We describe addiction consult services (ACS) adaptations implemented during the Novel Coronavirus Disease 2019 (COVID-19) pandemic across four different North American sites: St. Paul’s Hospital in Vancouver, British Columbia; Oregon Health & Sciences University in Portland, Oregon; Boston Medical Center in Boston, Massachusetts; and Yale New Haven Hospital in New Haven, Connecticut. Experiences ACS made system, treatment, harm reduction, and discharge planning adaptations. System changes included patient visits shifting to primarily telephone-based consultations and ACS leading regional COVID-19 emergency response efforts such as substance use treatment care coordination for people experiencing homelessness in COVID-19 isolation units and regional substance use treatment initiatives. Treatment adaptations included providing longer buprenorphine bridge prescriptions at discharge with telemedicine follow-up appointments and completing benzodiazepine tapers or benzodiazepine alternatives for people with alcohol use disorder who could safely detoxify in outpatient settings. We believe that regulatory changes to buprenorphine, and in Vancouver other medications for opioid use disorder, helped increase engagement for hospitalized patients, as many of the barriers preventing them from accessing care on an ongoing basis were reduced. COVID-19 specific harm reductions recommendations were adopted and disseminated to inpatients. Discharge planning changes included peer mentors and social workers increasing hospital in-reach and discharge outreach for high-risk patients, in some cases providing prepaid cell phones for patients without phones. Recommendations for the future We believe that ACS were essential to hospitals’ readiness to support patients that have been systematically marginilized during the pandemic. We suggest that hospitals invest in telehealth infrastructure within the hospital, and consider cellphone donations for people without cellphones, to help maintain access to care for vulnerable patients. In addition, we recommend hospital systems evaluate the impact of such interventions. As the economic strain on the healthcare system from COVID-19 threatens the very existence of ACS, overdose deaths continue rising across North America, highlighting the essential nature of these services. We believe it is imperative that health care systems continue investing in hospital-based ACS during public health crises.

Abstract Background Depression is strongly associated with chronic disease; yet, the direction of this relationship is poorly understood. Allostatic load (AL) provides a framework for elucidating depression-disease pathways. We aimed to investigate bidirectional, longitudinal associations of baseline depressive symptoms or AL with 5-year AL or depressive symptoms, respectively. Methods Data were from baseline, 2-year, and 5-year visits of 620 adults (45–75 years) enrolled in the Boston Puerto Rican Health Study. The Center for Epidemiology Studies Depression (CES-D) scale (0–60) captured depressive symptoms, which were categorized at baseline as low (<8), subthreshold (8–15), or depression-likely (⩾16) symptoms. AL was calculated from 11 parameters of biological functioning, representing five physiological systems. Baseline AL scores were categorized by the number of dysregulated parameters: low (0–2), moderate (3–5), or high (⩾6) AL. Multivariable, multilevel random intercept and slope linear regression models were used to examine associations between 3-category baseline CES-D score and 5-year continuous AL score, and between baseline 3-category AL and 5-year continuous CES-D score. Results Baseline subthreshold depressive symptoms [(mean (95% CI)): 4.8 (4.5–5.2)], but not depression-likely symptoms [4.5 (4.2–4.9)], was significantly associated with higher 5-year AL scores, compared to low depressive symptoms [4.3 (3.9–4.7)]. Baseline high AL [19.4 (17.6–21.2)], but not low AL [18.5 (16.5–20.6)], was significantly associated with higher 5-year CES-D score, compared to baseline moderate AL [16.9 (15.3–18.5)]. Conclusions Depressive symptoms and AL had a bi-directional relationship over time, indicating a nuanced pathway linking depression with chronic diseases among a minority population.

Abstract Background There is an increasing prevalence of physical inactivity during childhood, which is associated with a variety of health problems. However, the mechanisms by which acute exercise benefits cognition in childhood remains unknown. Here we describe the protocol for a randomized crossover trial called SNEACY (Sympathetic Nervous System & Exercise Affects Cognition in Youth), a study designed to better understand mechanisms linking acute exercise and cognition in 9–10-year-old healthy, cognitively normal children. Methods Children from the Greater Boston, MA region will be recruited to participate in this single center study. A randomized crossover design will be utilized, such that participants will act as their own controls, through initial randomization to condition assignment and condition counterbalancing across participants. One hundred three children will participate in three randomized acute interventions: moderate intensity treadmill exercise (20 min, 70–75% of their maximal heart rate), seated rest (20 min), and a Trier Social Stress Test for Children (14 min). These visits will occur on 3 three separate days, approximately 5–8 days apart. Before and after each intervention, children complete a variety of cognitive tasks measuring attentional inhibition while their neuroelectric activity is recorded. Variables of interest include EEG data, accuracy and reaction time, academic achievement, and salivary alpha amylase. Academic achievement is also assessed following interventions. In addition, children provide passive drool samples throughout the interventions to measure various biomarkers that may explain the acute exercise benefit on cognition. Discussion The results from this study could influence educational and public health recommendations to enhance cognition and learning in pre-adolescent children. Trial registration ClinicalTrials.gov NCT03592238. Registered on 19 July 2018

Objective This study aimed to describe maternal characteristics and clinical outcomes of infants born to mothers with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests during pregnancy at an urban, safety-net hospital in Boston. Study Design We abstracted electronic chart data from 75 pregnant women with positive SARS-CoV-2 tests at any stage of gestation until 72 hours after birth who delivered consecutively between March 31 and August 6, 2020 at our center. We collected clinical data on maternal and infant characteristics, including testing, signs, and symptoms of coronavirus disease 2019 (COVID-19), delivery outcomes, newborn care practices (skin-to-skin care, location of care, and breastfeeding) and 30-day postdischarge infant emergency room visits and readmissions. We described categorical characteristics as percentages for this case series. Results Among 75 pregnant women, 47 (63%) were Hispanic, 10 (13%) had hypertension, 23 (30%) had prepregnancy obesity, and 57 (76%) had symptomatic SARS-CoV-2 infection. Regarding birth outcomes, 32 (41%) had cesarean delivery and 14 (19%) had preterm birth. Among 75 infants, 5 (7%) had positive SARS-CoV-2 polymerase chain reaction tests in the first week of life, all of whom were born to Hispanic mothers with symptomatic SARS-CoV-2 infection and had clinical courses consistent with gestational age. Six (8%) infants visited the emergency department within 30 days of discharge; one was admitted with a non-COVID-19 diagnosis. Conclusion At our urban, safety-net hospital among pregnant women with positive SARS-CoV-2 tests, 41% had a cesarean delivery and 19% had a preterm birth. Seven percent of infants had one or more positive SARS-CoV-2 tests and all infants had clinical courses expected for gestational age. Key Points

Introduction: Postpartum hypertension can be persistent, following a pregnancy complicated by hypertension, or new onset ( de novo ), following a normotensive pregnancy. The postpartum period is traditionally defined as six weeks after delivery, yet accruing evidence shows that hypertension underlies the majority of severe maternal morbidity events through a year postpartum. While guidelines for enhanced monitoring of women at risk of persistent postpartum hypertension exist, less is known about risk factors for de novo postpartum hypertension. The aim of this study is to estimate the incidence of and identify risk factors for de novo postpartum hypertension among a diverse safety-net hospital population through the entire year postpartum. Hypothesis: We assessed the hypothesis that women with de novo postpartum hypertension share similar demographic and reproductive characteristics to women at increased risk of cardiovascular related maternal morbidity. Methods: We conducted a cohort study of 8,531 deliveries at Boston Medical Center from 2016-2018. Data on demographics, reproductive history, and labor and delivery were obtained from medical records. All documented blood pressure measures from pregnancy through 12 months postpartum were extracted. Women with chronic hypertension or hypertensive disorders of pregnancy were excluded. De novo postpartum hypertension was defined as two separate blood pressure readings with systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥90 mmHg at least 48 hours after delivery. Severe de novo hypertension was defined using criteria of SBP ≥160 and/or DPB ≥110. We examined the distribution of demographic and pregnancy characteristics among women with and without de novo postpartum hypertension. Secondary analyses restricting to women with healthcare visits after six weeks postpartum were also conducted. Results: Among the 6,631 women without a history of hypertension, 10% (n=660) developed de novo postpartum hypertension; a third of whom had severe hypertension (n=225). Compared to women without de novo hypertension; cases were more likely to be non-Hispanic Black; delivered via cesearean section; have had a preterm delivery; and be multiparous. In analyses restricted to women with visits extending past six weeks postpartum (n=3,272), the incidence of de novo postpartum hypertension was 16.6%. Approximately 30% of these cases were diagnosed after the traditionally used six week period. Conclusion: In conclusion, 1 in 10 women with normotensive pregnancies experience de novo hypertension in the year after delivery, with a third of these cases developing after six weeks. Opportunities to monitor and manage women at the highest risk of de novo hypertension throughout the entire year postpartum could mitigate cardiovascular related maternal morbidity.

ObjectiveIn this panel, attendees will learn about how disaster surveillance was conducted in response to Hurricanes Irma and Harvey, as well as the role of CDC at the federal level in supporting local response efforts. By hearing and discussing the challenges faced and solutions identified, attendees will be better able to respond in the event of a low-frequency/high-consequence disaster occurring within their jurisdiction.IntroductionIn this panel, the presenters will discuss their perspective in responding to Hurricanes Harvey and Irma. Hurricane Harvey made landfall on August 25th and over the course of 4 days dropped approximately 27 trillion gallons of water on Texas and Louisiana.1 The flooding that ensued was unprecedented and forced over 13,000 people into shelters.2 These individuals needed to have their basic needs -food, shelter, clothing, sanitation- met as well as their physical and mental health needs. The George R Brown Conference Center (GRB) and NRG Stadium Center were set up as mega-shelters to house shelterees. Hurricane Irma made landfall on September 10th in the Florida Keys as a Category 4 Hurricane. The Hurricane caused 72 deaths3 and forced thousands of people into shelters.4 These weather events created novel challenges for local response efforts. Decision makers needed timely and actionable data, including surveillance data.DescriptionAt the federal level, Aaron Kite-Powell will discuss his experiences in supporting local efforts to acquire timely and actionable data collected by on-site federally deployed disaster medical assistance teams (DMAT). DMAT provided clinical services to residents who were staying in a mega-shelter. Data collected from DMAT was electronically sent to CDC through the National Syndromic Surveillance Program (NSSP) where it could be accessed in CDC's instance of ESSENCE. Additionally, in Houston, 3 area hospitals submitted their data to NSSP. The City of Houston Health Department (HHD) was given access to DMAT and hospital syndromic data through ESSENCE. Once access was established, just in time training was conducted for HHD.David Atrubin will discuss how Florida’s syndromic surveillance system was utilized during Hurricane Irma in September 2017. ESSENCE-FL provided critical near real-time surveillance data before, during, and after the storm. Multiple data sources, within the ESSENCE-FL, were utilized including emergency department, poison control, death record, and DMAT data. In addition to the anticipated increases in animal bites, injuries, medication refills, dialysis visits, and carbon monoxide exposures, some unexpected increases were observed as well.Eric Bakota will describe his experience in coordinating the remote shelter surveillance team for the City of Houston Health Department. In the immediate aftermath of the flooding, several organizations opened shelters for people who were forced to leave their homes. Many of these facilities were not officially connected to the City. An ad hoc process was used to identify and connect with these facilities. Once identified as a shelter, a team of 6 epidemiologists conducted daily check-ins to determine the census and status of shelterees. Several tools to coordinate activities and record the data collected were used, including Dropbox, Googlesheets, and MAVEN. Each tool had its own strengths and limitations that will be discussed.How the Moderator Intends to Engage the Audience in Discussions on the TopicThe moderator should engage the panelists by asking questions the following questions:● How did each panelist work with their Federal/State/Local partners● How did each panelist integrate into the larger response framework (e.g., ICS)● How did each panelist use technology to address any novel surveillance barriers during the disasterReferences1. Sanchez R, Yan H, Simon D. Harvey aftermath: Houston 'open for business'; other cities suffering. CNN. 2017 Sep 1.2. Sullivan K, Hernandez A, Fahrenthold D. Harvey leaving record rainfall, at least 22 deaths behind in Houston. Chicago Tribune. 2017 Aug 29.3. Impact of Hurricane Irma. Boston Globe. Accessed 2017 Oct 10. https://www.bostonglobe.com/news/bigpicture/2017/09/11/impact-hurricane-irma/W6WBN9K2lXd4gPmtu26auN/story.html4. Smith A. After Hurricane Irma, Many Ask: How Safe Are Shelters? Tampa Bay Times. 2017 September 21.

We (I, Robert Lawrence and, in a rare display of unity, all my online avatars and agents)hereby render and proclaim thisMANIFESTO OF PIECES AND BITS IN SERVICE OF CONTRADICTIONAL AESTHETICSWe start with the simple premise that art has the job of telling us who we are, and that through the modern age doing this job while KEEPING UP with accelerating cultural change has necessitated the invention of something we might call the avant-garde. Along the way there has been an on-again-off-again affair between said avant-garde and technology. We are now in a new phase of the new and the technology under consideration is the Internet.The recent hyperventilating about the term postInternet reflects the artworld’s overdue recognition of the effect of the Internet on the culture at large, and on art as a cultural practice, a market, and a historical process.I propose that we cannot fully understand what the Internet is doing to us through a consideration of what happens on the screen, nor by considering what happens in the physical space we occupy either before or behind the screen. Rather we must critically and creatively fathom the flow of cultural practice between and across these realms. This requires Hybrid art combining both physical and Internet forms.I do not mean to imply that single discipline-based art cannot communicate complexity, but I believe that Internet culture introduces complexities that can only be approached through hybrid practices. And this is especially critical for an art that, in doing the job of “telling us who we are”, wants to address the contradictory ways we now form and promote, or conceal and revise, our multiple identities through online social media profiles inconsistent with our fleshly selves.We need a different way of talking about identity. A history of identity:In the ancient world, individual identity as we understand it did not exist.The renaissance invented the individual.Modernism prioritized and alienated him (sic).Post-Modernism fragmented him/her.The Internet hyper-circulates and amplifies all these modalities, exploding the possibilities of identity.While reducing us to demographic market targets, the Web facilitates mass indulgence in perversely individual interests. The now common act of creating an “online profile” is a regular reiteration of the simple fact that identity is an open-ended hypothesis. We can now live double, or extravagantly multiple, virtual lives. The “me meme” is a ceaseless morph. This is a profound change in how identity was understood just a decade ago. Other historical transformations of identity happened over centuries. This latest and most radical change has occurred in the click of a mouse. Selfhood is now imbued with new complexity, fluidity and amplified contradictions.To fully understand what is actually happening to us, we need an art that engages the variant contracts of the physical and the virtual. We need a Hybrid art that addresses variant temporal and spatial modes of the physical and virtual. We need an art that offers articulations through the ubiquitous web in concert with the distinct perspectives that a physical gallery experience uniquely offers: engagement and removal, reflection and transference. Art that tells us who we are today calls for an aesthetics of contradiction. — Ro Lawrence (and all avatars) 2011, revised 2013, 2015, 2018. The manifesto above grew from an artistic practice beginning in 1998 as I started producing a website for every project that I made in traditional media. The Internet work does not just document or promote the project, nor is it “Netart” in the common sense of creative work restricted to a browser window. All of my efforts with the Internet are directly linked to my projects in traditional media and the web components offer parallel aesthetic voices that augment or overtly contradict the reading suggested by the traditional visual components of each project.This hybrid work grew out of a previous decade of transmedia work in video installation and sculpture, where I would create physical contexts for silent video as a way to remove the video image from the seamless flow of broadcast culture. A video image can signify very differently in a physical context that separates it from the flow of mass media and rather reconnects it to lived physical culture. A significant part of the aesthetic pleasure of this kind of work comes from nuances of dissonance arising from contradictory ways viewers had learned to read the object world and the ways we were then still learning to read the electronic image world. This video installation work was about “relocating” the electronic image, but I was also “locating” the electronic image in another sense, within the boundaries of geographic and cultural location. Linking all my projects to specific geographic locations set up contrasts with the spatial ubiquity of electronic media. In 1998 I amplified this contrast with my addition of extensive Internet components with each installation I made.The Way Things Grow (1998) began as an installation of sculptures combining video with segments of birch trees. Each piece in the gallery was linked to a specific geographic location within driving distance of the gallery exhibiting the work. In the years just before this piece I had moved from a practice of text-augmented video installations to the point where I had reduced the text to small printed handouts that featured absurd Scripts for Performance. These text handouts that viewers could take with them suggested that the work was to be completed by the viewer later outside the gallery. This to-be-continued dynamic was the genesis of a serial form in work going forward from then on. Thematic and narrative elements in the work were serialized via possible actions viewers would perform after leaving the gallery. In the installation for The Way Things Grow, there was no text in the gallery at all to suggest interpretations of this series of video sculptures. Even the titles offered no direct textual help. Rather than telling the viewers something about the work before them in the gallery, the title of each piece led the viewer away from the gallery toward serial actions in the specific geographic locations the works referred to. Each piece was titled with an Internet address.Figure 1: Lawrence, Robert, The Way Things Grow, video Installation with web components at http://www.h-e-r-e.com/grow.html, 1998.When people went to the web site for each piece they found only a black page referencing a physical horizon with a long line of text that they could scroll to right for meters. Unlike the determinedly embodied work in the gallery, the web components were disembodied texts floating in a black void, but texts about very specific physical locations.Figure 2: Lawrence, Robert, The Way Things Grow, partial view of webpage at http://www.h-e-r-e.com/growth_variant4.html, 1998.The texts began with the exact longitude and latitude of a geographical site in some way related to birch trees. ... A particularly old or large tree... a factory that turned birch trees into popsicle sticks and medical tongue depressors... etc. The website texts included directions to the site, and absurd scripts for performance. In this way the Internet component transformed the suite of sculptures in the gallery to a series of virtual, and possibly actual, events beyond the gallery. These potential narratives that viewers were invited into comprised an open-ended serial structure. The gallery work was formal, minimal, essentialist. On the web it was social, locative, deconstructive. In both locations, it was located. Here follows an excerpt from the website. GROWTH VARIANT #25: North 44:57:58 by West 93:15:56. On the south side of the Hennepin County Government Center is a park with 9 birch trees. These are urban birches, and they display random scratchings, as well as proclamations of affection expressed with pairs of initials and a “+” –both with and without encircling heart symbols. RECOMMENDED PERFORMANCE: Visit these urban birches once each month. Photograph all changes in their bark made by humans. After 20 years compile a document entitled, "Human Mark Making on Urban Birches, a Visual Study of Specific Universalities". Bring it into the Hennepin County Government Center and ask that it be placed in the archives.An Acre of Art (2000) was a collaborative project with sculptor Mark Knierim. Like The Way Things Grow, this new work, commissioned by the Minneapolis Art Institute, played out in the gallery, in a specific geographic location, and online. In the Art Institute was a gallery installation combining sculptures with absurd combinations of physical rural culture fitting contradictorily into an urban "high art" context. One of the pieces, entitled Landscape (2000), was an 18’ chicken coop faced with a gold picture frame. Inside were two bard rock hens and an iMac. The computer was programmed to stream to the Internet live video from the coop, the world’s first video chicken cam. As a work unfolding across a long stretch of time, the web cam video was a serial narrative without determined division into episodes. The gallery works also referenced a specific acre of agricultural land an hour from the Institute. Here we planted a row of dwarf corn at a diagonal to the mid-western American rural geometric grid of farmland. Visitors to the rural site could sit on “rural art furniture,” contemplate the corn growing, and occasionally witness absurd performances. The third stream of the piece was an extensive website, which playfully theorized the rural/urban/art trialectic. Each of the three locations of the work was exploited to provide a richer transmedia interpretation of the project’s themes than any one venue or medium could. Location Sequence is a serial installation begun in 1999. Each installation has completely different physical elements. The only consistent physical element is 72 segments of a 72” collapsible carpenter's ruler evenly spaced to wrap around the gallery walls. Each of the 72 segments of the ruler displays an Internet web address. Reversing the notion of the Internet as a place of rapid change compared to a more enduring physical world, in this case the Internet components do not change with each new episode of the work, while the physical components transform with each new installation. Thematically, all aspects of the work deal with various shades of meaning of the term "location." Beginning/Middle/End is a 30-year conceptual serial begun in 2002, presenting a series of site-specific actions, objects, or interventions combined with corresponding web pages that collectively negotiate concepts related to time, location, and narrative. Realizing a 30-year project via the web in this manner is a self-conscious contradiction of the culture of the instantaneous that the Internet manifests and propagates.The installation documented here was completed for a one-night event in 2002 with Szilage Gallery in St Petersburg, Florida. Bricks moulded with the URLs for three web sites were placed in a historic brick road with the intention that they would remain there through a historical time frame. The URLs were also projected in light on a creek parallel to the brick road and seen only for several hours. The corresponding web site components speculate on temporal/narrative structures crossing with geographic features, natural and manufactured.Figure 3: Lawrence, Robert, Beginning/Middle/End, site-specific installation with website in conjunction with 30-year series, http://www.h-e-r-e.com/beginning.html, 2002-32.The most recent instalment was done as part of Conflux Festival in 2014 in collaboration with painter Ld Lawrence. White shapes appeared in various public spaces in downtown Manhattan. Upon closer inspection people realized that they were not painted tags or stickers, but magnetic sheets that could be moved or removed. An optical scan tag hidden on the back of each shape directed to a website which encouraged people to move the objects to other locations and send a geo-located photo to the web site to trace the shape's motion through the world. The work online could trace the serial narrative of the physical installation components following the installation during Conflux Festival. Figure 4: Lawrence, Robert w/Lawrence, Ld, Gravity Ace on the Move, site-specific installation with geo-tracking website at http://www.h-e-r-e.com/gravityace/. Completed for Conflux Festival NYC, 2014, as part of Beginning/Middle/End.Dad's Boots (2003) was a multi-sited sculpture/performance. Three different physical manifestations of the work were installed at the same time in three locations: Shirakawa-go Art Festival in Japan; the Phipps Art Center in Hudson, Wisconsin; and at the Tampa Museum of Art in Florida. Physical components of the work included silent video projection, digital photography, computer key caps, and my father's boots. Each of these three different installations referred back to one web site. Because all these shows were up at the same time, the work was a distributed synchronous serial. In each installation space the title of the work was displayed as an Internet address. At the website was a series of popup texts suggesting performances focused, however absurdly, on reassessing paternal relationships.Figure 5: Lawrence, Robert, Dad’s Boots, simultaneous gallery installation in Florida, Wisconsin and Japan, with website, 2003. Coincidently, beginning the same time as my transmedia physical/Internet art practice, since 1998 I have had a secret other-life as a tango dancer. I came to this practice drawn by the music and the attraction of an after-dark subculture that ran by different rules than the rest of life. While my life as a tanguero was most certainly an escape strategy, I quickly began to see that although tango was different from the rest of the world, it was indeed a part of this world. It had a place and a time and a history. Further, it was a fascinating history about the interplays of power, class, wealth, race, and desire. Figure 6: Lawrence, Robert, Tango Intervention, site-specific dance interventions with extensive web components, 2007-12.As Marta Savigliano points out in Tango and the Political Economy of Passion, “Tango is a practice already ready for struggle. It knows about taking sides, positions, risks. It has the experience of domination/resistance from within. …Tango is a language of decolonization. So pick and choose. Improvise... let your feet do the thinking. Be comfortable in your restlessness. Tango” (17). The realization that tango, my sensual escape from critical thought, was actually political came just about the time I was beginning to understand the essential dynamic of contradiction between the physical and Internet streams of my work. Tango Intervention began in 2007. I have now, as of 2018, done tango interventions in over 40 cities. Overall, the project can be seen as a serial performance of contradictions. In each case the physical dance interventions are manifestations of sensual fantasy in public space, and the Internet components recontextualize the public actions as site-specific performances with a political edge, revealing a hidden history or current social situation related to the political economy of tango. These themes are further developed in a series of related digital prints and videos shown here in various formats and contexts.In Tango Panopticon (2009), a “spin off” from the Tango Intervention series, the hidden social issue was the growing video surveillance of public space. The first Tango Panopticon production was Mayday 2009 with people dancing tango under public video surveillance in 15 cities. Mayday 2010 was Tango Panopticon 2.0, with tangointervention.org streaming live cell phone video from 16 simultaneous dance interventions on 4 continents. The public encountered the interventions as a sensual reclaiming of public space. Contradictorily, on the web Tango Panopticon 2.0 became a distributed worldwide action against the growing spectre of video surveillance and the increasing control of public commons. Each intervention team was automatically located on an online map when they started streaming video. Visitors to the website could choose an action from the list of cities or click on the map pins to choose which live video to load into the grid of 6 streaming signals. Visitors to the physical intervention sites could download our free open source software and stream their own videos to tangointervention.org.Figure 7: Lawrence, Robert, Tango Panopticon 2.0, worldwide synchronous dance intervention with live streaming video and extensive web components, 2010.Tango Panopticon also has a life as a serial installation, initially installed as part of the annual conference of “Digital Resources for Humanities and the Arts” at Brunel University, London. All shots in the grid of videos are swish pans from close-ups of surveillance cameras to tango interveners dancing under their gaze. Each ongoing installation in the series physically adapts to the site, and with each installation more lines of video frames are added until the images become too small to read.Figure 8: Lawrence, Robert, Tango Panopticon 2.0 (For Osvaldo), video installation based on worldwide dance intervention series with live streaming video, 2011.My new work Equivalence (in development) is quite didactic in its contradictions between the online and gallery components. A series of square prints of clouds in a gallery are titled with web addresses that open with other cloud images and then fade into randomly loading excerpts from the CIA torture manual used at Guantanamo Bay Detention Center.Figure 9: Lawrence, Robert, Eauivalence, digital prints, excerpts from CIA Guantanamo Detention Center torture manual, work-in-progress.The gallery images recall Stieglitz’s Equivalents photographs from the early 20th century. Made in the 1920s to 30s, the Equivalents comprise a pivotal change in photographic history, from the early pictorial movement in which photography tried to imitate painting, and a new artistic approach that embraced features distinct to the photographic medium. Stieglitz’s Equivalents merged photographic realism with abstraction and symbolist undertones of transcendent spirituality. Many of the 20th century masters of photography, from Ansel Adams to Minor White, acknowledged the profound influence these photographs had on them. Several images from the Equivalents series were the first photographic art to be acquired by a major art museum in the US, the Boston Museum of Fine Arts.My series Equivalence serves as the latest episode in a serial art history narrative. Since the “Pictures Generation” movement in the 1970s, photography has cannibalized its history, but perhaps no photographic body of work has been as quoted as Stieglitz’s Equivalents. A partial list includes: John Baldessari’s series Blowing Cigar Smoke to Match Clouds That Are the Same(1973), William Eggleston’s series Wedgwood Blue (1979), John Pfahl’s smoke stack series (1982-89), George Legrady’s Equivalents II(1993), Vik Muniz’sEquivalents(1997), Lisa Oppenheim (2012), and most recently, Berndnaut Smilde’s Nimbus Series, begun in 2012. Over the course of more than four decades each of these series has presented a unique vision, but all rest on Stieglitz’s shoulders. From that position they make choices about how to operate relative the original Equivalents, ranging from Baldessari and Muniz’s phenomenological playfulness to Eggleston and Smilde’s neo-essentialist approach.My series Equivalence follows along in this serial modernist image franchise. What distinguishes it is that it does not take a single position relative to other Equivalents tribute works. Rather, it exploits its gallery/Internet transmediality to simultaneously assume two contradictory positions. The dissonance of this positioning is one of my main points with the work, and it is in some ways resonant with the contradictions concerning photographic abstraction and representation that Stieglitz engaged in the original Equivalents series almost a century ago.While hanging on the walls of a gallery, Equivalence suggests the same metaphysical intentions as Stieglitz’s Equivalents. Simultaneously, in its manifestation on the Internet, my Equivalence series transcends its implied transcendence and claims a very specific time and place –a small brutal encampment on the island of Cuba where the United States abandoned any remaining claim to moral authority. In this illegal prison, forgotten lives drag on invisibly, outside of time, like untold serial narratives without resolution and without justice.Partially to balance the political insistence of Equivalence, I am also working on another series that operates with very different modalities. Following up on the live streaming technology that I developed for my Tango Panopticon public intervention series, I have started Horizon (In Development).Figure 10: Lawrence, Robert, Horizon, worldwide synchronous horizon interventions with live streaming video to Internet, work-in-progress.In Horizon I again use live cell phone video, this time streamed to an infinitely wide web page from live actions around the world done in direct engagement with the horizon line. The performances will begin and automatically come online live at noon in their respective time zone, each added to the growing horizontal line of moving images. As the actions complete, the streamed footage will begin endlessly looping. The project will also stream live during the event to galleries, and then HD footage from the events will be edited and incorporated into video installations. Leading up to this major event day, I will have a series of smaller instalments of the piece, with either live or recorded video. The first of these preliminary versions was completed during the Live Performers Workshop in Rome. Horizon continues to develop, leading to the worldwide synchronous event in 2020.Certainly, artists have always worked in series. However, exploiting the unique temporal dimensions of the Internet, a series of works can develop episodically as a serial work. If that work unfolds with contradictory thematics in its embodied and online forms, it reaches further toward an understanding of the complexities of postInternet culture and identity. ReferencesSaviligliano, Marta. Tango and the Political Economy of Passion. Boulder: Westview Press, 1995.

Image 1: View from Geodha Sgoilt towards the sea stacks, Uig, Isle of Lewis. Image credit: George Jaramillo.IntroductionOver the cliffs of Mangerstadh on the west coast of the Isle of Lewis, is a small plot of land called Geodha Sgoilt that overlooks the North Atlantic Ocean (Image 1). On the site is a small dirt gravel road and the remnants of a World War II listening station. Below, sea stacks rise from the waters, orange and green cliff sides stand in defiance to the crashing waves. An older gentleman began to tell me of what he believed could be located here on the site. A place where visitors could learn of the wonders of St Kilda that contained all types of new storytelling technologies to inspire them. He pointed above the ruined buildings, mentioning that a new road for the visitors’ vehicles and coaches would be built. With his explanations, you could almost imagine such a place on these cliffs. Yet, before that new idea could even be built, this gentleman and his group of locals and incomers had to convince themselves and others that this new heritage centre was something desired, necessary and inevitable in the development of the Western Isles.This article explores the developing relationships that come about through design innovation with community organisations. This was done through a partnership between an academic institution and a non-profit heritage community group as part of growing study in how higher education design research can play an active partner in community group development. It argues for the use of design thinking and innovation in improving strategy and organisational processes within non-profit organisations. In this case, it looks at what role it can play in building and enabling organisational confidence in its mission, as well as, building “beyond the museum”. The new approach to this unique relationship casts new light towards working with complexities and strategies rather than trying to resolve issues from the outset of a project. These enabling relationships are divided into three sections of this paper: First it explores the context of the island community group and “building” heritage, followed by a brief history of St Kilda and its current status, and designation as a World Heritage site. Second, it seeks the value of developing strategy and the introduction of the Institute of Design Innovation (INDI). This is followed by a discussion of the six-month relationship and work that was done that elucidates various methods used and ending with its outcomes. The third section reflects upon the impacts at the relationship building between the two groups with some final thoughts on the partnership, where it can lead, and how this can represent new ways of working together within community groups. Building HeritageCurrent community research in Scotland has shown struggles in understanding issues within community capability and development (Barker 11; Cave 20; Jacuniak-Suda, and Mose 23) though most focus on the land tenure and energy (McMorran 21) and not heritage groups. The need to maintain “resilient” (Steiner 17) communities has shown that economic resilience is of primary importance for these rural communities. Heritage as economic regenerator has had a long history in the United Kingdom. Some of these like the regeneration of Wirksworth in the Peak District (Gordon 20) have had great economic results with populations growing, as well as, development in the arts and design. These changes, though positive, have also adversely impacted the local community by estranging and forcing lower income townspeople to move away due to higher property values and lack of work. Furthermore, current trends in heritage tourism have managed to turn many rural regions into places of historic consumption (Ronström 7) termed “heritagisation” (Edensor 35). There is thus a need for critical reflection within a variety of heritage organisations with the increase in heritage tourism.In particular, existing island heritage organisations face a variety of issues that they focus too much on the artefactual or are too focused to strive for anything beyond the remit of their particular heritage (Jacuniak-Suda, and Mose 33; Ronström 4). Though many factors including funding, space, volunteerism and community capability affect the way these groups function they have commonalities that include organisational methods, volunteer fatigue, and limited interest from community groups. It is within this context that the communities of the Outer Hebrides. Currently, projects within the Highlands and islands focus on particular “grassroots” development (Cave 26; Robertson 994) searching for innovative ways to attract, maintain, and sustain healthy levels of heritage and development—one such group is Ionad Hiort. Ionad Hiort Ionad Hiort is a community non-profit organisation founded in 2010 to assist in the development of a new type of heritage centre in the community of Uig on the Isle of Lewis (“Proposal-Ionad Hiort”). As stated in their website, the group strives to develop a centre on the history and contemporary views of St Kilda, as well as, encouraging a much-needed year-round economic impetus for the region. The development of the group and the idea of a heritage centre came about through the creation of the St Kilda Opera, a £1.5 million, five-country project held in 2007, led by Scotland’s Gaelic Arts agency, Proiseact nan Ealan (Mckenzie). This opera, inspired by the cliffs, people, and history of St Kilda used creative techniques to unite five countries in a live performance with cliff aerobatics and Gaelic singing to present the island narrative. From this initial interest, a commission from the Western Isles council (2010), developed by suggestions and commentary from earlier reports (Jura Report 2009; Rebanks 2009) encouraged a fiercely contentious competition, which saw Ionad Hiort receive the right to develop a remote-access heritage centre about the St Kilda archipelago (Maclean). In 2013, the group received a plot of land from the local laird for the establishment of the centre (Urquhart) thereby bringing it closer to its goal of a heritage centre, but before moving onto this notion of remote-heritage, a brief history is needed on the archipelago. Image 2: Location map of Mangerstadh on the Isle of Lewis and St Kilda to the west, with inset of Scotland. Image credit: © Crown Copyright and Database Right (2017). Ordnance Survey (Digimap Licence).St KildaSt Kilda is an archipelago about 80 kilometres off the coast of the Outer Hebrides in the North Atlantic (Image 2). Over 2000 years of habitation show an entanglement between humans and nature including harsh weather, limited resources, but a tenacity and growth to develop a way of living upon a small section of land in the middle of the Atlantic. St Kilda has maintained a tenuous relationship between the sea, the cliffs and the people who have lived within its territory (Geddes, and Gannon 18). Over a period of three centuries beginning in the eighteenth century an outside influence on the island begin to play a major role, with the loss of a large portion of its small (180) population. This population would later decrease to 100 and finally to 34 in 1930, when it was decided to evacuate the final members of the village in what could best be called a forced eviction.Since the evacuation, the island has maintained an important military presence as a listening station during the Second World War and in its modern form a radar station as part of the Hebridean Artillery (Rocket) Range (Geddes 14). The islands in the last thirty years have seen an increase in tourism with the ownership of the island by the National Trust of Scotland. The UNESCO World Heritage Organisation (UNESCO), who designated St Kilda in 1986 and 2004 as having outstanding universal value, has seen its role evolve from not just protecting (or conserving) world heritage sites, but to strategically understand sustainable tourism of its sites (“St Kilda”). In 2012, UNESCO selected St Kilda as a case study for remote access heritage conservation and interpretation (Hebrides News Today; UNESCO 15). This was partly due to the efforts of 3D laser scanning of the islands by a collaboration between The Glasgow School of Art and Historic Environment Scotland called the Centre for Digital Documentation and Visualisation (CDDV) in 2009.The idea of a remote access heritage is an important aspect as to what Ionad Hiort could do with creating a centre at their site away from St Kilda. Remote access heritage is useful in allowing for sites and monuments to be conserved and monitored “from afar”. It allows for 3D visualisations of sites and provides new creative engagements with a variety of different places (Remondino, and Rizzi 86), however, Ionad Hiort was not yet at a point to even imagine how to use the remote access technology. They first needed a strategy and direction, as after many years of moving towards recognition of proposing the centre at their site in Uig, they had lost a bit of that initial drive. This is where INDI was asked to assist by the Highlands and Islands Enterprise, the regional development organisation for most of rural Scotland. Building ConfidenceINDI is a research institute at The Glasgow School of Art. It is a distributed, creative collective of researchers, lecturers and students specialising in design innovation, where design innovation means enabling creative capabilities within communities, groups and individuals. Together, they address complex issues through new design practices and bespoke community engagement to co-produce “preferable futures” (Henchley 25). Preferable futures are a type of future casting that seeks to strive not just for the probable or possible future of a place or idea, but for the most preferred and collectively reached option for a society (McAra-McWilliam 9). INDI researches the design processes that are needed to co-create contexts in which people can flourish: at work, in organisations and businesses, as well as, in public services and government. The task of innovation as an interactive process is an example of the design process. Innovation is defined as “a co-creation process within social and technological networks in which actors integrate their resources to create mutual value” (Russo‐Spena, and Mele 528). Therefore, innovation works outside of standard consultancy practices; rather it engenders a sense of mutual co-created practices that strive to resolve particular problems. Examples include the work that has looked at creating cultures of innovation within small and medium-sized enterprises (Lockwood 4) where the design process was used to alter organisational support (Image 3). These enterprises tend to emulate larger firms and corporations and though useful in places where economies of scale are present, smaller business need adaptable, resilient and integrated networks of innovation within their organisational models. In this way, innovation functioned as a catalyst for altering the existing organisational methods. These innovations are thus a useful alternative to existing means of approaching problems and building resilience within any organisation. Therefore, these ideas of innovation could be transferred and play a role in enabling new ways of approaching non-profit organisational structures, particularly those within heritage. Image 3: Design Council Double Diamond model of the design process. Image credit: Lockwood.Developing the WorkIonad Hiort with INDI’s assistance has worked together to develop a heritage centre that tries to towards a new definition of heritage and identity through this island centre. Much of this work has been done through local community investigations revolving around workshops and one-on-one talks where narratives and ideas are held in “negative capability” (McAra-McWilliam 2) to seek many alternatives that would be able to work for the community. The initial aims of the partnership were to assist the Uig community realise the potential of the St Kilda Centre. Primarily, it would assist in enabling the capabilities of two themes. The first would be, strategy, for Ionad Hiort’s existing multi-page mission brief. The second would be storytelling the narrative of St Kilda as a complex and entangled, however, its common views are limited to the ‘fall from grace’ or ‘noble savage’ story (Macdonald 168). Over the course of six months, the relationship involved two workshops and three site visits of varying degrees of interaction. An initial gathering had InDI staff meet members of Ionad Hiort to introduce members to each other. Afterwards, INDI ran two workshops over two months in Uig to understand, reflect and challenge Ionad Hiort’s focus on what the group desired. The first workshop focused on the group’s strategy statement. In a relaxed and facilitated space in the Uig Community Hall, the groups used pens, markers, and self-adhesive notes to engage in an open dialogue about the group’s desires. This session included reflecting on what their heritage centre could look like, as well as what their strategy needed to get there. These resulted in a series of drawings of their ‘preferred’ centre, with some ideas showing a centre sitting over the edge of the cliffs or one that had the centre be an integral component of the community. In discussing that session, one of members of the group recalled:I remember his [one of INDI’s staff] interrogation of the project was actually pretty – initially – fairly brutal, right? The first formal session we had talking about strategy and so on. To the extent that I think it would be fair to say he pissed everybody off, right? So much so that he actually prompted us to come back with some fairly hard hitting ripostes, which, after a moment’s silence he then said, ‘That’s it, you’ve convinced me’, and at that point we kind of realised that that’s what he’d been trying to do; he’d been trying to really push us to go further in our articulation of what we were doing and … why we were doing it in this particular way than we had done before. (Participant A, 2016).The group through this session found out that their strategy could be refined into a short mission statement giving a clear focus as to what they wanted and how they wanted to go about doing it. In the end, drawings, charts, stories (Image 4) were drawn to reflect on what the community had discussed. These artefacts became a key role-player in the following months of the development of the group. Image 4: View of group working through their strategy workshop session. Image credit: Fergus Fullarton-Pegg (2014). The second set of workshops and visits involved informal discussion with individual members of the group and community. This included a visit to St Kilda with members from INDI, Ionad Hiort and the Digital Design Studio, which allowed for everyone to understand the immensity of the project and its significance to World Heritage values. The initial aims thus evolved into understanding the context of self-governance for distributed communities and how to develop the infrastructure of development. As discussed earlier, existing development processes are useful, though limited to only particular types of projects, and as exemplified in the Highlands and Islands Enterprise and Western Isles Council commission, it tends to put communities against each other for limited pots of money. This existing system can be innovated upon by becoming creative liaisons, sharing and co-creating from existing studies to help develop more effective processes for the future of Ionad Hiort and their ‘preferable future’. Building RelationshipsWhat the relationship with GSA has done, as a dialogue with the team of people that have been involved, has been to consolidate and clarify our own thinking and to get us to question our own thinking across several different aspects of the whole project. (Participant A, 2016)As the quote states, the main notion of using design thinking has allowed Ionad Hiort to question their thinking and challenge preconceptions of what a “heritage centre” is, by being a critical sounding board that is different from what is provided by consultants and other stakeholders. Prior to meeting INDI, Ionad Hiort may have been able to reach their goal of a strategy, however, it would have taken a few more years. The work, which involved structured and unstructured workshops, meetings, planning events, and gatherings, gave them a structured focus to move ahead with their prospectus planning and bidding. INDI enabled the compression and focus of their strategy making and mission strategy statement over the course of six months into a one-page statement that gave direction to the group and provided the impetus for the development of the prospectus briefs. Furthermore, INDI contributed a sense of contemporary content to the historic story, as well as, enable the community to see that this centre would not just become another gallery with café. The most important outcome has been an effective measure in building relationships in the Outer Hebrides, which shows the changing roles between academic and third sector partnerships. Two key points can be deemed from these developing relationships: The first has been to build a research infrastructure in and across the region that engages with local communities about working with the GSA, including groups in North Uist, Barra and South Uist. Of note is a comment made by one of the participants saying: “It’s exciting now, there’s a buzz about it and getting you [INDI] involved, adding a dimension—we’ve got people who have got an artistic bent here but I think your enthusiasm, your skills, very much complement what we’ve got here.” (Participant B, 2016). Second, the academic/non-profit partnership has encouraged younger people to work and study in the area through a developing programme of student research activity. This includes placing taught masters students with local community members on the South Uist, as well as, PhD research being done on Stornoway. These two outcomes then have given rise to interest in not only how heritage is re-developed in a community, but also, encourages future interest, by staff and students to continue the debate and fashion further developments in the region (GSAmediacentre). Today, the cliffs of Mangerstadh continue to receive the pounding of waves, the blowing wind and the ever-present rain on its rocky granite surface. The iterative stages of work that the two groups have done showcase the way that simple actions can carve, change and evolve into innovative outcomes. The research outcomes show that through this new approach to working with communities we move beyond the consultant and towards an ability of generating a preferable future for the community. In this way, the work that has been created together showcases a case study for further island community development. We do not know what the future holds for the group, but with continued support and maintaining an open mind to creative opportunities we will see that the community will develop a space that moves “beyond the museum”. AcknowledgementsThe author would like to thank Ionad Hiort and all the residents of Uig on the Isle of Lewis for their assistance and participation in this partnership. For more information on their work please visit http://www.ionadhiort.org/. The author also thanks the Highlands and Islands Enterprise for financial support in the research and development of the project. Finally, the author thanks the two reviewers who provided critical commentary and critiques to improve this paper. ReferencesBarker, Adam. “Capacity Building for Sustainability: Towards Community Development in Coastal Scotland.” Journal of Environmental Management 75.1 (2005): 11-19. Canavan, Brendan. “Tourism Culture: Nexus, Characteristics, Context and Sustainability.” Tourism Management 53 (2016): 229-43. ———. “The Extent and Role of Domestic Tourism in a Small Island: The Case of the Isle of Man.” Journal of Travel Research 52.3 (2012): 340-52. Cape, Ruth. Exploring Growth and Empowerment of Communities in the Western Isles. Stornoway, 2013. Bullen, Elizabeth, Simon Robb, and Jane Kenway. “‘Creative Destruction’: Knowledge Economy Policy and the Future of the Arts and Humanities in the Academy.” Journal of Education Policy 19.1 (2004): 3–22. Brown, Tim, and Jocelyn Wyatt. “Design Thinking for Social Innovation.” Stanford Social Innovation Review Winter (2010): 30-35. <https://ssir.org/articles/entry/design_thinking_for_social_innovation>.Briscoe, Gerard, and Mark Plumbley. Creating Cultures of Innovation: The Digital Creative Industries. <https://qmro.qmul.ac.uk/xmlui/bitstream/handle/123456789/11403/Creating%20Cultures%20of%20Innovation.pdf?sequence=7>.Edensor, Tim. Industrial Ruins: Spaces, Aesthetics, and Materiality. Oxford: Berg, 2005. Geddes, George. The Magazine and Gun Emplacement, St Kilda A Conservation Statement. Edinburgh, 2008. Geddes, George, and Angela Gannon. St Kilda: The Last and Outmost Isle. Edinburgh: Royal Commission on the Ancient & Historical Monuments of Scotland, 2015. Gordon, Michel, and Arthur Percival. The Wirksworth Story: New Life for An Old Town. Wirksworth: Civic Trust, 1984. GSAmediacentre. “The Glasgow School of Art Contributes to St Kilda Centre Symposium in Stornoway.” GSA Media Centre, The Glasgow School of Art, 17 Aug. 2016. 6 Apr. 2017 <www.gsapress.blogspot.co.uk/2016/08/the-glasgow-school-of-art-contributes.html>.Henchley, Norman. "Making Sense of Future Studies." Alternatives 7.2 (1978): 24-28. Jacuniak-Suda, Marta, and Ingo Mose. “Social Enterprises in the Western Isles (Scotland) – Drivers of Sustainable Rural Development ?” Europa Regional 19.2011.2 (2014): 23-40. Lockwood, Joseph, Madeline Smith, and Irene McAra-McWilliam. “Work-Well: Creating a Culture of Innovation through Design.” International Design Management Research Conference, Boston, 2012. 1-11. McAra-McWilliam, Irene. “Impossible Things? Negative Capability and the Creative Imagination.” Creativity or Conformity Conference, Cardiff, 2007. 1-8. <https://www.academia.edu/1246770/Impossible_things_Negative_Capability>.McKenzie, Steven. "Opera Celebrates St Kilda History." BBC News 23 Jun. 2007. 6 Apr. 2017 <http://news.bbc.co.uk/1/hi/scotland/highlands_and_islands/6763371.stm>.McMorran, Rob, and Alister Scott. “Community Landownership: Rediscovering the Road to Sustainability.” Lairds: Scottish Perspectives on Upland Management (2013): 20-31. Maclean, Diane. “Bitter Strife over St Kilda Visitor Centre.” The Caledonian Mercury 29 Jan. 2010. 6 Apr. 2017 <http://www.caledonianmercury.com/2010/01/29/bitter-strife-over-st-kilda-visitor-centre/001383>.News Editor. “Double Boost for St Kilda Project.” Hebrides News Today 20 Nov. 2013. 6 Apr. 2017 <www.hebridestoday.com/2013/11/double-boost-for-st-kilda-project/>.Portschy, Szabolcs. “Design Partnerships between Community-Engaged Architecture and Academic Education Programs.” Pollack Periodica 10.1 (2015): 173-180.“Proposal – Ionad Hiort.” Ionad Hiort. 6 Apr. 2017 <http://www.ionadhiort.org/the-proposal>. Rebanks, James. “World Heritage Status: Is There Opportunity for Economic Gain? Research and Analysis of the Socio-Economic Impact Potential of UNESCO World Heritage Site Status.” 2009. <http://icomos.fa.utl.pt/documentos/2009/WHSTheEconomicGainFinalReport.pdf>.Robertson, Iain James McPherson. “Hardscrabble Heritage: The Ruined Blackhouse and Crofting Landscape as Heritage from Below.” Landscape Research 40.8 (2015): 993–1009. Ronström, Owe. “Heritage Production in the Island of Gotland.” The International Journal of Research into Island Cultures 2.2 (2008): 1-18. Russo‐Spena, Tiziana, and Cristina Mele. “‘Five Co‐s’ in Innovating: A Practice‐Based View.” Ed. Evert Gummesson. Journal of Service Management 23.4 (2012): 527-53. “St Kilda.” World Heritage Centre. UNESCO. 6 Apr. 2017 <www.whc.unesco.org/en/list/387/>.Steiner, Artur, and Marianna Markantoni. “Unpacking Community Resilience through Capacity for Change.” Community Development Journal 49.3 (2014): 407-25.Shortall, S. “Rural Development in Practice: Issues Arising in Scotland and Northern Ireland.” Community Development Journal 36.2 (2001): 122-33. UNESCO. Using Remote Access Technologies: Lessons Learnt from the Remote Access to World Heritage Sites – St Kilda to Uluru Conference. London, 2012. Urquhart, Frank. “St Kilda Visitor Centre in Hebrides Step Closer.” People Places, The Scotsman 20 Nov. 2013. 6 Apr. 2017 <www.scotsman.com/heritage/people-places/st-kilda-visitor-centre-in-hebrides-step-closer-1-3195287>. Watson, Amy. “Plans for St Kilda Centre at Remote World Heritage Site.” People Places, The Scotsman 16 Aug. 2016. 6 Apr. 2017 <www.scotsman.com/heritage/people-places/plans-for-st-kilda-centre-at-remote-world-heritage-site-1-4204606>.

ObjectiveTo explore the timeliness of emergency room surveillance data after the advent of federal Meaningful Use initiatives and determine potential areas for improvement.IntroductionTimeliness of emergency room (ER) data is arguably its strongest attribute in terms of its contribution to disease surveillance. Timely data analyses may improve the efficacy of prevention and control measures.There are a number of studies that have looked at timeliness prior to the advent of Meaningful Use, and these studies note that ER data were not fast enough for them to be useful in real time2,3. However, the change in messaging practices in the Meaningful Use era potentially changes this.Other studies have shown that changes in processes and protocol can dramatically improve timeliness1,4 and this motivates the current study of timeliness to identify processes that can be changed to improve timeliness.MethodsER data were collected from March 2017 through September 2017 from both the Georgia Department of Public Health’s (GDPH) State Electronic Notifiable Disease Surveillance System (SendSS) Syndromic Surveillance Module and the Centers for Disease Control and Prevention (CDC) National Syndromic Surveillance Program’s (NSSP) ESSENCE systems. Patients from hospitals missing 10 or more days of data, as well as patients with missing or invalid triage times, and all visits after August 1st were excluded in order to ensure data were representative of a “typical” time period and that a sufficient amount of time was given for visits to arrive from hospitals.The timeliness of individual records was determined in a number of different ways. All timeliness measurements were determined by subtracting the earlier time event from the later time of the event. The overall measure of timeliness is the time between the patient’s triage time and the data being present in the ESSENCE data system. In between, Georgia’s SendSS system receives and processes the data. This is illustrated in Figure 1. Due to the skewed nature of these measures, they were analyzed using medians and Gaussian kernel density plots.ResultsThe study in total included records from 118 Georgia hospitals, 14,203 data files and 1,897,501 patient records. Overall median timeliness of data from Triage Time to being available in SendSS for analyses was 33.62 hours (IQR=28.5), and in ESSENCE was 45.08 hours (IQR=37.05).The distributions of Triage Time of Day, Time Available in SendSS Staging, and Time Available in ESSENCE Analysis can be seen in Figure 2. Additionally, lines were added for when SendSS makes data available for its own analyses and when it sends data to ESSENCE. These latter lines represent places where the SendSS system itself could improve, and potential improved times were noted based on the kernel densities.Peak triage times for Georgia hospitals were between 10 am to 11 pm, shown in black. This represents the ideal timeliness if Hospitals sent their data immediately. However, data was all batched by Georgia hospitals and sent at different times of the day. The distribution of the time patient records arrived at SendSS staging was indicated in blue.During the period of this study, Georgia processed data into its SendSS system at 6:30am and 11:30am every day and sent data to the ESSENCE system at 1pm each day. These times are highlighted on the plot in green, and red respectively. New potential improved times, based on the kernel density of data being available in SendSS staging, are shown in the lighter shades of these colors at 8:30am and 12pm every day, while being sent to ESSENCE at 9am and 12:30pm to ensure time for data to be properly processed. These were determined to be optimal times for reducing lag in the data, however, may not be optimal for daily analysis.The purple line on the plot represents the times that data were available in ESSENCE’s system for analysis. This was notably delayed by a median 4.15 hours after the data was sent to ESSENCE on a typical day.ConclusionsA data driven approach to choosing processing times could improve timeliness of data analyses in the SendSS and ESSENCE systems. By conducting this type of analysis in an ongoing periodic basis, processing lag times can be kept at a minimum.1. Centers for Disease Control. Progress in improving state and local disease surveillance--United States, 2000-2005. MMWR Morbidity and mortality weekly report. 2005;54(33):822-825.2. Jajosky R, Groseclose S. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases. BMC Public Health. 2004;4(1).3. Travers D, Barnett C, Ising A, Waller A. Timeliness of emergency department diagnoses for syndromic surveillance. AMIA Annual Symposium Proceedings. 2006;Vol. 2006:769.4. Ward M, Brandsema P, van Straten E, Bosman A. Electronic reporting improves timeliness and completeness of infectious disease notification, The Netherlands, 2003. Eurosurveillance. 2005;10(1):7-8.

The term “coffee palace” was primarily used in Australia to describe the temperance hotels that were built in the last decades of the 19th century, although there are references to the term also being used to a lesser extent in the United Kingdom (Denby 174). Built in response to the worldwide temperance movement, which reached its pinnacle in the 1880s in Australia, coffee palaces were hotels that did not serve alcohol. This was a unique time in Australia’s architectural development as the economic boom fuelled by the gold rush in the 1850s, and the demand for ostentatious display that gathered momentum during the following years, afforded the use of richly ornamental High Victorian architecture and resulted in very majestic structures; hence the term “palace” (Freeland 121). The often multi-storied coffee palaces were found in every capital city as well as regional areas such as Geelong and Broken Hill, and locales as remote as Maria Island on the east coast of Tasmania. Presented as upholding family values and discouraging drunkenness, the coffee palaces were most popular in seaside resorts such as Barwon Heads in Victoria, where they catered to families. Coffee palaces were also constructed on a grand scale to provide accommodation for international and interstate visitors attending the international exhibitions held in Sydney (1879) and Melbourne (1880 and 1888). While the temperance movement lasted well over 100 years, the life of coffee palaces was relatively short-lived. Nevertheless, coffee palaces were very much part of Australia’s cultural landscape. In this article, I examine the rise and demise of coffee palaces associated with the temperance movement and argue that coffee palaces established in the name of abstinence were modelled on the coffee houses that spread throughout Europe and North America in the 17th and 18th centuries during the Enlightenment—a time when the human mind could be said to have been liberated from inebriation and the dogmatic state of ignorance. The Temperance Movement At a time when newspapers are full of lurid stories about binge-drinking and the alleged ill-effects of the liberalisation of licensing laws, as well as concerns over the growing trend of marketing easy-to-drink products (such as the so-called “alcopops”) to teenagers, it is difficult to think of a period when the total suppression of the alcohol trade was seriously debated in Australia. The cause of temperance has almost completely vanished from view, yet for well over a century—from 1830 to the outbreak of the Second World War—the control or even total abolition of the liquor trade was a major political issue—one that split the country, brought thousands onto the streets in demonstrations, and influenced the outcome of elections. Between 1911 and 1925 referenda to either limit or prohibit the sale of alcohol were held in most States. While moves to bring about abolition failed, Fitzgerald notes that almost one in three Australian voters expressed their support for prohibition of alcohol in their State (145). Today, the temperance movement’s platform has largely been forgotten, killed off by the practical example of the United States, where prohibition of the legal sale of alcohol served only to hand control of the liquor traffic to organised crime. Coffee Houses and the Enlightenment Although tea has long been considered the beverage of sobriety, it was coffee that came to be regarded as the very antithesis of alcohol. When the first coffee house opened in London in the early 1650s, customers were bewildered by this strange new drink from the Middle East—hot, bitter, and black as soot. But those who tried coffee were, reports Ellis, soon won over, and coffee houses were opened across London, Oxford, and Cambridge and, in the following decades, Europe and North America. Tea, equally exotic, entered the English market slightly later than coffee (in 1664), but was more expensive and remained a rarity long after coffee had become ubiquitous in London (Ellis 123-24). The impact of the introduction of coffee into Europe during the seventeenth century was particularly noticeable since the most common beverages of the time, even at breakfast, were weak “small beer” and wine. Both were safer to drink than water, which was liable to be contaminated. Coffee, like beer, was made using boiled water and, therefore, provided a new and safe alternative to alcoholic drinks. There was also the added benefit that those who drank coffee instead of alcohol began the day alert rather than mildly inebriated (Standage 135). It was also thought that coffee had a stimulating effect upon the “nervous system,” so much so that the French called coffee une boisson intellectuelle (an intellectual beverage), because of its stimulating effect on the brain (Muskett 71). In Oxford, the British called their coffee houses “penny universities,” a penny then being the price of a cup of coffee (Standage 158). Coffee houses were, moreover, more than places that sold coffee. Unlike other institutions of the period, rank and birth had no place (Ellis 59). The coffee house became the centre of urban life, creating a distinctive social culture by treating all customers as equals. Egalitarianism, however, did not extend to women—at least not in London. Around its egalitarian (but male) tables, merchants discussed and conducted business, writers and poets held discussions, scientists demonstrated experiments, and philosophers deliberated ideas and reforms. For the price of a cup (or “dish” as it was then known) of coffee, a man could read the latest pamphlets and newsletters, chat with other patrons, strike business deals, keep up with the latest political gossip, find out what other people thought of a new book, or take part in literary or philosophical discussions. Like today’s Internet, Twitter, and Facebook, Europe’s coffee houses functioned as an information network where ideas circulated and spread from coffee house to coffee house. In this way, drinking coffee in the coffee house became a metaphor for people getting together to share ideas in a sober environment, a concept that remains today. According to Standage, this information network fuelled the Enlightenment (133), prompting an explosion of creativity. Coffee houses provided an entirely new environment for political, financial, scientific, and literary change, as people gathered, discussed, and debated issues within their walls. Entrepreneurs and scientists teamed up to form companies to exploit new inventions and discoveries in manufacturing and mining, paving the way for the Industrial Revolution (Standage 163). The stock market and insurance companies also had their birth in the coffee house. As a result, coffee was seen to be the epitome of modernity and progress and, as such, was the ideal beverage for the Age of Reason. By the 19th century, however, the era of coffee houses had passed. Most of them had evolved into exclusive men’s clubs, each geared towards a certain segment of society. Tea was now more affordable and fashionable, and teahouses, which drew clientele from both sexes, began to grow in popularity. Tea, however, had always been Australia’s most popular non-alcoholic drink. Tea (and coffee) along with other alien plants had been part of the cargo unloaded onto Australian shores with the First Fleet in 1788. Coffee, mainly from Brazil and Jamaica, remained a constant import but was taxed more heavily than tea and was, therefore, more expensive. Furthermore, tea was much easier to make than coffee. To brew tea, all that is needed is to add boiling water, coffee, in contrast, required roasting, grinding and brewing. According to Symons, until the 1930s, Australians were the largest consumers of tea in the world (19). In spite of this, and as coffee, since its introduction into Europe, was regarded as the antidote to alcohol, the temperance movement established coffee palaces. In the early 1870s in Britain, the temperance movement had revived the coffee house to provide an alternative to the gin taverns that were so attractive to the working classes of the Industrial Age (Clarke 5). Unlike the earlier coffee house, this revived incarnation provided accommodation and was open to men, women and children. “Cheap and wholesome food,” was available as well as reading rooms supplied with newspapers and periodicals, and games and smoking rooms (Clarke 20). In Australia, coffee palaces did not seek the working classes, as clientele: at least in the cities they were largely for the nouveau riche. Coffee Palaces The discovery of gold in 1851 changed the direction of the Australian economy. An investment boom followed, with an influx of foreign funds and English banks lending freely to colonial speculators. By the 1880s, the manufacturing and construction sectors of the economy boomed and land prices were highly inflated. Governments shared in the wealth and ploughed money into urban infrastructure, particularly railways. Spurred on by these positive economic conditions and the newly extended inter-colonial rail network, international exhibitions were held in both Sydney and Melbourne. To celebrate modern technology and design in an industrial age, international exhibitions were phenomena that had spread throughout Europe and much of the world from the mid-19th century. According to Davison, exhibitions were “integral to the culture of nineteenth century industrialising societies” (158). In particular, these exhibitions provided the colonies with an opportunity to demonstrate to the world their economic power and achievements in the sciences, the arts and education, as well as to promote their commerce and industry. Massive purpose-built buildings were constructed to house the exhibition halls. In Sydney, the Garden Palace was erected in the Botanic Gardens for the 1879 Exhibition (it burnt down in 1882). In Melbourne, the Royal Exhibition Building, now a World Heritage site, was built in the Carlton Gardens for the 1880 Exhibition and extended for the 1888 Centennial Exhibition. Accommodation was required for the some one million interstate and international visitors who were to pass through the gates of the Garden Palace in Sydney. To meet this need, the temperance movement, keen to provide alternative accommodation to licensed hotels, backed the establishment of Sydney’s coffee palaces. The Sydney Coffee Palace Hotel Company was formed in 1878 to operate and manage a number of coffee palaces constructed during the 1870s. These were designed to compete with hotels by “offering all the ordinary advantages of those establishments without the allurements of the drink” (Murdoch). Coffee palaces were much more than ordinary hotels—they were often multi-purpose or mixed-use buildings that included a large number of rooms for accommodation as well as ballrooms and other leisure facilities to attract people away from pubs. As the Australian Town and Country Journal reveals, their services included the supply of affordable, wholesome food, either in the form of regular meals or occasional refreshments, cooked in kitchens fitted with the latest in culinary accoutrements. These “culinary temples” also provided smoking rooms, chess and billiard rooms, and rooms where people could read books, periodicals and all the local and national papers for free (121). Similar to the coffee houses of the Enlightenment, the coffee palaces brought businessmen, artists, writers, engineers, and scientists attending the exhibitions together to eat and drink (non-alcoholic), socialise and conduct business. The Johnson’s Temperance Coffee Palace located in York Street in Sydney produced a practical guide for potential investors and businessmen titled International Exhibition Visitors Pocket Guide to Sydney. It included information on the location of government departments, educational institutions, hospitals, charitable organisations, and embassies, as well as a list of the tariffs on goods from food to opium (1–17). Women, particularly the Woman’s Christian Temperance Union (WCTU) were a formidable force in the temperance movement (intemperance was generally regarded as a male problem and, more specifically, a husband problem). Murdoch argues, however, that much of the success of the push to establish coffee palaces was due to male politicians with business interests, such as the one-time Victorian premiere James Munro. Considered a stern, moral church-going leader, Munro expanded the temperance movement into a fanatical force with extraordinary power, which is perhaps why the temperance movement had its greatest following in Victoria (Murdoch). Several prestigious hotels were constructed to provide accommodation for visitors to the international exhibitions in Melbourne. Munro was responsible for building many of the city’s coffee palaces, including the Victoria (1880) and the Federal Coffee Palace (1888) in Collins Street. After establishing the Grand Coffee Palace Company, Munro took over the Grand Hotel (now the Windsor) in 1886. Munro expanded the hotel to accommodate some of the two million visitors who were to attend the Centenary Exhibition, renamed it the Grand Coffee Palace, and ceremoniously burnt its liquor licence at the official opening (Murdoch). By 1888 there were more than 50 coffee palaces in the city of Melbourne alone and Munro held thousands of shares in coffee palaces, including those in Geelong and Broken Hill. With its opening planned to commemorate the centenary of the founding of Australia and the 1888 International Exhibition, the construction of the Federal Coffee Palace, one of the largest hotels in Australia, was perhaps the greatest monument to the temperance movement. Designed in the French Renaissance style, the façade was embellished with statues, griffins and Venus in a chariot drawn by four seahorses. The building was crowned with an iron-framed domed tower. New passenger elevators—first demonstrated at the Sydney Exhibition—allowed the building to soar to seven storeys. According to the Federal Coffee Palace Visitor’s Guide, which was presented to every visitor, there were three lifts for passengers and others for luggage. Bedrooms were located on the top five floors, while the stately ground and first floors contained majestic dining, lounge, sitting, smoking, writing, and billiard rooms. There were electric service bells, gaslights, and kitchens “fitted with the most approved inventions for aiding proficients [sic] in the culinary arts,” while the luxury brand Pears soap was used in the lavatories and bathrooms (16–17). In 1891, a spectacular financial crash brought the economic boom to an abrupt end. The British economy was in crisis and to meet the predicament, English banks withdrew their funds in Australia. There was a wholesale collapse of building companies, mortgage banks and other financial institutions during 1891 and 1892 and much of the banking system was halted during 1893 (Attard). Meanwhile, however, while the eastern States were in the economic doldrums, gold was discovered in 1892 at Coolgardie and Kalgoorlie in Western Australia and, within two years, the west of the continent was transformed. As gold poured back to the capital city of Perth, the long dormant settlement hurriedly caught up and began to emulate the rest of Australia, including the construction of ornately detailed coffee palaces (Freeman 130). By 1904, Perth had 20 coffee palaces. When the No. 2 Coffee Palace opened in Pitt Street, Sydney, in 1880, the Australian Town and Country Journal reported that coffee palaces were “not only fashionable, but appear to have acquired a permanent footing in Sydney” (121). The coffee palace era, however, was relatively short-lived. Driven more by reformist and economic zeal than by good business sense, many were in financial trouble when the 1890’s Depression hit. Leading figures in the temperance movement were also involved in land speculation and building societies and when these schemes collapsed, many, including Munro, were financially ruined. Many of the palaces closed or were forced to apply for liquor licences in order to stay afloat. Others developed another life after the temperance movement’s influence waned and the coffee palace fad faded, and many were later demolished to make way for more modern buildings. The Federal was licensed in 1923 and traded as the Federal Hotel until its demolition in 1973. The Victoria, however, did not succumb to a liquor licence until 1967. The Sydney Coffee Palace in Woolloomooloo became the Sydney Eye Hospital and, more recently, smart apartments. Some fine examples still survive as reminders of Australia’s social and cultural heritage. The Windsor in Melbourne’s Spring Street and the Broken Hill Hotel, a massive three-story iconic pub in the outback now called simply “The Palace,” are some examples. Tea remained the beverage of choice in Australia until the 1950s when the lifting of government controls on the importation of coffee and the influence of American foodways coincided with the arrival of espresso-loving immigrants. As Australians were introduced to the espresso machine, the short black, the cappuccino, and the café latte and (reminiscent of the Enlightenment), the post-war malaise was shed in favour of the energy and vigour of modernist thought and creativity, fuelled in at least a small part by caffeine and the emergent café culture (Teffer). Although the temperance movement’s attempt to provide an alternative to the ubiquitous pubs failed, coffee has now outstripped the consumption of tea and today’s café culture ensures that wherever coffee is consumed, there is the possibility of a continuation of the Enlightenment’s lively discussions, exchange of news, and dissemination of ideas and information in a sober environment. References Attard, Bernard. “The Economic History of Australia from 1788: An Introduction.” EH.net Encyclopedia. 5 Feb. (2012) ‹http://eh.net/encyclopedia/article/attard.australia›. Blainey, Anna. “The Prohibition and Total Abstinence Movement in Australia 1880–1910.” Food, Power and Community: Essays in the History of Food and Drink. Ed. Robert Dare. Adelaide: Wakefield Press, 1999. 142–52. Boyce, Francis Bertie. “Shall I Vote for No License?” An address delivered at the Convention of the Parramatta Branch of New South Wales Alliance, 3 September 1906. 3rd ed. Parramatta: New South Wales Alliance, 1907. Clarke, James Freeman. Coffee Houses and Coffee Palaces in England. Boston: George H. Ellis, 1882. “Coffee Palace, No. 2.” Australian Town and Country Journal. 17 Jul. 1880: 121. Davison, Graeme. “Festivals of Nationhood: The International Exhibitions.” Australian Cultural History. Eds. S. L. Goldberg and F. B. Smith. Cambridge: Cambridge UP, 1989. 158–77. Denby, Elaine. Grand Hotels: Reality and Illusion. London: Reaktion Books, 2002. Ellis, Markman. The Coffee House: A Cultural History. London: Weidenfeld & Nicolson, 2004. Federal Coffee Palace. The Federal Coffee Palace Visitors’ Guide to Melbourne, Its Suburbs, and Other Parts of the Colony of Victoria: Views of the Principal Public and Commercial Buildings in Melbourne, With a Bird’s Eye View of the City; and History of the Melbourne International Exhibition of 1880, etc. Melbourne: Federal Coffee House Company, 1888. Fitzgerald, Ross, and Trevor Jordan. Under the Influence: A History of Alcohol in Australia. Sydney: Harper Collins, 2009. Freeland, John. The Australian Pub. Melbourne: Sun Books, 1977. Johnson’s Temperance Coffee Palace. International Exhibition Visitors Pocket Guide to Sydney, Restaurant and Temperance Hotel. Sydney: Johnson’s Temperance Coffee Palace, 1879. Mitchell, Ann M. “Munro, James (1832–1908).” Australian Dictionary of Biography. Canberra: National Centre of Biography, Australian National U, 2006-12. 5 Feb. 2012 ‹http://adb.anu.edu.au/biography/munro-james-4271/text6905›. Murdoch, Sally. “Coffee Palaces.” Encyclopaedia of Melbourne. Eds. Andrew Brown-May and Shurlee Swain. 5 Feb. 2012 ‹http://www.emelbourne.net.au/biogs/EM00371b.htm›. Muskett, Philip E. The Art of Living in Australia. New South Wales: Kangaroo Press, 1987. Standage, Tom. A History of the World in 6 Glasses. New York: Walker & Company, 2005. Sydney Coffee Palace Hotel Company Limited. Memorandum of Association of the Sydney Coffee Palace Hotel Company, Ltd. Sydney: Samuel Edward Lees, 1879. Symons, Michael. One Continuous Picnic: A Gastronomic History of Australia. Melbourne: Melbourne UP, 2007. Teffer, Nicola. Coffee Customs. Exhibition Catalogue. Sydney: Customs House, 2005.

AWARDSSome major international children’s literature awards have just been announced as I compile the news for this issue. Several of these have Canadian connections.2016 ALSC (Association for Library Service to Children) Book & Media Award WinnersJohn Newbery Medal"Last Stop on Market Street,” written by Matt de la Peña, illustrated by Christian Robinson and published by G. P. Putnam’s Sons, an imprint of Penguin Books (USA) LLC Newbery Honor Books"The War that Saved My Life," written by Kimberly Brubaker Bradley and published by Dial Books for Young Readers, an imprint of Penguin Books (USA) LLC“Roller Girl,” written and illustrated by Victoria Jamieson and published by Dial Books for Young Readers, an imprint of Penguin Books (USA) LLC“Echo,” written by Pam Muñoz Ryan and published by Scholastic Press, an imprint of Scholastic Inc.Randolph Caldecott Medal"Finding Winnie: The True Story of the World’s Most Famous Bear," illustrated by Sophie Blackall, written by Lindsay Mattick and published by Little, Brown and Company, a division of Hachette Book Group, Inc.Caldecott Honor Books"Trombone Shorty," illustrated by Bryan Collier, written by Troy Andrews and published by Abrams Books for Young Readers, an imprint of ABRAMS“Waiting,” illustrated and written by Kevin Henkes, published by Greenwillow Books, an imprint of HarperCollins Publishers“Voice of Freedom Fannie Lou Hamer Spirit of the Civil Rights Movement,” illustrated by Ekua Holmes, written by Carole Boston Weatherford and published by Candlewick Press“Last Stop on Market Street,” illustrated by Christian Robinson, written by Matt de le Peña and published by G. P. Putnam’s Sons, an imprint of Penguin Books (USA) LLC Laura Ingalls Wilder AwardJerry Pinkney -- His award-winning works include “The Lion and the Mouse,” recipient of the Caldecott Award in 2010. In addition, Pinkney has received five Caldecott Honor Awards, five Coretta Scott King Illustrator Awards, and four Coretta Scott King Illustrator Honors. 2017 May Hill Arbuthnot Honor Lecture AwardJacqueline Woodson will deliver the 2017 May Hill Arbuthnot Honor Lecture. Woodson is the 2014 National Book Award winner for her New York Times bestselling memoir, “Brown Girl Dreaming.” Mildred L. Batchelder Award“The Wonderful Fluffy Little Squishy,” published by Enchanted Lion Books, written and illustrated by Beatrice Alemagna, and translated from the French by Claudia Zoe BedrickBatchelder Honor Books“Adam and Thomas,” published by Seven Stories Press, written by Aharon Appelfeld, iIllustrated by Philippe Dumas and translated from the Hebrew by Jeffrey M. Green“Grandma Lives in a Perfume Village,” published by NorthSouth Books, an imprint of Nordsüd Verlag AG, written by Fang Suzhen, iIllustrated by Sonja Danowski and translated from the Chinese by Huang Xiumin“Written and Drawn by Henrietta,” published by TOON Books, an imprint of RAW Junior, LLC and written, illustrated, and translated from the Spanish by Liniers.Pura Belpre (Author) Award“Enchanted Air: Two Cultures, Two Wings: A Memoir," written by Margarita Engle and published by Atheneum Books for Young Readers, an imprint of Simon & Schuster Children’s Publishing DivisionBelpre (Author) Honor Books"The Smoking Mirror," written by David Bowles and published by IFWG Publishing, Inc."Mango, Abuela, and Me," written by Meg Medina, illustrated by Angela Dominguez and published by Candlewick PressPura Belpre (Illustrator) Award"The Drum Dream Girl," illustrated by Rafael López, written by Margarita Engle and published by Houghton Mifflin HarcourtBelpre (Illustrator) Honor Books"My Tata’s Remedies = Los remedios de mi tata,” iIllustrated by Antonio Castro L., written by Roni Capin Rivera-Ashford and published by Cinco Puntos Press“Mango, Abuela, and Me,” illustrated by Angela Dominguez, written by Meg Medina and published by Candlewick Press“Funny Bones: Posada and His Day of the Dead Calaveras,” illustrated and written by Duncan Tonatiuh and published by Abrams Books for Young Readers, an imprint of ABRAMSAndrew Carnegie Medal "That Is NOT a Good Idea," produced by Weston Woods Studios, Inc.Theodor Seuss Geisel Award"Don’t Throw It to Mo!" written by David A. Adler, illustrated by Sam Ricks and published by Penguin Young Readers, and imprint of Penguin Group (USA), LLCGeisel Honor Books "A Pig, a Fox, and a Box," written and illustrated by Jonathan Fenske and published by Penguin Young Readers, an Imprint of Penguin Group (USA) LLC"Supertruck," written and illustrated by Stephen Savage and published by A Neal Porter Book published by Roaring Brook Press, a division of Holtzbrinck Publishing Holdings Limited Partnership"Waiting," written and illustrated by Kevin Henkes and published by Greenwillow Books, an imprint of HarperCollins Publishers.Odyssey Award"The War that Saved My Life," produced by Listening Library, an imprint of the Penguin Random House Audio Publishing Group, written by Kimberly Brubaker Bradley and narrated by Jayne EntwistleOdyssey Honor Audiobook"Echo," produced by Scholastic Audio / Paul R. Gagne, written by Pam Munoz Ryan and narrated by Mark Bramhall, David De Vries, MacLeod Andrews and Rebecca SolerRobert F. Sibert Informational Book Medal"Funny Bones: Posada and His Day of the Dead Calaveras,” written and illustrated by Duncan Tonatiuh and published by Abrams Books for Young Readers, an imprint of ABRAMSSibert Honor Books"Drowned City: Hurricane Katrina and New Orleans," written and illustrated by Don Brown and published by Houghton Mifflin Harcourt"The Boys Who Challenged Hitler: Knud Pedersen and the Churchill Club," by Phillip Hoose and published by Farrar Straus Giroux Books for Young Readers"Turning 15 on the Road to Freedom: My Story of the 1965 Selma Voting Rights March," written by Lynda Blackmon Lowery as told to Elspeth Leacock and Susan Buckley, illustrated by PJ Loughran and published by Dial Books, an imprint of Penguin Group (USA) LLC"Voice of Freedom: Fannie Lou Hamer, Spirit of the Civil Rights Movement," written by Carole Boston Weatherford, illustrated by Ekua Holmes and published by Candlewick PressCONFERENCES & EVENTSThis 2016 is shaping up to be a busy year for those of us involved with Canadian children’s literature. To tantalize your appetite (and encourage you to get involved) here are some highlights:January:Vancouver Children’s Literature Roundtable event: A Celebration of BC’s Award Children’s Authors and Illustrators with special guests Rachel Hartman and the Children’s Literature Roundtables of Canada 2015 Information Book Award winners Margriet Ruurs & Katherine Gibson, January 27, 2016, 7 – 9 pm. Creekside Community Centre, 1 Athletes Way, Vancouver. Free to members and students.April:Wordpower programs from the Young Alberta Book Society feature teams of Albertan children’s literary artists touring to schools in rural areas. Thanks to the generous sponsorship of Cenovus Energy, schools unable to book artist visits due to prohibitive travel costs are able to participate.April 4-8: Wordpower South will send 8 artist teams to communities roughly between Drumheller and Medicine Hat. Artists include Karen Bass, Lorna Shultz-Nicholson, Bethany Ellis, Marty Chan, Mary Hays, Sigmund Brouwer, Carolyn Fisher, Natasha DeenApril 25-29: Wordpower North will have a team of 8 artists traveling among communities in north-eastern Alberta such as Fort MacKay, Conklin, Wabasca, Lac La Biche, Cold Lake, and Bonnyville. The artists include Kathy Jessup, Lois Donovan, Deborah Miller, David Poulsen, Gail de Vos, Karen Spafford-Fitz, Hazel Hutchins, Georgia Graham May: COMICS AND CONTEMPORARY LITERACY: May 2, 2016; 8:30am - 4:30pm at the Rozsa Centre, University of Calgary. This is a one day conference featuring presentations and a workshop by leading authors, scholars, and illustrators from the world of comics and graphic novels. This conference is the 5th in the annual 'Linguistic Diversity and Language Policy' series sponsored by the Chair, English as an Additional Language, Werklund School of Education, University of Calgary. Tom Ricento is the current Chair-holder. The conference is free and lunch is provided. Seating is limited, so register early. The four presenters are:Jillian Tamaki, illustrator for This One Summer, and winner of the Governor General's Award for children's illustration.Richard van Camp, best-selling author of The Lesser Blessed and Three Feathers, and member of the Dogrib Nation.Dr. Nick Sousanis, post-doctoral scholar, teacher and creator of the philosophical comic Unflattening.Dr. Bart Beaty, University of Calgary professor, acclaimed comics scholar and author of Comics vs. Art TD Canadian Children’s Book Week 2016. In 2016, the Canadian Children's Book Centre celebrates 40 years of bringing great Canadian children's books to young readers across the country and the annual TD Canadian Children’s Book Week will be occurring this May across Canada. The theme this year is the celebration of these 40 years of great books written, illustrated and published in Canada as well as stories that have been told over the years. The 2016 tour of storytellers, authors and illustrators and their area of travel are as follows:Alberta: Bob Graham, storyteller; Kate Jaimet, authorBritish Columbia (Interior region) Lisa Dalrymple, author; (Lower Mainland region) Graham Ross, illustrator; (Vancouver Island region) Wesley King, author; (Northern region, Rebecca Bender, author & illustrator.Manitoba: Angela Misri, author; Allison Van Diepen, authorNew Brunswick: Mary Ann Lippiatt, storytellerNewfoundland: Maureen Fergus, authorLabrador: Sharon Jennings, authorNorthwest Territories: Geneviève Després, illustratorNova Scotia: Judith Graves, authorNunavut: Gabrielle Grimard, illustratorOntario: Karen Autio, author; Marty Chan, author; Danika Dinsmore, author; Kallie George, author; Doretta Groenendyk, author & illustrator; Alison Hughes, author; Margriet Ruurs, author.Prince Edward Island: Wallace Edwards, author & illustratorQuebec (English-language tour): LM Falcone, author; Simon Rose, author; Kean Soo, author & illustrator; Robin Stevenson, author; and Tiffany Stone, author/poet.Saskatchewan: (Saskatoon and northern area) Donna Dudinsky, storyteller; (Moose Jaw/Regina and southern area) Sarah Ellis, authorYukon: Vicki Grant, author-----Gail de Vos is an adjunct professor who teaches courses on Canadian children's literature, young adult literature, and comic books & graphic novels at the School of Library and Information Studies (SLIS) at the University of Alberta. She is the author of nine books on storytelling and folklore. Gail is also a professional storyteller who has taught the storytelling course at SLIS for over two decades.

IntroductionAs both a historical and cultural entity, the city of New Orleans has long-maintained a reputation as a centre for hedonistic and carnivaleque pleasures. Historically, images of mardi gras, jazz, and parties on the shores of the Mississippi have pervaded the cultural vision of the city as a “mecca” for “social life” (Marina 2), and successfully fed its tourism narratives. Simultaneously, however, a different kind of narrative also exists in the historical folds of the city’s urban mythology. Many tales of vampire sightings and supernatural accounts surround the area, and have contributed, over the years, to the establishment and mystification of New Orleans as a ‘vampire city’. This has produced, in turn, its own brand of vampire tourism (Murphy 2015). Mixed with historical rumours and Gothic folklore, the recent narratives of popular culture lie at the centre of the re-imagination of New Orleans as a vampire hub. Taking this idea as a point of departure, this article provides culturally- and historically-informed critical considerations of New Orleans as a ‘vampire city’, especially as portrayed in The Originals (2013-2017), a contemporary television series where vampires are the main protagonists. In the series, the historical narratives of New Orleans become entangled with – and are, at times, almost inseparable from – the fictional chronicles of the vampire in both aesthetic and conceptual terms.The critical connection between urban narratives and vampires representation, as far as New Orleans is concerned, is profoundly entangled with notions of both tourism and fictionalised popular accounts of folklore (Piatti-Farnell 172). In approaching the conceptual relationship between New Orleans as a cultural and historical entity and the vampire — in its folkloristic and imaginative context — the analysis will take a three-pronged approach: firstly, it will consider the historical narrative of tourism for the city of New Orleans; secondly, the city’s connection to vampires and other Gothicised entities will be considered, both historically and narratively; and finally, the analysis will focus on how the connection between New Orleans and Gothic folklore of the vampire is represented in The Originals, with the issue of cultural authenticity being brought into the foreground. A critical footnote must be given to the understanding of the term ‘New Orleans’ in this article as meaning primarily the French Quarter – or, the Vieux Carre – and its various representations. This geographical focus principally owes its existence to the profound cultural significance that the French Quarter has occupied in the history of New Orleans as a city, and, in particular, in its connection to narratives of magic and Gothic folklore, as well as the broader historical and contemporary tourism structures. A History of TourismSocial historian Kevin Fox Gotham agues that New Orleans as a city has been particularly successful in fabricating a sellable image of itself; tourism, Gotham reminds us, is about “the production of local difference, local cultures, and different local histories that appeal to visitors’ tastes for the exotic and the unique” (“Gentrification” 1100). In these terms, both the history and the socio-cultural ‘feel’ of the city cannot be separated from the visual constructs that accompany it. Over the decades, New Orleans has fabricated a distinct network of representational patterns for the Vieux Carre in particular, where the deployment of specific images, themes and motifs – which are, in truth, only peripherally tied to the city’ actual social and political history, and owe their creation and realisation more to the success of fictional narratives from film and literature – is employed to “stimulate tourist demands to buy and consume” (Gotham, “Gentrification” 1102). This image of the city as hedonistic site is well-acknowledged, has to be understood, at least partially, as a conscious construct aimed at the production an identity for itself, which the city can in turn sell to visitors, both domestically and internationally. New Orleans, Gotham suggests, is a ‘complex and constantly mutating city’, in which “meanings of place and community” are “inexorably intertwined with tourism” (Authentic 5). The view of New Orleans as a site of hedonistic pleasure is something that has been heavily capitalised upon by the tourism industry of the city for decades, if not centuries. A keen look at advertising pamphlets for the city, dating form the late Nineteenth century onwards, provides an overview of thematic selling points, that primarily focus on notions of jazz, endless parties and, in particular, nostalgic and distinctly rose-tinted views of the Old South and its glorious plantations (Thomas 7). The decadent view of New Orleans as a centre of carnal pleasures has often been recalled by scholars and lay observers alike; this vision of he city indeed holds deep historical roots, and is entangled with the city’s own economic structures, as well as its acculturated tourism ones. In the late 19th and early 20th century one of the things that New Orleans was very famous for was actually Storyville, the city’s red-light district, sanctioned in 1897 by municipal ordinance. Storyville quickly became a centralized attraction in the heart of New Orleans, so much so that it began being heavily advertised, especially through the publication of the ‘Blue Book’, a resource created for tourists. The Blue Book contained, in alphabetical order, information on all the prostitutes of Storyville. Storyville remained very popular and the most famous attraction in New Orleans until its demolition in 1919 Anthony Stanonis suggests that, in its ability to promote a sellable image for the city, “Storyville meshed with the intersts of business men in the age before mass tourism” (105).Even after the disappearance of Storyville, New Orleans continued to foster its image a site of hedonism, a narrative aided by a favourable administration, especially in the 1930s and 1940s. The French Quarter, in particular, “became a tawdry mélange of brothers and gambling dens operating with impunity under lax law enforcement” (Souther 16). The image of the city as a site for pleasures of worldly nature continued to be deeply rooted, and even survives in the following decades today, as visible in the numerous exotic dance parlours located on the famous Bourbon Street.Vampire TourismSimultaneously, however, a different kind of narrative also exists in the recent historical folds of the city’s urban mythology, where vampires, magic, and voodoo are an unavoidable presence. Many tales of vampire sightings and supernatural accounts surround the area, and have contributed, over the years, to the establishment and mystification of New Orleans as a ‘vampire city’. Kenneth Holditch contends that ‘”New Orleans is a city in love with its myths, mysteries and fantasies” (quoted in McKinney 8). In the contemporary era, these qualities are profoundly reflected in the city’s urban tourism image, where the vampire narrative is pushed into the foreground. When in the city, one might be lucky enough to take one of the many ‘vampire tours’ — often coupled with narratives of haunted locations — or visit the vampire bookshop, or even take part in the annual vampire ball. Indeed, the presence of vampires in New Orleans’s contemporary tourism narrative is so pervasive that one might be tempted to assume that it has always occupied a prominent place in the city’s cultural fabric. Nonetheless, this perception is not accurate: the historical evidence from tourism pamphlets for the city do not make any mentions of vampire tourism before the 1990s, and even then, the focus on the occult side of new Orleans tended to privilege stories of voodoo and hoodoo — a presence that still survives strongly in the cultural narrative city itself (Murphy 91). While the connection between vampires and New Orleans is a undoubtedly recent one, the development and establishment of New Orleans as vampire city cannot be thought of as a straight line. A number of cultural and historical currents appear to converge in the creation of the city’s vampire mystique. The history and geography of the city here could be an important factor, and a useful starting point; as the site of extreme immigration and ethnic and racial mingling New Orleans holds a reputation for mystery. The city was, of course, the regrettable site of a huge marketplace for the slave trade, so discussions of political economy could also be important here, although I’ll leave them for another time. As a city, New Orleans has often been described – by novelists, poets, and historians alike – as being somewhat ‘peculiar’. Simone de Behaviour was known to have remarked that that the city is surrounded by a “pearl grey” and ‘luminous’ air” (McKinney 1). In similar fashion, Oliver Evans claims the city carries “opalescent hints” (quoted in McKinney 1). New Orleans is famous for having a quite thick mist, the result of a high humidity levels in the air. To an observing eye, New Orleans seems immersed in an almost otherworldly ‘glow’, which bestows upon its limits an ethereal and mysterious quality (Piatti-Farnell 173). While this intention here is not to suggest that New Orleans is the only city to have mist – especially in the Southern States – one might venture to say that this physical phenomenon, joined with other occurrences and legends, has certainly contributed to the city’s Gothicised image. The geography of the city also makes it sadly famous for floods and their subsequent devastation, which over centuries have wrecked parts of the city irrevocably. New Orleans sits at a less than desirable geographical position, is no more than 17 feet above sea level, and much of it is at least five feet below (McKinney 5). In spite of its lamentable fame, hurricane Katrina was not the first devastating geo-meteorological phenomenon to hit and destroy most of New Orleans; one can trace similar hurricane occurrences in 1812 and 1915, which at the time significantly damaged parts of the French Quarter. The geographical position of New Orleans also owes to the city’s well-known history of disease such as the plague and tuberculosis – often associated, in previous centuries, with the miasma proper to reclaimed river lands. In similar terms, one must not forget New Orleans’s history of devastating fires – primarily in the years 1788, 1794, 1816, 1866 and 1919 – which slowly destroyed the main historical parts of the city, particularly in the Vieux Carre, and to some extent opened the way for regeneration and later gentrification as well. As a result of its troubled and destructive history, Louise McKinnon claims that the city ‒ perhaps unlike any others in the United States ‒ hinges on perpetual cycles of destruction and regeneration, continuously showing “the wear and tear of human life” (McKinney 6).It is indeed in this extremely important element that New Orleans finds a conceptual source in its connection to notions of the undead, and the vampire in particular. Historically, one can identify the pervasive use of Gothic terminology to describe New Orleans, even if, the descriptions themselves were more attuned to perceptions of the city’s architecture and metrological conditions, rather than the recollection of any folklore-inspired narratives of unread creatures. Because of its mutating, and often ill-maintained historical architecture – especially in the French Quarter - New Orleans has steadily maintained a reputation as a city of “splendid decay” (McKinney, 6). This highly lyrical and metaphorical approach plays an important part in building the city as a site of mystery and enchantment. Its decaying outlook functions as an unavoidable sign of how New Orleans continues to absorb, and simultaneously repel, as McKinney puts it, “the effects of its own history” (6).Nonetheless, the history of New Orleans as a cultural entity, especially in terms of tourism, has not been tied to vampires for centuries, as many imagine, and the city itself insists in its contemporary tourism narratives. Although a lot of folklore has survived around the city in connection to magic and mysticism, for a number of reasons, vampires have not always been in the foreground of its publicised cultural narratives. Mixed with historical rumours and Gothic folklore, the recent narratives of popular culture lie at the centre of the re-imagination of New Orleans as a vampire spot: most scholars claim that it all started with the publication of Anne Rice’s Interview with the Vampire (1976), but actually evidence shows that the vampire narrative for the city of New Orleans did not fully explode until the release of Neil Jordan’s cinematic adaptation of Interview with the Vampire (1994). This film really put New Orleans at the centre of the vampire narrative, indulging in the use of many iconic locations in the city as tied to vampire, and cementing the idea of New Orleans as a vampiric city (Piatti-Farnell 175). The impact of Rice’s work, and its adaptations, has also been picked up by numerous other examples of popular culture, including Charlaine Harris’s Southern Vampire mystery series, and its well-known television adaptation True Blood. Harris herself states in one of her novels: “New Orleans had been the place to go for vampires and those who wanted to be around them ever since Anne Rice had been proven right about their existence” (2). In spite of the fact that popular culture, rather than actual historical evidence, lies at the heart of the city’s cultural relationship with vampires, this does not detract from the fact that vampires themselves – as fabricated figures lying somewhere between folklore, history, and fiction – represent an influential part of New Orleans’s contemporary tourism narrative, building a bridge between historical storytelling, mythologised identities, and consumerism. The Originals: Vampires in the CityIndeed, the impact of popular culture in establishing and re-establishing the success of the vampire tourism narrative in New Orleans is undeniable. Contemporary examples continue to capitalise on the visual, cultural, and suggestively historical connection between the city’s landmarks and vampire tales, cementing the notion of New Orleans as a solid entity within the Gothic tourism narrative. One such successful example is The Originals. This television show is actually a spin-off of the Vampires Diaries, and begins with three vampires, the Mikaelson siblings (Niklaus, Elijah, and Rebekkah) returning to the city of New Orleans for the first time since 1919, when they were forced to flee by their vengeful father. In their absence, Niklaus's protégé, Marcel, took charge of the city. The storyline of The Originals focuses on battles within the vampire factions to regain control of the city, and eliminate the hold of other mystical creatures such as werewolves and witches (Anyiwo 175). The central narrative here is that the city belongs to the vampire, and there can be no other real Gothic presence in the Quarter. One can only wonder, even at this embryonic level, how this connects functions in a multifaceted way, extending the critique of the vampire’s relationship to New Orleans from the textual dimension of the TV show to the real life cultural narrative of the city itself. A large number of the narrative strands in The Originals are tied to city and its festivals, its celebrations, and its visions of the past, whether historically recorded, or living in the pages of its Gothic folklore. Vampires are actually claimed to have made New Orleans what it is today, and they undoubtedly rule it. As Marcel puts it: “The blood never stops flowing, and the party never ends” (Episode 1, “Always and Forever”). Even the vampiric mantra for New Orleans in The Originals is tied to the city’s existing and long-standing tourism narrative, as “the party never ends” is a reference to one of Bourbon Street’s famous slogans. Indeed, the pictorial influence of the city’s primary landmarks in The Originals is undeniable. In spite of the fact the inside scenes for The Originals were filmed in a studio, the outside shots in the series reveal a strong connections to the city itself, as viewers are left with no doubt as to the show’s setting. New Orleans is continuously mentioned and put on show – and pervasively referred to as “our city”, by the vampires. So much so, that New Orleans becomes the centre of the feud between supernatural forces, as the vampires fight witches and werewolves – among others- to maintain control over the city’s historical heart. The French Quarter, in particular, is given renewed life from the ashes of history into the beating heart of the vampire narrative, so much so that it almost becomes its own character in its own right, instrumental in constructing the vampire mystique. The impact of the vampire on constructing an image for the city of New Orleans is made explicit in The Originals, as the series explicitly shows vampires at the centre of the city’s history. Indeed, the show’s narrative goes as far as justifying the French Quarter’s history and even legends through the vampire metaphor. For instance, the series explains the devastating fire that destroyed the French Opera House in 1919 as the result of a Mikaelson vampire family feud. In similar terms, the vampires of the French Quarter are shown at the heart of the Casquette Girls narrative, a well-known tale from Eighteenth-century colonial New Orleans, where young women were shipped from France to the new Louisiana colony, in order to marry. The young women were said to bring small chests – or casquettes – containing their clothes (Crandle 47). The Originals, however, capitalises on the folkloristic interpretation that perceives the girls’ luggage as coffins potentially containing the undead, a popular version of the tale that can often be heard if taking part in one of the many vampire tours in New Orleans. One can see here how the chronicles of the French Quarter in New Orleans and the presumed narratives of the vampire in the city merge to become one and the same, blurring the lines between history and fiction, and presenting the notion of folklore as a verifiable entity of the everyday (Kirshenblatt-Gimblett 25) It is essential to remember, en passant, that, as far as giving the undead their own historical chronicles in connection to New Orleans, The Originals is not alone in doing this. Other TV series like American Horror Story have provided Gothicised histories for the city, although in this case more connected to witchcraft, hoodoo, and voodoo, rather than vampires.What one can see taking place in The Originals is a form of alternate and revisionist history that is reminiscent of several instances of pulp and science fiction from the early 20th century, where the Gothic element lies at the centre of not only the fictional narrative, but also of the re-conceptualisation of historical time and space, as not absolute entities, but as narratives open to interpretation (Singles 103). The re-interpretation here is of course connected to the cultural anxieties that are intrinsic to the Gothic – of changes, shifts, and unwanted returns - and the vampire as a figure of intersections, signalling the shift between stages of existence. If it is true that, to paraphrase Paul Ricoeur’s famous contention, the past returns to “haunt” us (105), then the history of New Orleans in The Originals is both established and haunted by vampires, a pervasive shadow that provides the city itself with an almost tangible Gothic afterlife. This connection, of course, extends beyond the fictional world of the television series, and finds fertile ground in the cultural narratives that the city constructs for itself. The tourism narrative of New Orleans also lies at the heart of the reconstructive historical imagination, which purposefully re-invents the city as a constructed entity that is, in itself, extremely sellable. The Originals mentions on multiple occasions that certain bars — owned, of course, by vampires — host regular ‘vampire themed events’, to “keep the tourists happy”. The importance of maintaining a steady influx of vampire tourism into the Quarter is made very clear throughout, and the vampires are complicit in fostering it for a number of reasons: not only because it provides them and the city with a constant revenue, but also because it brings a continuous source of fresh blood for the vampires to feed on. As Marcel puts it: “Something's gotta draw in the out-of-towners. Otherwise we'd all go hungry” (Episode 1, “Always and Forever”). New Orleans, it is made clear, is not only portrayed as a vampire hub, but also as a hot spot for vampire tourism; as part of the tourism narratives, the vampires themselves — who commonly feign humanity — actually further ‘pretend’ to be vampires for the tourists, who expect to find vampires in the city. It is made clear in The Originals that vampires often put on a show – and bear in mind, these are vampires who pretend to be human, who pretend to be vampires for the tourists. They channel stereotypes that belong in Gothic novels and films, and that are, as far as the ‘real’ vampires of the series, are concerned, mostly fictional. The vampires that are presented to the tourists in The Originals are, inevitably, inauthentic, for the real vampires themselves purposefully portray the vision of vampires put forward by popular culture, together with its own motifs and stereotypes. The vampires happily perform their popular culture role, in order to meet the expectations of the tourist. This interaction — which sociologist Dean MacCannell would refer to, when discussing the dynamics of tourism, as “staged authenticity” (591) — is the basis of the appeal, and what continues to bring tourists back, generating profits for vampires and humans alike. Nina Auerbach has persuasively argued that the vampire is often eroticised through its connections to the “self-obsessed’ glamour of consumerism that ‘subordinates history to seductive object” (57).With the issue of authenticity brought into sharp relief, The Originals also foregrounds questions of authenticity in relation to New Orleans’s own vampire tourism narrative, which ostensibly bases into historical narratives of magic, horror, and folklore, and constructs a fictionalised urban tale, suitable to the tourism trade. The vampires of the French Quarter in The Originals act as the embodiment of the constructed image of New Orleans as the epitome of a vampire tourist destination. ConclusionThere is a clear suggestion in The Originals that vampires have evolved from simple creatures of old folklore, to ‘products’ that can be sold to expectant tourists. This evolution, as far as popular culture is concerned, is also inevitably tied to the conceptualisation of certain locations as ‘vampiric’, a notion that, in the contemporary era, hinges on intersecting narratives of culture, history, and identity. Within this, New Orleans has successfully constructed an image for itself as a vampire city, exploiting, in a number ways, the popular and purposefully historicised connection to the undead. In both tourism narratives and popular culture, of which The Originals is an ideal example, New Orleans’s urban image — often sited in constructions and re-constructions, re-birth and decay — is presented as a result of the vampire’s own existence, and thrives in the Gothicised afterlife of imagery, symbolism, and cultural persuasion. In these terms, the ‘inauthentic’ vampires of The Originals are an ideal allegory that provides a channelling ground for the issues surrounding the ‘inauthentic’ state of New Orleans a sellable tourism entity. As both hinge on images of popular representation and desirable symbols, the historical narratives of New Orleans become entangled with — and are, at times, almost inseparable from — the fictional chronicles of the vampire in both aesthetic and conceptual terms. ReferencesAnyiwo, U. Melissa. “The Female Vampire in Popular Culture.” Gender in the Vampire Narrative. Eds. Amanda Hobson and U. Melissa Anyiwo. Rotterdam: Sense Publishers, 2016. 173-192. Auerbach, Nina. Our Vampires, Ourselves. Chicago: University of Chicago Press, 1995.Crandle, Marita Woywod. New Orleans Vampires: History and Legend. Stroud: The History Press, 2017.Gotham, Kevin Fox. Authentic New Orleans: Tourism, Culture, and Race in the Big Easy. New York: New York University Press, 2007.———. “Tourism Gentrification: The Case of New Orleans’ Vieux Carre’.” Urban Studies 42.7 (2005): 1099-1121. Harris, Charlaine. All Together Dead. London: Gollancz, 2008.Interview with the Vampire. Dir. Neil Jordan. Geffen Pictures, 1994. Kirshenblatt-Gimblett, Barbara. “Mistaken Dichotomies.” Public Folklore. Eds. Robert Baron and Nick Spitzer. Oxford: University of Missisippi Press, 2007. 28-48.Marina, Peter J. Down and Out in New Orleans: Trangressive Living in the Informal Economy. New York: Columia University Press, 2017. McKinney, Louise. New Orleans: A Cultural History. Oxford: Oxford University Press, 2006.Murphy, Michael. Fear Dat New Orleans: A Guide to the Voodoo, Vampires, Graveyards & Ghosts of the Crescent City. New York: W.W. Norton & Company, 2015.Piatti-Farnell, Lorna. The Vampire in Contemporary Popular Literature. London: Routledge, 2014. Ricoeur, Paul. Memory, History, Forgetting. Chicago: University of Chicago Press, 2004. Singles, Kathleen. Alternate History: Playing with Contingency and Necessity. Boston: de Gruyter, 2013.Souther, Mark. New Orleans on Parade: Tourism and the Transformation of the Crescent City. Baton Rouge: University of Louisiana Press, 2006. Stanonis, Anthony J. Creating the Big Easy: New Orleans and the Emergence of Modern Tourism, 1918-1945. Athens: University of Georgia Press, 2006.The Originals. Seasons 1-4. CBS/Warner Bros Television. 2013-2017.Thomas, Lynell. Desire and Disaster in New Orleans: Tourism, Race, and Historical Memory. Durham: Duke University Press, 2014.

Introduction Utopia has always been countercultural, and ever since technological progress has allowed, utopia has been using alternative media to promote and strengthen its underpinning ideals. In this article, I am seeking to clarify the connections between counterculture and alternative media in utopian contexts to demonstrate their reciprocity, then draw together these threads through reference to a well-known figure of the Rainbow Region–Rusty Miller. His trajectory from iconic surfer and Aquarian reporter to mediator for utopian politics and ideals in the Rainbow Region encompasses in a single identity the three elements underpinning this study. In concluding, I will turn to Rusty’s Byron Guide, questioning its classification as alternative or mainstream media, and whether Byron Bay is represented as countercultural and utopian in this long-running and ongoing publication. Counterculture and Alternative Media in Utopian Contexts Counterculture is an umbrella that enfolds utopia, among many other genres and practices. It has been most often situated in the 1960s and 1970s as a new form of social movement embodying youth resistance to the technocratic mainstream and its norms of gender, sexuality, politics, music, and language (Roszak). Many scholars of counterculture underscore its utopian impulses both in the projection of better societies where the social goals are achieved, and in the withdrawal from mainstream society into intentional communities (Yinger 194-6; McKay 5; Berger). Before exploring further the connections between counterculture and alternative media, I want to define the scope of countercultural utopian contexts in general, and the Rainbow Region in particular. Utopia is a neologism created by Sir Thomas More almost 500 years ago to designate the island community that demonstrates order, harmony, justice, hope and desire in the right balance so that it seems like an ideal land. This imaginary place described in Utopia (1516) as a counterpoint to the social, political and religious shortcomings of contemporary 16th century British society, has attracted accusations of heresy (Molner), and been used as a pejorative term, an insult to denigrate political projects that seem farfetched or subversive, especially during the 19th century. Almost every study of utopian theory, literature and practice points to a dissatisfaction with the status quo, which inspires writers, politicians, architects, artists, individuals and communities to rail against it (see for example Davis, Moylan, Suvin, Levitas, Jameson). Kingsley Widmer’s book Counterings: Utopian Dialectics in Contemporary Contexts reiterates what many scholars have stated when he writes that utopias should be understood in terms of what they are countering. Lyman Tower Sargent defines utopia as “a non-existent society described in considerable detail and normally located in time and space” and utopianism as “social dreaming” (9), to which I would add that both indicate an improvement on the alternatives, and may indeed be striving to represent the best place imaginable. Utopian contexts, by extension, are those situations where the “social dreaming” is enhanced through human agency, good governance, just laws, education, and work, rather than being a divinely ordained state of nature (Schaer et al). In this way, utopian contexts are explicitly countercultural through their very conception, as human agency is required and their emphasis is on social change. These modes of resistance against dominant paradigms are most evident in attempts to realise textual projections of a better society in countercultural communal experiments. Almost immediately after its publication, More’s Utopia became the model for Bishop Vasco de Quiroga’s communitarian hospital-town Santa Fe de la Laguna in Michoacan, Mexico, established in the 1530s as a counterculture to the oppressive enslavement and massacres of the Purhépecha people by Nuno Guzmán (Green). The countercultural thrust of the 1960s and 1970s provided many utopian contexts, perhaps most readily identifiable as the intentional communities that spawned and flourished, especially in the United States, the United Kingdom, Australia, and New Zealand (Metcalf, Shared Lives). They were often inspired by texts such as Charles A. Reich’s The Greening of America (1970) and Ernest Callenbach’s Ecotopia (1975), and this convergence of textual practices and alternative lifestyles can be seen in the development of Australia’s own Rainbow Region. Located in northern New South Wales, the geographical area of the Northern Rivers that has come to be known as the Rainbow Region encompasses Byron Bay, Nimbin, Mullumbimby, Bangalow, Clunes, Dunoon, Federal, with Lismore as the region’s largest town. But more evocative than these place names are the “rivers and creeks, vivid green hills, fruit and nut farms […] bounded by subtropical beaches and rainforest mountains” (Wilson 1). Utopian by nature, and recognised as such by the indigenous Bundjalung people who inhabited it before the white settlers, whalers and dairy farmers moved in, the Rainbow Region became utopian through culture–or indeed counterculture–during the 1973 Aquarius Festival in Nimbin when the hippies of Mullumbimby and the surfers of Byron Bay were joined by up to 10,000 people seeking alternative ways of being in the world. When the party was over, many Aquarians stayed on to form intentional communities in the beautiful region, like Tuntable Falls, Nimbin’s first and largest such cooperative (Metcalf, From Utopian Dreaming to Communal Reality 74-83). In utopian contexts, from the Renaissance to the 1970s and beyond, counterculture has underpinned and alternative media has circulated the aims and ideals of the communities of resistance. The early utopian context of the Anabaptist movement has been dubbed as countercultural by Sigrun Haude: “During the reign of the Münster (1534-5) Anabaptists erected not only a religious but also a social and political counterculture to the existing order” (240). And it was this Protestant Reformation that John Downing calls the first real media war, with conflicting movements using pamphlets produced on the new technology of the Gutenberg press to disseminate their ideas (144). What is striking here is the confluence of ideas and practices at this time–countercultural ideals are articulated, published, and disseminated, printing presses make this possible, and utopian activists realise how mass media can be used and abused, exploited and censored. Twentieth century countercultural movements drew on the lessons learnt from historical uprising and revolutions, understanding the importance of getting the word out through their own forms of media which, given the subversive nature of the messages, were essentially alternative, according to the criteria proposed by Chris Atton: alternative media may be understood as a radical challenge to the professionalized and institutionalized practices of the mainstream media. Alternative media privileges a journalism that is closely wedded to notions of social responsibility, replacing an ideology of “objectivity” with overt advocacy and oppositional practices. Its practices emphasize first person, eyewitness accounts by participants; a reworking of the populist approaches of tabloid newspapers to recover a “radical popular” style of reporting; collective and antihierarchical forms of organization which eschew demarcation and specialization–and which importantly suggest an inclusive, radical form of civic journalism. (267) Nick Couldry goes further to point out the utopian processes required to identify agencies of change, including alternative media, which he defines as “practices of symbolic production which contest (in some way) media power itself–that is, the concentration of symbolic power in media institutions” (25). Alternative media’s orientation towards oppositional and contestatory practices demonstrates clear parallels between its ambitions and those of counterculture in utopian contexts. From the 1960s onwards, the upsurge in alternative newspaper numbers is commensurate with the blossoming of the counterculture and increased utopian contexts; Susan Forde describes it thus: “a huge resurgence in the popularity of publications throughout the ‘counter-culture’ days of the 1960s and 1970s” (“Monitoring the Establishment”, 114). The nexus of counterculture and alternative media in such utopian contexts is documented in texts like Roger Streitmatter’s Voices of Revolution and Bob Osterlag’s People’s Movements, People’s Press. Like the utopian newspapers that came out of 18th and 19th century intentional communities, many of the new alternative press served to educate, socialise, promote and represent the special interests of the founders and followers of the countercultural movements, often focusing on the philosophy and ideals underpinning these communities rather than the everyday events (see also Frobert). The radical press in Australia was also gaining ground, with OZ in Australia from 1963-1969, and then from 1967-1973 in London. Magazines launched by Philip Frazer like The Digger, Go-Set, Revolution and High Times, and university student newspapers were the main avenues for youth and alternative expression on the Vietnam war and conscription, gay and lesbian rights, racism, feminism and ecological activism (Forde, Challenging the News; Cock & Perry). Nimbin 1973: Rusty Miller and The Byron Express The 1973 Aquarius Festival of counterculture in Nimbin (12-23 May) was a utopian context that had an alternative media life of its own before it arrived in the Rainbow Region–in student publications like Tharnuka and newsletters distributed via the Aquarius Foundation. There were other voices that announced the coming of the Aquarius Festival to Nimbin and reported on its impact, like The Digger from Melbourne and the local paper, The Northern Star. During the Festival, the Nimbin Good Times first appeared as the daily bulletin and continues today with the original masthead drawn by the Festival’s co-organiser, Graeme Dunstan. Some interesting work has been done on this area, ranging from general studies of the Rainbow Region (Wilson; Munro-Clark) to articles analysing its alternative press (Ward & van Vuuren; Martin & Ellis), but to date, there has been no focus on the Rainbow Region’s first alternative newspaper, The Byron Express. Co-edited by Rusty Miller and David Guthrie, this paper presented and mediated the aims and desires of the Aquarian movement. Though short-lived, as only 7 issues were published from 15 February 1973 to September 1973, The Byron Express left a permanent printed vestige of the Aquarian counterculture movement’s activism and ideals from an independent regional perspective. Miller’s credentials for starting up the newspaper are clear–he has always been a trailblazer, mixing “smarts” with surfing and environmental politics. After graduating from a Bachelor of Arts in history from San Diego State College, he first set foot in Byron Bay during his two semesters with the inaugural Chapman College affiliated University of the Seven Seas in 1965-6. Returning to his hometown of Encinitas, he co-founded the Surf Research accessory company with legendary Californian surfer Mike Doyle, and launched Waxmate, the first specially formulated surf wax in 1967 (Davis, Witzig & James; Warshaw 217), selling his interest in the business soon after to spend a couple of years “living the counterculture life on the Hawaiian Island of Kauai” (Davis, Witzig & James), before heading back to Byron Bay via Bells Beach in 1970 (Miller & Shantz) and Sydney, where he worked as an advertising salesman and writer with Tracks surfing magazine (Martin & Ellis). In 1971, he was one of the first to ride the now famous waves of Uluwatu in Bali, and is captured with Steven Cooney in the iconic publicity image for Albe Falzon’s 1971 film, Morning Of The Earth. The champion surfer from the US knew a thing or two about counterculture, alternative media, advertising and business when he found his new utopian context in Byron Bay. Miller and Guthrie’s front-page editorial of the inaugural issue of The Byron Express, published on 15 February 1973, with the byline “for a higher shire”, expressed the countercultural (cl)aims of the publication. Land use, property development and the lack of concern that some people in Byron had for their impact on the environment and people of the region were a prime target: With this first issue of the Byron Express, we hope to explain that the area is badly in need of a focal point. The transitions of present are vast and moving fast. The land is being sold and resold. Lots of money is coming into the area in the way of developments […] caravan parts, hotels, businesses and real estate. Many of the trips incoming are not exactly “concerned” as to what long term effect such developments might have on the environment and its people. We hope to serve as a focus of concern and service, a centre for expression and reflection. We would ask your contributions in vocal and written form. We are ready for some sock it to ya criticism… and hope you would grab us upon the street to tell us how you feel…The mission of this alternative newspaper is thereby defined by the need for a “focal point” that inscribes the voices of the community in a freely accessible narrative, recorded in print for posterity. Although this first issue contains no mention of the Aquarius Festival, there were already rumours circulating about it, as organisers Graeme Dunstan and Johnny Allen had been up to Main Arm, Mullumbimby and Nimbin on reconnaissance missions beginning in September 1972. Instead, there was an article on “Mullumbimby Man–Close to the Land” by Nicholas Shand, who would go on to found the community-based weekly newspaper The Echo in 1986, then called The Brunswick Valley Echo and still going strong. Another by Bob McTavish asked whether there could be a better form of government; there was a surf story, and a soul food section with a recipe for honey meade entitled “Do you want to get out of it on 10 cents a bottle?” The second issue continues in much the same vein. It is not until the third issue comes out on 17 March 1973 that the Aquarius Festival is mentioned in a skinny half column on page four. And it’s not particularly promising: Arrived at Nimbin, sleepy hamlet… Office in disused R.S.L. rooms, met a couple of guys recently arrived, said nothing was being done. “Only women here, you know–no drive”. Met Joanne and Vi, both unable to say anything to be reported… Graham Dunstan (codenamed Superfest) and John Allen nowhere in sight. Allen off on trip overseas. Dunstan due back in a couple of weeks. 10 weeks to go till “they” all come… and to what… nobody is quite sure. This progress report provides a fascinating contemporary insight into the tensions–between the local surfies and hippies on one hand, and the incoming students on the other–around the organisation of the Aquarius Festival. There is an unbridled barb at the sexist comments made by the guys, implicit criticism of the absent organisers, obvious skepticism about whether anyone will actually come to the festival, and wonderment at what it will be like. Reading between the lines, we might find a feeling of resentment about not being privy to new developments in their own backyard. The final lines of the article are non-committal “Anyway, let’s see what eventuates when the Chiefs return.” It seems that all has been resolved by the fifth issue of 11 May, which is almost entirely dedicated to the Aquarius Festival with the front page headline “Welcome to the New Age”. But there is still an undertone of slight suspicion at what the newcomers to the area might mean in terms of property development: The goal is improving your fellow man’s mind and nourishment in concert with your own; competition to improve your day and the quality of the day for society. Meanwhile, what is the first thing one thinks about when he enters Byron and the area? The physical environment is so magnificent and all encompassing that it can actually hold a man’s breath back a few seconds. Then a man says, “Wow, this land is so beautiful that one could make a quid here.” And from that moment the natural aura and spells are broken and the mind lapses into speculative equations, sales projections and future interest payments. There is plenty of “love” though, in this article: “The gathering at Nimbin is the most spectacular demonstration of the faith people have in a belief that is possible (and possible just because they want it to be) to live in love, through love together.” The following article signed by Rusty Miller “A Town Together” is equally focused on love: “See what you could offer the spirit at Nimbin. It might introduce you to a style that could lead to LOVE.” The centre spread features photos: the obligatory nudes, tents, and back to nature activities, like planting and woodworking. With a text box of “random comments” including one from a Lismore executive: ‘I took my wife and kids out there last weekend and we had such a good time. Seems pretty organized and the town was loaded with love. Heard there is some hepatitis about and rumours of VD. Everyone happy.” And another from a land speculator (surely the prime target of Miller’s wrath): “Saw guys kissing girls on the street, so sweet, bought 200 acres right outside of town, it’s going to be valuable out there some day.” The interview with Johnny Allen as the centrepiece includes some pertinent commentary on the media and reveals a well-founded suspicion of the mediatisation of the Aquarius Festival: We have tried to avoid the media actually. But we haven’t succeeded in doing so. Part of the basic idea is that we don’t need to be sold. All the down town press can do is try and interpret you. And by doing that it automatically places it in the wrong sort of context. So we’ve tried to keep it to people writing about the festival to people who will be involved in it. It’s an involvement festival. Coopting The Byron Express as an “involved” party effects a fundamental shift from an external reporting newspaper to a kind of proponent or even propaganda for the Aquarius festival and its ideas, like so many utopian newspapers had done before. It is therefore perhaps inevitable that The Byron Express should disappear very soon after the Aquarius festival. Fiona Martin and Rhonda Ellis explain that Rusty Miller stopped producing the paper because he “found the production schedule exhausting and his readership too small to attract consistent advertising” (5). At any rate, there were only two more issues, one in June–with some follow up reporting of the festival–and another in September 1973, which was almost entirely devoted to environmentally focused features, including an interview with Kath Walker (Oodgeroo Noonuccal). Byron Bay 2013: Thirty Years of Rusty’s Byron Guide What Rusty did next is fairly well known locally–surfing and teaching people how to surf and a bit of writing. When major local employer Walkers slaughterhouse closed in 1983, he and his wife, social geographer Tricia Shantz, were asked by the local council to help promote Byron Bay as a tourist destination, writing the first Byron guide in 1983-4. Incorporating essays by local personalities and dedicated visitors, the Byron guide perpetuates the ideal of environmental awareness, spiritual experimentation, and respect for the land and sea. Recent contributors have included philosopher Peter Singer, political journalist Kerry O’Brien, and writer John Ralston Saul, and Miller and Shantz always have an essay in there themselves. “People, Politics and Culture” is the new byline for the 2013 edition. And Miller’s opening essay mediates the same utopian desires and environmental community messages that he espoused from the beginning of The Byron Express: The name Byron Bay represents something that we constantly try to articulate. If one was to dream up a menu of situations and conditions to compose a utopia, Australia would be the model of the nation-state and Byron would have many elements of the actual place one might wish to live for the rest of their lives. But of course there is always the danger of excesses in tropical paradises especially when they become famous destinations. Australia is being held to ransom for the ideology that we should be slaves to money and growth at the cost of a degraded and polluted physical and social environment. Byron at least was/is a refuge against this profusion of the so-called real-world perception that holds profit over environment as the way we must choose for our future. Even when writing for a much more commercial medium, Miller retains the countercultural utopian spirit that was crystallised in the Aquarius festival of 1973, and which remains relevant to many of those living in and visiting the Rainbow Region. Miller’s ethos moves beyond the alternative movements and communities to infiltrate travel writing and tourism initiatives in the area today, as evidenced in the Rusty’s Byron Guide essays. By presenting more radical discourses for a mainstream public, Miller together with Shantz have built on the participatory role that he played in launching the region’s first alternative newspaper in 1973 that became albeit briefly the equivalent of a countercultural utopian gazette. Now, he and Shantz effectively play the same role, producing a kind of countercultural form of utopian media for Byron Bay that corresponds to exactly the same criteria mentioned above. Through their free publication, they aim to educate, socialise, promote and represent the special interests of the founders and followers of the Rainbow Region, focusing on the philosophy and ideals underpinning these communities rather than the everyday events. The Byron Bay that Miller and Shantz promote is resolutely utopian, and certainly countercultural if compared to other free publications like The Book, a new shopping guide, or mainstream media elsewhere. Despite this new competition, they are planning the next edition for 2015 with essays to make people think, talk, and understand the region’s issues, so perhaps the counterculture is still holding its own against the mainstream. References Atton, Chris. “What Is ‘Alternative’ Journalism?” Journalism: Theory, Practice, Criticism 4.3 (2003): 267-72. Berger, Bennett M. The Survival of a Counterculture: Ideological Work and Everyday Life among Rural Communards. New Brunswick: Transaction Publishers, 2004. Cock, Peter H., & Paul F. Perry. “Australia's Alternative Media.” Media Information Australia 6 (1977): 4-13. Couldry, Nick. “Mediation and Alternative Media, or Relocating the Centre of Media and Communication Studies.” Media International Australia, Incorporating Culture & Policy 103, (2002): 24-31. Davis, Dale, John Witzig & Don James. “Rusty Miller.” Encyclopedia of Surfing. 10 Nov. 2014 ‹http://encyclopediaofsurfing.com/entries/miller-rusty›. Downing, John. Radical Media: Rebellious Communication and Social Movements. Thousand Oaks: Sage. Davis, J.C. Utopia and the Ideal Society: A Study of English Utopian Writing 1516-1700. Cambridge: Cambridge UP, 1983. Forde, Susan. Challenging the News: The Journalism of Alternative and Independent Media. Palgrave Macmillan: London, 2011. ---. “Monitoring the Establishment: The Development of the Alternative Press in Australia” Media International Australia, Incorporating Culture & Policy 87 (May 1998): 114-133. Frobert, Lucien. “French Utopian Socialists as the First Pioneers in Development.” Cambridge Journal of Economics 35 (2011): 729-49. Green, Toby. Thomas More’s Magician: A Novel Account of Utopia in Mexico. London: Phoenix, 2004. Goffman, Ken, & Dan Joy. Counterculture through the Ages: From Abraham to Acid House. New York: Villard Books. 2004. Haude, Sigrun. “Anabaptism.” The Reformation World. Ed. Andrew Pettegree. London: Routledge, 2000. 237-256. Jameson, Fredric. Archeologies of the Future: The Desire Called Utopia and Other Science Fictions. New York: Verso, 2005. Levitas, Ruth. Utopia as Method. London: Palgrave Macmillan, 2013. Martin, Fiona, & Rhonda Ellis. “Dropping In, Not Out: The Evolution of the Alternative Press in Byron Shire 1970-2001.” Transformations 2 (2002). 10 Nov. 2014 ‹http://www.transformationsjournal.org/journal/issue_02/pdf/MartinEllis.pdf›. McKay, George. Senseless Acts of Beauty: Cultures of Resistance since the Sixties. London: Verso, 1996. Metcalf, Bill. From Utopian Dreaming to Communal Reality: Cooperative Lifestyles in Australia. Sydney: University of New South Wales Press, 1995. ---. Shared Visions, Shared Lives: Communal Living around the Globe. Forres, UK: Findhorn Press, 1996. Miller, Rusty & Tricia Shantz. Turning Point: Surf Portraits and Stories from Bells to Byron 1970-1971. Surf Research. 2012. Molnar, Thomas. Utopia: The Perennial Heresy. London: Tom Stacey, 1972. Moylan, Tom. Demand the Impossible: Science Fiction and the Utopian Imagination. New York: Methuen, 1986. Munro-Clark, Margaret. Communes in Rural Australia: The Movement since 1970. Sydney: Hale & Iremonger, 1986. Osterlag, Bob. People’s Movements, People’s Press: The Journalism of Social Justice Movements. Boston: Beacon Press, 2006. Roszak, Theodore. The Making of a Counter Culture: Reflections on the Technocratic Society and Its Youthful Opposition. New York: Anchor, 1969. Sargent, Lyman Tower. “Three Faces of Utopianism Revisited.” Utopian Studies 5.1 (1994): 1-37. Schaer, Roland, Gregory Claeys, and Lyman Tower Sargent, eds. Utopia: The Search for the Ideal Society in the Western World. New York: New York Public Library/Oxford UP, 2000. Streitmatter, Roger. Voices of Revolution: The Dissident Press in America. Columbia: Columbia UP, 2001. Suvin, Darko. Metamorphoses of Science Fiction: On the Poetics and History of a Literary Genre. New Haven: Yale UP, 1979. Ward, Susan, & Kitty van Vuuren. “Belonging to the Rainbow Region: Place, Local Media, and the Construction of Civil and Moral Identities Strategic to Climate Change Adaptability.” Environmental Communication 7.1 (2013): 63-79. Warshaw, Matt. The History of Surfing. San Francisco: Chronicle Books, 2011. Wilson, Helen. (Ed.). Belonging in the Rainbow Region: Cultural Perspectives on the NSW North Coast. Lismore, NSW: Southern Cross University Press, 2003. Widmer, Kingsley. Counterings: Utopian Dialectics in Contemporary Contexts. Ann Arbor, London: UMI Research Press, 1988. Yinger, J. Milton. Countercultures: The Promise and Peril of a World Turned Upside Down. New York: The Free Press, 1982.

In rejoinder to a New York Times’s article claiming, “the value of used pianos, especially uprights, has plummeted … Instead of selling them … , donating them … or just passing them along … , owners are far more likely to discard them” (Walkin), artists Kathleen Irwin (scenography) and Jeff Morton (sound/composition) responded to this ignoble passing with an installation playing with the borders delineating music, theatre, digital technology, and economies of value using two upright red pianos, sound and video projection—and the sensibility of relational aesthetics. The installation was a collaboration between two artists who share a common interest in the performative qualities of public space and how technological augmentation is used in identificatory and embodied art processes as a means of extending the human body and enhancing the material space of person-to-person interaction. The title of the installation, PLAY, referenced the etymology of the word itself and how it has been variously understood over time, across artistic disciplines, and in digital and physical environments. Fundamentally, it explored the relative value of a material object (the piano) and how its social and cultural signification persists, shifts, is diminished or augmented by technology. The installation was mounted at the Dunlop Art Gallery, in the Regina Public Library (Saskatchewan, Canada, 14 June - 25 August 2013) and, as such, it illustrated the Library’s mandate to support all forms of literacy through community accessibility and forms of public outreach, social arrangements, and encounters. Indirectly, (as this was not the initial focus), it also exemplified the artists’s gentle probing of the ways, means, claims, and values when layering information and enhancing our visual experience as we interact with (literally, walk through) our physical landscapes and environments—“to see the world for what it is,” as Matt Turbow says “and to see the elements within” (Chapeau). The installation reflected on, among other things, the piano as a still potent cultural signifier, the persistent ability of our imagination to make meaning and codify experience even without digital overlay, and the library as an archive and disseminator of public knowledge. The artists questioned whether old technologies such as the piano will lose their hold on us entirely as technological augmentation develops the means to enhance or colonize the natural world, through graphics, sounds, haptic feedback, smell and, eventually, commodified experiences. This paper intends to reflect on our work and initiate a friendly (playful) interdisciplinary discussion about material objects in the age of physical and digital interactivity, and the terms of augmentation as we chose to understand it through our installation. In response to the call proposed by this journal on the subject of augmentation, we considered: 1. How audio/visual apparatuses in the gallery space augmented the piano’s expressivity; 2. How the piano augmented the social function of its physical situation; 3. How the technology augmented random and fragmentary musical phrases, creating a prolonged musical composition; 4. How each spectator augmented the art through his/her subjective engagement: how there is always meaning generated in excess of the artists’s intention. Image 1: Piano installed outside Dunlop Gallery/ Regina Public Library (photo credit: Jeff Morton) To begin, a brief description of the site of the installation is in order. The first of the red pianos was installed outside the main doors of the Central Library, located in the city’s downtown. The library’s entrance is framed within a two-story glass atrium and the red piano repeated the architecture’s function to open the space by breaking down perceived barriers, and beckoning the passersby inside. Reflecting Irwin’s community-oriented, site-specific practice, this was the relational catalyst of the work—the piano made available for anyone to play and enjoy, day or night, an invitation to respond to an object inserted into the shared space of the sidewalk: to explore, as Nicolas Bourriaud suggests, “the art as a state of encounter” (16). It was the centerpiece of the exhibition's outreach, which included the exhibition’s vernissage featuring new music and performance artists in concert, a costume and prop workshop for a late night public choir procession, and a series of artist talks. This was, arguably, a defining characteristic of the work, underscoring how the work of art, in this case the piano itself, its abjection illustrated by the perfunctory means typically used to dispose of them, is augmented or gains value through its social construction, over-and-above any that is originally ascribed to it. As Bourriaud writes, any kind of production takes on a social form which no longer has anything to do with its original usefulness. It acquires exchange value that partly covers and shrouds its primary “nature”. The fact is that a work of art has no a priori useful function—not that it is socially useless, but because it is available and flexible, and has an “infinite tendency”. (42) In the Dunlop’s press release, curator Blair Fornwald also confers a supplemental value ascribed to the reframed material object. She describes how the public space in front of the library, as a place of social interaction and cultural identification—of “being seen”—is augmented by the red piano: its presence in an unfamiliar setting underscores the multitude of creative and performative possibilities inherent within it, possibilities that may extend far beyond playing a simple melody. By extension, its presence asserts that the every day is a social, cultural, and physical environment rich with potentiality and promise. (Fornwald) Juxtaposed with the first red piano, the second was dramatically staged within the Dunlop gallery. The room, painted black, formally replicated the framing and focusing conventions of the theatre: its intention to propose other ways of “being seen” and to suggest the blurring of lines between “on stage and off,” and by extension, “on line and off.” A camera embedded in the front of the piano and a large projection screen in the space provided a celebrity moment for anyone approaching the instrument and implied, arguably, the ubiquitous surveillance associated with public space. Indeed, a plausible way of reading the red piano in the darkened gallery was as a provocation to think about how the digital and physical are increasingly enmeshed in our daily lives (Jurgenson). Lit by a chandelier and staged on a circular red carpet, this piano was also available to be played. Unlike the one outside of the building, it was augmented by speakers, a microphone, and a webcam. Through a custom-built digital system (using MaxMSP software), it recorded and played back the sound and image of everyone who sat down to perform, then repeated and superimposed these over similar previously captured material. Enhanced by the unusual stark acoustics of the gallery, the sound filled the reverberant space. Affixed to the gallery’s back wall was the projection screen made up of sheet music (Bach, Debussy and Mozart) taken from the Irwin family’s piano bench, a veritable time capsule from the 1950s. Image 2: Piano installed inside Dunlop Gallery (photo credit: Jeff Morton) In addition to the centrally placed piano, a miniature red piano was situated near the gallery entrance. It and a single red chair placed near the screen, repeated the vivid colour and drew the eye into and around the space underscoring its theatrical quality. The toy piano functioned as a lighthearted invitation, as well as a serious citation of other artists—Eikoh Sudoh, Margaret Leng Tan, John Cage, and Charles M. Schulz’s “Schroeder”—who have employed the miniature instrument to great advantage. It was intended as an illustration of the infinite resonances that material objects may provide and the diverse ways they may signify contingent on the viewer. Considered in a historical context, in the golden age of the upright and at the turn of the twentieth-century, piano lessons signified for many, the formation of a modern citizen schooled in European culture and values. Owning one of these intricately engineered and often beautiful machines, as one in five households did, reflected the social aspirations of its owners and marked their upward economic mobility (Canadian Encyclopedia). One hundred years later, pianos are often relegated to the basement or dump. Irretrievably out of tune, their currency as musical instruments largely devalued. Nonetheless, their cultural and social value persists, no longer the pervasive marker of status, but through the ways they are mediated by artists who prepare, deconstruct, and leave them to deteriorate in beautiful ways. They seem to retain their hold on us through the natural impulse to engage them kinetically, ergonomically, and metaphorically. Built to be an extension of the human hand, body, and imagination, they are a sublime human-scale augmentation of a precise musical system of notation, and a mechanism evolved over centuries through physical augmentations meant to increase the expressivity of both instrument and player. In PLAY, the use of the pianos referenced both their traditional role in public life, and our current relationship with forms of digital media that have replaced these instruments as our primary means of being linked, informed, and entertained—an affirmation of the positive attributes of technology and a reminder of what we may have lost. Indeed, while this was not necessarily clear from the written responses in the Gallery’s guest book (Gorgeous!: Neat!; Too, too cool!; etc.), we surmised that memory might have played a key role in the experience of the installation, set in motion by the precise arrangement of the few material objects – red piano, the piano bench, red chair, and toy piano, each object designed to fit the shape of the body and hold the memory of physical contact. These were designed to trigger a chain of recollections, each chasing the next; each actively participating in what follows. In the Gallery’s annual exhibition catalogue, Ellen Moffat suggests that the relationship the piano builds with the player is important: “the piano plays and is played by the performer. Performing the piano assigns a posture for the performer in relation to the keyboard physically and figuratively” (Moffat 80). Technically, the piano is the sum of many parts, understandable finally as a discrete mechanical system, but unbounded in imagination and limited only by our capacity to play it. Functionally, it acts as an affective repository of memory and feeling, a tool to control the variables of physical and expressive interaction. In PLAY, the digital system in the gallery piano captured, delayed and displayed audio and video clips according to a rubric of cause and effect. Controlled by computer software designed by Morton, the installation captured musical phrases played randomly by individuals and augmented these notes by playing them back at variable speeds and superimposing one over another—musical phrases iterated and reiterated. The effect was fugue-like—an indeterminate composition with a determinant structure, achieved by intertwining physical and digital systems with musical content supplied by participants. The camera hidden in the front of the piano recorded individuals as they sat at the instrument and, immediately, they saw themselves projected in extreme close up onto the screen behind. As the individual struck a note, their image faded and the screen was filled again with the image of a previous participant abstracted and in slow motion. The effect, we suggest, was dreamlike—an echo or a fleeting fragment of something barely remembered. Like the infinite variations the piano permits, the software was also capable of expressing immense variety—each sound and image adding to an expanding archive in an ever-changing improvised composition developed through iterative call and response. Drawing on elements of relational aesthetics, scenographic representation, and digital technology, in PLAY we attempted to cross disciplines in ways that distinguished it from the other piano projects seen over the past several years. Indeed, the image of the upright piano has resonated in the zeitgeist of the international art scene with colourful uprights placed in public places in urban centers across Europe and North America. Wherever they are, individuals engage enthusiastically with them and they, in turn, become the centre of attention: this is part of their appeal. The pianos seem to evoke a utopian sense of community, however temporary, providing opportunities to rediscover old neighbours and make new friends. In PLAY, we posed two different social and aesthetic encounters—one analogue, real, “off-line” and one digital, theatrical, and “on-line,” illustrating less a false binary between two possible realities that ascribes more value to one than the other, than a world where the digital and the physical comingle. Working within a public library, this was a germane train of thought considering how these institutes struggle to stay relevant in the age of Google search and the promise of technological augmentation. The piano also represents a dichotomy: both a failure to represent and an excess of meaning. For decades replete with social signification, they have now become an encumbrance, fit only for the bone yard. As these monumental relics come to the end of their mechanical life, there is more money made in their disposal than in musical production, and more value in their recycled metals, solid wooden bodies, and ivory keys then in their tone and function. The industry that supported their commodification collapsed years ago, as has the market for their sale and the popular music publishing industry that accompanied it. Of course, pianos will be with us for a long time in one form or another, but their history, as a culturally potent object, has diverged. The assumption could easily follow that they have been rendered useless as an aesthetic, generative, and social object. What this installation offered was the possibility of an alternative ending to the story of this erstwhile entertainment console even as we seek our amusement by other means and through other devices. Not surprisingly, the title of the installation suggests that the consideration of “play,” as social and recuperative engagement, is significant. In his seminal work, Homo Ludens, Johan Huizinga discusses the importance of play, suggesting that it is primary to and a necessary condition of the making of culture. He writes, “In play there is something in play, which transcends the immediate needs of life and imparts meaning to the action” (Huizinga 97). According to games theorist Mary Flanagan, playing may serve as a way of creating something beautiful, offering frameworks for new ways of thinking, exploring divergent logic, or for imaging what is possible. She writes, “Games, both digital and analog, offer a space to explore creativity, agency, representation and emergent behaviour” (Flanagan 2010). In reaching out to Regina’s downtown community, the Dunlop Art Gallery dispersed some of the playfulness of PLAY in planned and accidental ways, as the outdoor piano became a daily destination for individuals who live rough or in the city’s hostels, some of whom who have enviable musical skills and considerable stage presence. One man came daily with sheet music in hand to practice on the indoor piano—ignoring the inevitable echo and repeat that the software triggered. Another young woman appeared regularly to perform at the outdoor piano, her umbrella raised against sun and rain, wedged under her arm to keep both hands free. Children invariably drew parents to it as they entered or exited the library—for some it may have been the first time they had touched such an instrument. Overall, in press, blogs, and the visitors’s book, responses to the pianos were enthusiastic and positive. One blogger wrote in response to an online publication, Art, Music, News (Beatty), chapeau June 13, 2013 at 11:51am this is most definitely up and running, and it would be interesting to see/hear all that will go on with that red piano. my two-and-a-half year old daughter and i jammed a bit yesterday morning, while a stranger watched and listened, then insisted that i play the same mostly crappy c-blues again while he sang! so i did, and he did, and my daughter and i learned a bit about what he feels about his dog via his singing. it was the highlight of the day for us—I mean really, jamming outside on a very red upright piano with strangers—good times! (Simpson) As evidence of public approbation, for the better part of the summer it stood unprotected on the sidewalk in front of the library encountering only one minor incident of defacement—a rather fragile tag in white spray paint, someone’s name in proper cursive writing. Once repaired and retuned, it became a dynamic focus for the annual Folk Festival that takes over the area for a week in August. In these ways, PLAY fulfilled the Library’s aim of encouraging literacy and reinforcing a sense of community—a social augmentation, in a manner of speaking. As Moffat writes, it encourages the social dimension of participation through community-engagement and dialogic practices. It blurs distinctions between spectator and participant, professional and amateur. It generates relationships between people or social actions. (Moffat 76) Finally, PLAY toyed with the overtones of the word itself—as verb, noun, and adjective—signifier, and metaphor. The title illustrated its obvious current potential and evoked the piano’s past, referencing the glittering world of the stage. While many may have more memories of seeing pianos in disrepair than in the concert hall, its iconic stage setting is never far from the imagination, although this too changes as people from other cultures and backgrounds recognize little cultural capital in such activity. In current vernacular, the word “play” also implies the re-imagination of ourselves in the digital overlays of the future. So we ask, what will be the fate of the piano and its meme in the 22nd century? Will the augmentation of reality enhance our experience of the world in inverse proportion to a loss of social interaction? Conclusion In her essay, Moffat notes that as digital technology replaces the analog piano, a surplus of second-hand uprights has become available. Citing artists Luke Jerram, Monica Yunus, and Camille Zamora (among others), she argues that the use of them as public art coincides with their disappearance, suggesting a farewell or memorial to a collective cultural icon (Moffat 76). What is there in this piece of furniture that speaks to us in art practice? The answer, it would seem, is potential. In a curatorial interview, Irwin suggested the possibility that beyond the artist’s initial meaning, there is always something more—an augmentation. The pleasure of discovering this supplement is part of the pleasure of the subjective experience of the spectator. Similarly, the aleatoric in music composition, refers to the pursuit of chance as a formal determinant and its openness to individual interpretation at the moment of reception. For Morton, the randomness of memory and affect are key components in composition. They cannot be predicted, controlled or quantified; nor can they be denied. There is no correct interpretation or response to music or, indeed, to relational art practice. Moffat concludes, as a multi-faceted media installation, PLAY proposed “a suite, chorus or a polyphony of things” (Moffat 76). Depending on your point of reference, the installation provided a dynamic venue for considering our relationships with material objects, with each other and with new technologies asking how they may or may not augment our reality in ways that supplement real-time, person-to-person interaction. References Beatty, Gregory. “Exciting Goings-On at Central Library.” Prairie Dog Blog 11 June 2013. Bourriaud, Nicolas. Relational Aesthetics. Trans. Simon Pleasance and Fronza Woods. Paris: Les Presses du Réel, 1998. Canadian Encyclopedia. “Piano Building.” ‹http://www.thecanadianencyclopedia.com/en/article/piano-building-emc/›. Chapeau [David Simpson]. “One Response to ‘Exciting Goings-On at Central Library.’” Prairie Dog Blog 13 June 2013. Fornwald, Blair. PLAY. Regina, Saskatchewan: Dunlop Art Gallery. 2013. Flanagan, Mary. “Creating Critical Play.” In Ruth Catlow, Marc Garret and Corrado Morgana, eds., Artists Rethinking Games. Liverpool: Liverpool University Press, 2010. 49-53. Huizinga, Johan. Homo Ludens. Boston: Beacon Press, 1995. Jerram, Luke. Play Me, I’m Yours. Site-Specific Piano Installation. Multiple Venues. 2008-2013. Jurgenson, Nathan. “Digital Dualism versus Augmented Reality.” Cybergology: The Society Pages 24 Feb. 2011. 1 Dec. 2013 ‹http://thesocietypages.org/cyborgology/2011/02/24/digital-dualism-versus-augmented-reality/›. Moffat, Ellen. “Stages and Players” in DAG 2 (2013). Regina: Dunlop Art Gallery, 2013. 75-87. Walkin, Daniel J. “For More Pianos, Last Note Is Thud in the Dump.” New York Times 29 June 2012. Yunus, Monica, and Camille Zamora. Sing for Hope Pianos. Site-Specific Piano Installation and Performance. New York City. 2013.