The history of maize in Central America and surrounding areas has implications for the slow transition from hunting and gathering to agriculture. The spread of early forms of domesticated maize from southern Mexico across Mesoamerica and into South America has been dated to about 8,700–6,500 years ago on the basis of a handful of studies relying primarily on the analysis of pollen, phytoliths, or starch grains. Recent genomic data from southern Belize have been used to identify Archaic period south-to-north population movements from lower Central America, suggesting this migration pattern as a mechanism that introduced genetically improved maize races from South America. Gradually, maize productivity increased to the point that it was suitable for use as a staple crop. Here we present a summary of paleoecological data that support the late and uneven entry of maize into the Maya area relative to other regions of Central America and identify the Pacific coastal margin as the probable route by which maize spread southward into Panama and South America. We consider some implications of the early appearance of maize for Late Archaic populations in these areas; for example, with respect to the establishment of sedentary village life.

Background: Bacterial coinfections with COVID-19 appear to be rare, yet antibiotic use in this population is high. Limited guidance is available regarding the use of antibiotics in these patients. In response, a multidisciplinary group of physicians and pharmacists from 5 VISN9 facilities developed a guideline for the use of antibiotics with COVID-19 in July 2021. This guideline created a network-wide standard for antibiotic use and facilitates the assessment of antibiotic appropriateness in hospitalized veterans with COVID-19. Methods: In this observational, cross-sectional study, we reviewed veterans diagnosed with COVID-19 from August 1 through September 30, 2021, who were admitted to VISN9 facilities. Use of antibiotics was assessed during the first 4 days of admission. If antibiotics were prescribed, their use was determined to be appropriate or inappropriate based on the presence or absence of a finding concerning for bacterial coinfection as outlined in the guideline (Table 1). Additional data including procalcitonin results as well as positive sputum cultures were collected. Results: In total, 377 veterans were admitted for COVID-19 during the study period. Among them, 42 veterans (11%) received antibiotics for nonrespiratory infections and were removed from this analysis. Of the remaining 335 veterans, 229 (68%) received antibiotics and 116 (51%) of those met guideline criteria that were concerning for bacterial coinfection. Additionally, 32 (14%) of the 229 veterans who received antibiotics had >1 finding concerning for bacterial coinfection. Procalcitonin levels were obtained in 97 (42%) of 229. Only 33 veterans (14%) who received antibiotics had an elevated procalcitonin, and only 19 (8%) had a positive sputum culture. Conclusions: Antibiotic use was common in hospitalized veterans with COVID-19 in VISN9 facilities. This results are comparable to findings in the published literature. Among those receiving antibiotics early in their hospitalization, half were considered appropriate based on our guideline. Quality improvement initiatives are needed to improve implementation of the network guideline to reduce the overuse of antibiotics for management of COVID-19. Additionally, procalcitonin may be a helpful tool for hospitalized veterans with COVID-19.

Funding: None

Disclosures: None

Before Odysseus navigates the rocks on which live Scylla and Charybdis he is lulled by the Sirens, promising advance disclosure of earthly adventures. Forewarned by Circe, he enjoins his crew first to contain him; later (on pain of death) to release him from the mast to which he is bound. Held to his originally expressed wishes, they refuse, and bind him more tightly. In this way, Odysseus creates what may have been one of the first advance directives. Its enforcement illustrates one of the concerns which have latterly been expressed about making binding health care choices, possibly many years before they might take effect

‘People do not always mean what they say; they do not always say what they want; and they do not always want what they say they want. That much is, if not exactly clear, at least uncontroversial. What is controversial is, recognizing this, how to proceed.’

The new reproductive technologies, especially in vitro fertilization (IVF), have extended the possi- bilities of assisted reproduction to the benefit of the childless couples. At the same time these technologies and their added techniques, however, have fragmented reproduction and exposed the human egg to intervention yet unknown:

• The embryo may be divided into several embryos; may be sold; donated; cryopreserved; borne by another woman and returned; or used for research;

• Genetic parentage may be present without sexual intercourse, may be different from social parentage and the natural time-span between fertilization and birth may be interrupted.