Adverse life events precede the onset of functional neurological disorder (FND, also known as conversion disorder) more commonly than other neuropsychiatric conditions, but their aetiological role is unclear. We conducted a systematic review and quantitative analysis of the type, timing and number of life events preceding the onset of FND in adults, and a meta-analysis of the proportions of types of events in controlled studies. Fifty-one studies of different designs, covering 4247 patients, were eligible for inclusion. There was no clear majority of any type of preceding event. Family problems were the most common category of events, followed by relationship problems. Females were more likely to experience preceding family/relationship problems than males, who reported more work problems. Family problems were the commonest type of preceding event in studies in developing countries, whereas family and health problems were equally common in developed countries. Abuse was associated with early symptom onset, while patients with later onset were more likely to report family problems. The median number of events was one, and the events occurred closer to onset than in controls. Meta-analysis found that family, relationship and work events were all relatively more common in patients than pathological controls, as were events where symptoms might provide a solution to the stressor. In conclusion, although a range of events precede the onset of FND, they do not appear to do so uniformly. This may support a different aetiological role for stressors than in other disorders, although the support is indirect and the quality generally low.

Deposits of at least three glaciations are present in New Jersey and the New York City area. The oldest deposits are magnetically reversed. Pollen and stratigraphic relations suggest that they are from the earliest Laurentide advance at ~2.4 Ma. Deposits of a second advance are overlain by peat dated to 41 ka and so are pre-Marine Isotope Stage (pre-MIS) 2. Their relation to marine deposits indicates that they predate MIS 5 but postdate MIS 11 and may postdate MIS 7 or 9, suggesting an MIS 6 age. The most recent deposits are of MIS 2 (last glacial maximum [LGM]) age. Radiocarbon dates and varve counts tied to glacial-lake events indicate that LGM ice arrived at its terminus at 25 ka, stood at the terminus until ~24 ka, retreated at a rate of 80 m/yr until 23.5 ka, and then retreated at a rate of 12 m/yr to 18 ka. At 18 ka the retreat record connects to the base of the North American Varve Chronology at Newburgh, New York. The 25–24 ka age for the LGM is slightly younger than, but within the uncertainty of, cosmogenic ages; it is significantly older than the oldest dated macrofossils in postglacial deposits in the region.

Background: With the emergence of antibiotic resistant threats and the need for appropriate antibiotic use, laboratory microbiology information is important to guide clinical decision making in nursing homes, where access to such data can be limited. Susceptibility data are necessary to inform antibiotic selection and to monitor changes in resistance patterns over time. To contribute to existing data that describe antibiotic resistance among nursing home residents, we summarized antibiotic susceptibility data from organisms commonly isolated from urine cultures collected as part of the CDC multistate, Emerging Infections Program (EIP) nursing home prevalence survey. Methods: In 2017, urine culture and antibiotic susceptibility data for selected organisms were retrospectively collected from nursing home residents’ medical records by trained EIP staff. Urine culture results reported as negative (no growth) or contaminated were excluded. Susceptibility results were recorded as susceptible, non-susceptible (resistant or intermediate), or not tested. The pooled mean percentage tested and percentage non-susceptible were calculated for selected antibiotic agents and classes using available data. Susceptibility data were analyzed for organisms with ≥20 isolates. The definition for multidrug-resistance (MDR) was based on the CDC and European Centre for Disease Prevention and Control’s interim standard definitions. Data were analyzed using SAS v 9.4 software. Results: Among 161 participating nursing homes and 15,276 residents, 300 residents (2.0%) had documentation of a urine culture at the time of the survey, and 229 (76.3%) were positive. Escherichia coli, Proteus mirabilis, Klebsiella spp, and Enterococcus spp represented 73.0% of all urine isolates (N = 278). There were 215 (77.3%) isolates with reported susceptibility data (Fig. 1). Of these, data were analyzed for 187 (87.0%) (Fig. 2). All isolates tested for carbapenems were susceptible. Fluoroquinolone non-susceptibility was most prevalent among E. coli (42.9%) and P. mirabilis (55.9%). Among Klebsiella spp, the highest percentages of non-susceptibility were observed for extended-spectrum cephalosporins and folate pathway inhibitors (25.0% each). Glycopeptide non-susceptibility was 10.0% for Enterococcus spp. The percentage of isolates classified as MDR ranged from 10.1% for E. coli to 14.7% for P. mirabilis. Conclusions: Substantial levels of non-susceptibility were observed for nursing home residents’ urine isolates, with 10% to 56% reported as non-susceptible to the antibiotics assessed. Non-susceptibility was highest for fluoroquinolones, an antibiotic class commonly used in nursing homes, and ≥ 10% of selected isolates were MDR. Our findings reinforce the importance of nursing homes using susceptibility data from laboratory service providers to guide antibiotic prescribing and to monitor levels of resistance.

Disclosures: None

Funding: None

Background: Antibiotics are among the most commonly prescribed drugs in nursing homes; urinary tract infections (UTIs) are a frequent indication. Although there is no gold standard for the diagnosis of UTIs, various criteria have been developed to inform and standardize nursing home prescribing decisions, with the goal of reducing unnecessary antibiotic prescribing. Using different published criteria designed to guide decisions on initiating treatment of UTIs (ie, symptomatic, catheter-associated, and uncomplicated cystitis), our objective was to assess the appropriateness of antibiotic prescribing among NH residents. Methods: In 2017, the CDC Emerging Infections Program (EIP) performed a prevalence survey of healthcare-associated infections and antibiotic use in 161 nursing homes from 10 states: California, Colorado, Connecticut, Georgia, Maryland, Minnesota, New Mexico, New York, Oregon, and Tennessee. EIP staff reviewed resident medical records to collect demographic and clinical information, infection signs, symptoms, and diagnostic testing documented on the day an antibiotic was initiated and 6 days prior. We applied 4 criteria to determine whether initiation of treatment for UTI was supported: (1) the Loeb minimum clinical criteria (Loeb); (2) the Suspected UTI Situation, Background, Assessment, and Recommendation tool (UTI SBAR tool); (3) adaptation of Infectious Diseases Society of America UTI treatment guidelines for nursing home residents (Crnich & Drinka); and (4) diagnostic criteria for uncomplicated cystitis (cystitis consensus) (Fig. 1). We calculated the percentage of residents for whom initiating UTI treatment was appropriate by these criteria. Results: Of 248 residents for whom UTI treatment was initiated in the nursing home, the median age was 79 years [IQR, 19], 63% were female, and 35% were admitted for postacute care. There was substantial variability in the percentage of residents with antibiotic initiation classified as appropriate by each of the criteria, ranging from 8% for the cystitis consensus, to 27% for Loeb, to 33% for the UTI SBAR tool, to 51% for Crnich and Drinka (Fig. 2). Conclusions: Appropriate initiation of UTI treatment among nursing home residents remained low regardless of criteria used. At best only half of antibiotic treatment met published prescribing criteria. Although insufficient documentation of infection signs, symptoms and testing may have contributed to the low percentages observed, adequate documentation in the medical record to support prescribing should be standard practice, as outlined in the CDC Core Elements of Antibiotic Stewardship for nursing homes. Standardized UTI prescribing criteria should be incorporated into nursing home stewardship activities to improve the assessment and documentation of symptomatic UTI and to reduce inappropriate antibiotic use.

Funding: None

Disclosures: None

Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance.

Contemporary US Supreme Court nominations are unavoidably and inevitably political. Although observers worry that political contestation over nominations undermines support for qualified nominees and threatens the Court's legitimacy, there is little empirical evidence to support these claims. The authors argue that political contestation over judicial nominations provides cues that shape the public's impressions about nominees and the Court and polarizes public opinion across partisan lines. Data from a conjoint experiment administered in the first days of the Trump presidency support this argument. Political rhetoric attributed to President Trump and Senate Democrats substantially polarized partisans’ views of nominees and evaluations of the Court's legitimacy, with Republicans (Democrats) expressing significantly more (less) favorable attitudes. Additional analyses suggest that contestation generates divergent partisan responses by affecting views about the nominee's impartiality. These findings challenge existing perspectives that depict attitudes toward the judiciary as resistant to partisan considerations and have important implications for the Court's legitimacy in a polarized era.

Though the demographic characteristics of judicial nominees in the United States have gained increased political attention in recent years, relatively little is known about how they affect public opinion toward judicial nominees and courts. We evaluate these relationships in the context of race and gender using a conjoint experiment conducted during a recent vacancy on the U.S. Supreme Court. We find consistent evidence that Americans are more supportive of coracial nominees, particularly among white Republicans and Black Democrats, but no evidence of a similar effect on the basis of gender. Our results have important implications for theories of descriptive representation and suggest limits to its use as a means for generating political support for judicial nominees.

In this paper we develop a novel ray solver for the time-harmonic linearized Euler equations used to predict high-frequency flow–acoustic interaction effects from point sources in subsonic mean jet flows. The solver incorporates solutions to three generic ray problems found in free-space flows: the multiplicity of rays at a receiver point, propagation of complex rays and unphysical divergences at caustics. We show that these respective problems can be overcome by an appropriate boundary value reformulation of the nonlinear ray equations, a bifurcation-theory-inspired complex continuation, and an appeal to the uniform functions of catastrophe theory. The effectiveness of the solver is demonstrated for sources embedded in isothermal parallel and spreading jets, with the fields generated containing a wide variety of caustic structures. Solutions are presented across a large range of receiver angles in the far field, both downstream, where evanescent complex rays generate the cone of silence, and upstream, where multiple real rays are organized about a newly observed cusp caustic. The stability of the caustics is verified for both jets by their persistence under parametric changes of the flow and source. We show the continuation of these caustics as surfaces into the near field is complicated due to a dense caustic network, featuring a chain of locally hyperbolic umbilic caustics, generated by the tangency of rays as they are channelled upstream within the jet.