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Los divertículos intestinales son muy frecuentes en medicina humana, siendo la ubicación más común en el colon (35-75%) y duodeno (15-42%). En medicina veterinaria son poco comunes. El presen-te reporte tiene por objetivo describir la presencia de un divertículo duodenal en un canino de raza Bóxer, de 25 kg de peso, pelaje bayo, de dos años de edad, cuya historia reflejaba vómitos esporádicos, pérdida de peso e hiporexia. Sometido a laparotomía exploratoria por presen-cia de cuerpo extraño en duodeno descendente, el paciente presen-tó in-situ, una deformación compatible con divertículos, hallándose como resultado histopatológico la confirmación del mismo. Ante la presencia de signos gastrointestinales en caninos, jóvenes en general y de raza Bóxer en particular, se sugiere considerar al divertículo intestinal como entidad patológica, dentro de los diagnósticos diferenciales.

La actual localización y el nivel de utilización de establecimientos escolares en el departamento de Caazapá, como en otras regiones del Paraguay, propician un incremento sostenido de costos de mantenimiento e inversión en infraestructura, destinándose a nivel nacional en los últimos 8 años 537 millones de USD a infraestructura. Hoy día, existen 469 establecimientos escolares localizados en este departamento, con un promedio de 83 alumnos por escuela. Si también se considera que el 66% de los establecimientos tiene menos de 25 alumnos se puede inferir que existe una subutilización de la infraestructura y sobrecostos de funcionamiento. En contraste, apenas el 1% de los establecimientos tiene más de 49 alumnos por aula. Esta distribución espacial de establecimientos escolares, y sus niveles de ocupación generan en el tiempo elevados costos de inversión para la mejora y mantenimiento, y ocasiona a su vez problemas de gestión de los recursos, que son escasos. Es imperativa, entonces, la aplicación de estrategias orientadas a la optimización de los recursos disponibles. Con este trabajo, se generó una distribución de escuelas, con la búsqueda de la mejor selección de establecimientos escolares, en el sentido de la minimización de los costos operativos, de inversión en infraestructura y de transporte de estudiantes. Para ello, se identificó previamente un modelo de programación matemática, existente en la literatura, y compatible con el caso de Caazapá en términos de variables, parámetros, restricciones y función objetivo. Las implicancias de este nuevo conjunto reorganizado de establecimientos abarcan el cierre de algunas escuelas, el cambio de la capacidad de otras, o bien, la continuidad sin cambio alguno. El modelo fue modificado, adaptado al caso paraguayo, y combinado con el uso de sistemas de información geográficas (SIG) para el análisis del problema y la presentación de los resultados.

Background. Early percutaneous coronary intervention (PCI) has been shown to be superior to fibrinolytic therapy and is associated with reduced morbidity and mortality for patients with ST-segment elevation myocardial infarction (STEMI). Objective. To determine the performance of a regional system with prehospital 12-lead electrocardiogram (ECG) identification of STEMI patients and direct paramedic transport to STEMI receiving centers (SRCs) for provision of primary PCI. Methods. This was a prospective study evaluating the first year of implementation of a regional SRC network to determine the key time intervals for patients identified with STEMI in the prehospital setting. Results. During the 12-month study period, 1,220 patients with a suspected STEMI were identified on prehospital 12-lead ECG, of whom 734 (60%) underwent emergency PCI.Adoor-to-balloon time of 90 minutes or less was achieved for 651 (89%) patients, and 459 (62.5%) had EMS-patient contact-to-balloon times

The effort to understand the genetic basis of human sociality has been encouraged by the diversity and heritability of social traits like cooperation. This task has remained elusive largely because most studies of sociality and genetics use sample sizes that are often unable to detect the small effects that single genes may have on complex social behaviors. The lack of robust findings could also be a consequence of a poor characterization of social phenotypes. Here, we explore the latter possibility by testing whether refining measures of cooperative phenotypes can increase the replication of previously reported associations between genetic variants and cooperation in small samples. Unlike most previous studies of sociality and genetics, we characterize cooperative phenotypes based on strategies rather than actions. Measuring strategies help differentiate between similar actions with different underlaying social motivations while controlling for expectations and learning. In an admixed Latino sample (n = 188), we tested whether cooperative strategies were associated with three genetic variants thought to influence sociality in humans-MAOA-uVNTR, OXTR rs53576, and AVPR1 RS3. We found no association between cooperative strategies and any of the candidate genetic variants. Since we were unable to replicate previous observations our results suggest that refining measurements of cooperative phenotypes as strategies is not enough to overcome the inherent statistical power problem of candidate gene studies.

Introduction: Behavioral health emergencies (BHEs) are a common patient encounter for emergency medical services (EMS) clinicians and other first responders, in particular law enforcement (LE) officers. It is critical for EMS clinicians to have management strategies for BHEs, yet relatively little information exists on best practices. In 2016, the Los Angeles County EMS Agency's Commission initiated a comprehensive evaluation of the 9-1-1 response for BHEs and developed a plan for improving the quality of care and safety for patients and first responders., Methods: A Behavioral Health Initiative Committee was assembled with broad representation from EMS, LE, health agencies, and the public. Committee objectives included: 1) produce a process map of the BHE response from the time of a 9-1-1 call to patient arrival at transport destination, 2) identify and describe the different agencies that respond, 3) describe the critical decision points in the EMS and LE field responses, 4) acquire data that quantitatively and/or qualitatively describe the services available, and 5) recommend interventions for system performance improvement., Results: The committee generated comprehensive process maps for the prehospital response to BHEs, articulated principles for evaluation, and described key observations of the current system including: 9-1-1 dispatch criteria are variable and often defaults to a LE response, the LE response inadvertently criminalizes BHEs, EMS field treatment protocols for BHEs (and especially agitated patients) are limited, substance use disorder treatment lacks integration, destination options differ by transporting agency, and receiving facilities' capabilities to address BHEs are variable. Recommendations for performance improvement interventions and initial implementation steps included: standardize dispatch protocols, shift away from a LE primary response, augment EMS treatment protocols for BHEs and the management of agitation, develop alternate destination for EMS transport., Conclusion: This paper describes a comprehensive performance improvement initiative in LAC-EMSA's 9-1-1 response to BHEs. The initiative included a thorough current state analysis, followed by future state mapping and the implementation of interventions to reduce LE as the primary responder when an EMS response is often warranted, and to improve EMS protocols and access to resources for BHEs.

Objective: Subsequent to the Emergency Use Authorization (EUA) by the Food and Drug Administration, Gilead Sciences Inc. donated a supply of remdesivir to the United States government for immediate treatment of patients with COVID-19. The Los Angeles County Emergency Medical Services Agency (LAC-EMS) was tasked with the allocation. The objective of this study was to describe the process for allocation and the patients who were treated with the donated remdesivir in LAC., Methods: LAC-EMS developed a strategic plan to distribute federal allocations of remdesivir to LAC hospitals based on the proportion of patients admitted with COVID-19 at each hospital. Criteria for treatment and its duration were based on the EUA at local hospital discretion. Data were collected on patients treated from May to December 2020. Variables included characteristics (age, sex, race/ethnicity), hospital care (level of care and respiratory support at start of treatment, ventilator support, total ventilator days), and outcomes (length of intensive care (ICU) and hospital stay, survival to discharge, disposition). We compared demographics of treated patients to the overall population of hospitalized patients in LAC., Results: LAC-EMS distributed 34,250 vials of remdesivir in 7 allocations, which treated 5,376 patients. The median age was 60 (IQR 48-70); 62% were male, 59% Hispanic, 17% White, 6% Asian, 5% Black. Prior to remdesivir, 96% of patients required respiratory support including 49% supplemental oxygen, 35% high-flow nasal cannula, 3% continuous or bilevel positive airway pressure and 9% mechanical ventilation, with one quarter of patients in the ICU. Overall, 26% of patients were mechanically ventilated during the hospitalization, median 11 days (IQR 8-23), while 41% required ICU care, median 10 days (IQR 5-19). Median length of stay for all patients was 10 days (IQR 7-18) with 4,218 patients (74%) surviving to discharge and 80% of survivors discharged home. Compared with overall hospitalized patients with COVID-19, treated patients more likely to be male and middle-aged, and less likely to be Black., Conclusion: LAC-EMS's strategic plan to distribute donated remdesivir to hospitals based on the number of inpatients with COVID-19 resulted in the treatment of 5,376 patients of whom 74% survived to hospital discharge.

Background and Purpose- We quantified population access to endovascular-capable centers, timing, and rates of thrombectomy in Los Angeles County before and after implementing 2-tiered routing in a regional stroke system of care. Methods- In 2018, the Los Angeles County Emergency Medical Services Agency implemented transport of patients with suspected large vessel occlusions identified by Los Angeles Motor Scale ≥4 directly to designated endovascular-capable centers. We calculated population access to a designated endovascular-capable center within 30 minutes comparing 2016, before 2-tiered system planning began, to 2018 after implementation. We analyzed data from stroke centers in the region from 1 year before and after implementation to delineate changes in rates and speed of administration of tPA (tissue-type plasminogen activator) and thrombectomy and frequency of interfacility transfer. Results- With implementation of the 2-tier system, certified endovascular-capable hospitals increased from 4 to 19 centers, and within 30-minute access to endovascular care for the public in Los Angeles County, from 40% in 2016 to 93% in 2018. Comparing Emergency Medical Services-transported stroke patients in the first post-implementation year (N=3303) with those transported in the last pre-implementation year (N=3008), age, sex, and presenting deficit severity were similar. The frequency of thrombolytic therapy increased from 23.8% to 26.9% (odds ratio, 1.2 [95% CI, 1.05-1.3]; P =0.006), and median first medical contact by paramedic-to-needle time decreased by 3 minutes ([95% CI, 0-5] P =0.03). The frequency of thrombectomy increased from 6.8% to 15.1% (odds ratio, 2.4 [95% CI, 2.0-2.9]; P <0.0001), although first medical contact-to-puncture time did not change significantly, median decrease of 8 minutes ([95% CI, -4 to 20] P =0.2). The frequency of interfacility transfers declined from 3.2% to 1.0% (odds ratio, 0.3 [95% CI, 0.2-0.5]; P <0.0001). Conclusions- After implementation of 2-tiered stroke routing in the most populous US county, thrombectomy access increased to 93% of the population, and the frequency of thrombectomy more than doubled, whereas interfacility transfers declined.

In the United States, black men who have sex with men (MSM) are the group most affected by the HIV/AIDS epidemic. Pre-exposure prophylaxis (PrEP) is an important new HIV prevention strategy that may help reduce new HIV infections among black MSM. This analysis examined the association between HIV/AIDS conspiracy beliefs and intentions to adopt PrEP among 224 black MSM. The likelihood of adopting PrEP was assessed and more than half (60%) of the study population indicated a high intention to adopt PrEP. HIV/AIDS genocidal and treatment-related conspiracies were assessed using scales previously validated with black MSM. Almost two-thirds (63%) endorsed at least one of eight HIV/AIDS conspiracy beliefs presented. In multivariable analyses, black MSM who agreed with the genocidal or treatment-related conspiracy beliefs scales had a lower intention to adopt PrEP (Adjusted Odds Ratio [AOR] = 0.73, 95% CI = 0.54, 0.99 and AOR = 0.36, 95% CI = 0.23, 0.55, respectively). Our findings indicate that preexisting HIV/AIDS conspiracy beliefs may deter some black MSM from adopting PrEP. We suggest strategies PrEP implementers may want to employ to address the influence that HIV/AIDS conspiracy beliefs may have on the adoption of PrEP among black MSM, a population disproportionately affected by HIV/AIDS.

Objectives: To determine the causes of software misinterpretation of ST elevation myocardial infarction (STEMI) compared to clinically identified STEMI to identify opportunities to improve prehospital STEMI identification., Methods: We compared ECGs acquired from July 2011 through June 2012 using the LIFEPAK 15 on adult patients transported by the Los Angeles Fire Department. Cases included patients ≥18 years who received a prehospital ECG. Software interpretation of the ECG (STEMI or not) was compared with data in the regional EMS registry to classify the interpretation as true positive (TP), true negative (TN), false positive (FP), or false negative (FN). For cases where classification was not possible using registry data, 3 blinded cardiologists interpreted the ECG. Each discordance was subsequently reviewed to determine the likely cause of misclassification. The cardiologists independently reviewed a sample of these discordant ECGs and the causes of misclassification were updated in an iterative fashion., Results: Of 44,611 cases, 50% were male (median age 65; inter-quartile range 52-80). Cases were classified as 482 (1.1%) TP, 711 (1.6%) FP, 43371 (97.2%) TN, and 47 (0.11%) FN. Of the 711 classified as FP, 126 (18%) were considered appropriate for, though did not undergo, emergent coronary angiography, because the ECG showed definite (52 cases) or borderline (65 cases) ischemic ST elevation, a STEMI equivalent (5 cases) or ST-elevation due to vasospasm (4 cases). The sensitivity was 92.8% [95% CI 90.6, 94.7%] and the specificity 98.7% [95% CI 98.6, 98.8%]. The leading causes of FP were ECG artifact (20%), early repolarization (16%), probable pericarditis/myocarditis (13%), indeterminate (12%), left ventricular hypertrophy (8%), and right bundle branch block (5%). There were 18 additional reasons for FP interpretation (<4% each). The leading causes of FN were borderline ST-segment elevations less than the algorithm threshold (40%) and tall T waves reducing the ST/T ratio below threshold (15%). There were 11 additional reasons for FN interpretation occurring ≤3 times each., Conclusion: The leading causes of FP automated interpretation of STEMI were ECG artifact and non-ischemic causes of ST-segment elevation. FN were rare and were related to ST-segment elevation or ST/T ratio that did not meet the software algorithm threshold.

Background: Prehospital identification of STEMI and activation of the catheterization lab can improve door-to-balloon (D2B) times but may lead to decreased specificity and unnecessary resource utilization. The purpose of this study was to examine the effect of electrocardiogram (ECG) transmission on false-positive (FP) cath lab activations and time to reperfusion., Methods: This is a retrospective cohort from a registry in a large metropolitan area with regionalized cardiac care and emergency medical services (EMS) with ECG transmission capabilities. Thirty-four designated STEMI receiving centers (SRC) contribute to this registry, from which patients with a prehospital ECG software interpretation of myocardial infarction (MI) indicated by ****Acute MI****, or manufacturer equivalent, were identified between April 2011 and September 2013. Frequency of FP field activations (defined as not resulting in emergent percutaneous coronary intervention [PCI] or referral for CABG during hospital admission) for patients with ECG transmission received by the SRC was compared to a reference group without successful ECG transmission. FP field activations were compared to the baseline frequency of FP ED activations. We hypothesized that successful transmission would reduce FP field activation to ED activation levels. Door-to-balloon and first medical contact-to-balloon (FMC2B) times were compared. The protocol for field cath lab activation varied by institution., Results: There were 7,768 patients presenting with a prehospital ECG indicating MI. The ECG was received by the SRC for 2,156 patients (28%). Regardless of transmission, the cath lab was activated 77% of the time; this activation occurred from the field in 73% and 74% of the activations in the transmission and reference group, respectively. The overall proportion of FP activation was 57%. Among field activations, successful ECG transmission reduced the FP activation rate compared to without ECG transmission, 55% vs. 61% (RD = -6%, 95%CI -9, -3%). This led to an overall system reduction in FP activations of 5% (95%CI 2, 8%). ECG transmission had no effect on D2B and FMC2B time., Conclusion: Prehospital ECG transmission is associated with a small reduction in false-positive field activations for STEMI and had no effect on time to reperfusion in this cohort.

Background: 16S ribosomal DNA (rDNA) amplicon sequencing is frequently used to analyse the structure of bacterial communities from oceans to the human microbiota. However, computational power is still a major bottleneck in the analysis of continuously enlarging metagenomic data sets. Analysis is further complicated by the technical complexity of current bioinformatics tools., Results: Here we present the less operational taxonomic units scripts (LotuS), a fast and user-friendly open-source tool to calculate denoised, chimera-checked, operational taxonomic units (OTUs). These are the basis to generate taxonomic abundance tables and phylogenetic trees from multiplexed, next-generation sequencing data (454, illumina MiSeq and HiSeq). LotuS is outstanding in its execution speed, as it can process 16S rDNA data up to two orders of magnitude faster than other existing pipelines. This is partly due to an included stand-alone fast simultaneous demultiplexer and quality filter C++ program, simple demultiplexer (sdm), which comes packaged with LotuS. Additionally, we sequenced two MiSeq runs with the intent to validate future pipelines by sequencing 40 technical replicates; these are made available in this work., Conclusion: We show that LotuS analyses microbial 16S data with comparable or even better results than existing pipelines, requiring a fraction of the execution time and providing state-of-the-art denoising and phylogenetic reconstruction. LotuS is available through the following URL: http://psbweb05.psb.ugent.be/lotus .

Background: Dismal prognosis after failed out-of-hospital resuscitation has previously been demonstrated. Changes in resuscitation and post-resuscitation care may affect patient outcomes. We describe characteristics and outcomes of patients with out-of-hospital cardiac arrest (OOHCA) transported to specialty cardiac centers after failure of out-of-hospital interventions., Methods: In Los Angeles (LA) County, patients with non-traumatic OOHCA with return of spontaneous circulation (ROSC) are transported to specialized cardiac care centers. Outcomes are reported to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report patient characteristics and outcomes for the subset of patients treated at these specialty centers in whom initial ROSC was achieved in the ED. The primary outcome was neurologically intact survival, defined by a cerebral performance category (CPC) score of 1 or 2., Results: 105 patients transported to the SRC after failure to achieve ROSC with out-of-hospital resuscitation were successfully resuscitated in the ED. The median age was 68 years (IQR 57-78); 74 (70%) were male. The presenting rhythm was ventricular fibrillation or ventricular tachycardia in 40 patients (38%) and 86 (82%) were witnessed. Twenty-two patients (21%) survived to hospital discharge. Of the 103 patients with known CPC scores, 13 (13% [95% CI 7-21%]) survived to hospital discharge with a CPC score of 1 or 2. No patient who survived with good neurologic outcome met criteria for termination of resuscitation in the field., Conclusion: Failure of out-of-hospital resuscitation is not universally predictive of poor neurologic outcome., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Post-resuscitation care of cardiac arrest patients at specialized centers may improve outcome after out-of-hospital cardiac arrest (OOHCA). This study describes experience with regionalized care of resuscitated patients., Methods: Los Angeles (LA) County established regionalized cardiac care in 2006. Since 2010, protocols mandate transport of nontraumatic OOHCA patients with field return of spontaneous circulation (ROSC) to a STEMI Receiving Center (SRC) with a hypothermia protocol. All SRC report outcomes to a registry maintained by the LA County Emergency Medical Services (EMS) Agency. We report the first year's data. The primary outcome was survival with good neurologic outcome, defined by a Cerebral Performance Category (CPC) score of 1 or 2., Results: The SRC treated 927 patients from April 2011 through March 2012 with median age 67; 38% were female. There were 342 patients (37%) who survived to hospital discharge. CPC scores were unknown in 47 patients. Of the 880 patients with known CPC scores, 197 (22%) survived to hospital discharge with a CPC score of 1 or 2. The initial rhythm was VF/VT in 311 (34%) patients, of whom 275 (88%) were witnessed. For patients with an initial shockable rhythm, 183 (59%) survived to hospital discharge and 120 (41%) had survival with good neurologic outcome. Excluding patients who were alert or died in the ED, 165 (71%) patients with shockable rhythms received therapeutic hypothermia (TH), of whom 67 (42%) had survival with good neurologic outcome. Overall, 387 patients (42%) received TH. In the TH group, the adjusted OR for CPC 1 or 2 was 2.0 (95%CI 1.2-3.5, p = 0.01), compared with no TH. In contrast, the proportion of survival with good neurologic outcome in the City of LA in 2001 for all witnessed arrests (irrespective of field ROSC) with a shockable rhythm was 6%., Conclusion: We found higher rates of neurologically intact survival from OOHCA in our system after regionalization of post-resuscitation care as compared to historical data.

Study Objective: We assess the effects of nearby hospital closures and other hospital characteristics on emergency department (ED) ambulance diversion., Methods: The study design was a retrospective, multiple interrupted time series with control group. We studied all ambulance-receiving hospitals with EDs in Los Angeles County from 1998 to 2004. The main outcome measure was monthly ambulance diversion hours because of ED saturation., Results: Our sample included 80 hospitals, of which 9 closed during the study period. There were increasing monthly diversion hours over time, from an average of 57 hours (95% confidence interval [CI] 51 to 63 hours) in 1998 to 190 hours (95% CI 180 to 200 hours) in 2004. In multivariate modeling, hospital closure increased ambulance monthly diversion hours by an average of 56 hours (95% CI 28 to 84 hours) for 4 months at the nearest ED. County-operated hospitals had 150 hours (95% CI 90 to 200 hours) and trauma centers had 48 hours (95% CI 9 to 87 hours) more diversion than other hospitals. Diversion hours for a given facility were positively correlated with diversion hours of the nearest ED (0.3; 95% CI 0.28 to 0.32). There was a significant and positive interaction between diversion hours of the nearest ED and time, suggesting that the effects of an adjacent facility's diversion hours increased during the study period., Conclusion: Hospital closure was associated with a significant but transient increase in ambulance diversion for the nearest ED. The temporal trend toward more diversion hours, as well as increasing effects of the nearest facility's diversion hours over time, implies that the capacity to absorb future hospital closures is declining.

Objective: To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of i.v. lines and saline locks by paramedics in the out-of-hospital setting., Methods: This was a retrospective consecutive case series at an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual i.v. access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of i.v. access was determined for each patient based on predetermined criteria developed by the investigators. i.v. access methods were ranked by cost of supplies as follows: i.v. line (i.v.) > saline lock (SL) > no i.v. line (No i.v.). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated., Results: 452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an i.v.. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253 (56%) discordant-overtreatment; and 33 (7%) discordant-undertreatment. Pediatric patients (< or =14 years of age) were more likely to be undertreated as compared with adults, 33% vs 3% (p < 0.001). Patients who had medical chief complaints were more likely to receive discordant-overtreatment as compared with patients who had trauma chief complaints, 61% vs 32% (p < 0.001). 73% of chest pain patients received discordant-overtreatment. Based on these data, the yearly cost of supplies used in i.v. access discordant-overtreatment was $13,735 for this base hospital and $560,000 for the Los Angeles County emergency medical services (EMS) system. 91% of the excess supply cost is due to patients' receiving an i.v. instead of a SL., Conclusion: Based on study criteria for utilization of i.v. lines vs SLs in the field, paramedics and base hospital personnel often provide discordant-overtreatment of patients by placement of an i.v. when a SL or No i.v. would suffice, resulting in unnecessary costs for EMS systems.