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We prove that the p-universality of a space does not depend on a prime p but only on its rational homotopy type. The minimal model of such a rational homotopy type is characterized by the existence of the trivial endomorphism in t...
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We prove that the p-universality of a space does not depend on a prime p but only on its rational homotopy type. The minimal model of such a rational homotopy type is characterized by the existence of the trivial endomorphism in the closure of its automorphism group.
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Abstract Intensification of the hydrological cycle resulting from climate change in West Africa poses significant risks for the region’s rapidly urbanising cities, but limited research on flood risk has been undertaken at the urb...
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Abstract Intensification of the hydrological cycle resulting from climate change in West Africa poses significant risks for the region’s rapidly urbanising cities, but limited research on flood risk has been undertaken at the urban domain scale. Furthermore, conventional climate models are unable to realistically represent the type of intense storms which dominate the West African monsoon. This paper presents a decision-first framing of climate research in co-production of a climate-hydrology-flooding modelling chain, linking scientists working on state-of-the-art regional climate science with decision-makers involved in city planning for future urban flood management in the city of Ouagadougou, Burkina Faso. The realistic convection-permitting model over Africa (CP4A) is applied at the urban scale for the first time and data suggest significant intensification of high-impact weather events and demonstrate the importance of considering the spatio-temporal scales in CP4A. Hydrological modelling and hydraulic modelling indicate increases in peak flows and flood extents in Ouagadougou in response to climate change which will be further exacerbated by future urbanisation. Advances in decision-makers’ capability for using climate information within Ouagadougou were observed, and key recommendations applicable to other regional urban areas are made. This study provides proof of concept that a decision-first modelling-chain provides a methodology for co-producing climate information that can, to some extent, bridge the usability gap between what scientists think is useful and what decision-makers need.
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Abstract Objective To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Background Headache is a common reason for presentation to EDs. Little is known about the epidemiology, ...
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Abstract Objective To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Background Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. Methods An international, multicenter, observational, cross‐sectional study was conducted over one calendar month in 2019. Participants were adults (≥18?years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re‐presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. Results We enrolled 4536 patients (67?hospitals, 10 countries). “Thunderclap” onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%–75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non‐SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti‐inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In‐hospital mortality was 0.3% (11/4526). Conclusion Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment.
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Abstract Objective To describe the characteristics, assessment and management of older emergency department (ED) patients with non‐traumatic headache. Methods Planned sub‐study of a prospective, multicentre, international, obser...
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Abstract Objective To describe the characteristics, assessment and management of older emergency department (ED) patients with non‐traumatic headache. Methods Planned sub‐study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non‐traumatic headache. Patients aged ≥75?years were compared to those aged <75?years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. Results A total of 298 patients (7%) in the parent study were aged ≥75?years. Older patients were less likely to report severe headache pain or subjective fever (both P?收起
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Abstract Objectives The objective was to assess the prognostic value of hypertension detected in the emergency department (ED). Methods The ED presents a unique opportunity to predict long‐term cardiovascular disease (CVD) outcom...
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Abstract Objectives The objective was to assess the prognostic value of hypertension detected in the emergency department (ED). Methods The ED presents a unique opportunity to predict long‐term cardiovascular disease (CVD) outcomes with its potential for high‐footfall, and large‐scale routine data collection applied to underserved patient populations. A systematic review and meta‐analyses were conducted to assess the prognostic performance and feasibility of ED‐measured hypertension as a risk factor for long‐term CVD outcomes. We searched MEDLINE and Embase databases and gray literature sources. The target populations were undifferentiated ED patients. The prognostic factor of interest was hypertension. Feasibility outcomes included prevalence, reliability, and follow‐up attendance. Meta‐analyses were performed for feasibility using a random effect and exact likelihood. Results The searches identified 1072 studies after title and abstract review, 53 studies had their full text assessed for eligibility, and 26 studies were included. Significant heterogeneity was identified, likely due to the international populations and differing study design. The meta‐analyses estimate of prevalence for ED‐measured hypertension was 0.31 (95% confidence interval? 0.25–0.37). ED hypertension was persistent outside the ED (FE estimate of 0.50). The proportion of patients attending follow‐up was low with an exact likelihood estimate of 0.41. Three studies examined the prognostic performance of hypertension and demonstrated an increased risk of long‐term CVD outcomes. Conclusion Hypertension can be measured feasibly in the ED and consequently used in a long‐term cardiovascular risk prediction model. There is an opportunity to intervene in targeted individuals, using routinely collected data.
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Workforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effecti...
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Workforce issues prevail across healthcare; in emergency medicine (EM), previous work improved retention, but the staffing problem changed rather than improved. More experienced doctors provide higher quality and more cost-effective care, and turnover of these physicians is expensive. Research focusing on staff retention is an urgent priority.This study is a scoping review of the academic literature relating to the retention of doctors in EM and describes current evidence about sustainable careers (focusing on factors influencing retention), as well as interventions to improve retention. The established and rigorous JBI scoping review methodology was followed. The data sources searched were MEDLINE, Embase, Cochrane, HMIC and PsycINFO, with papers published up to April 2020 included. Broad eligibility criteria were used to identify papers about retention or related terms, including turnover, sustainability, exodus, intention to quit and attrition, whose population included emergency physicians within the setting of the ED. Papers which solely measured the rate of one of these concepts were excluded.Eighteen papers met the inclusion criteria. Multiple factors were identified as linked with retention, including perceptions about teamwork, excessive workloads, working conditions, errors, teaching and education, portfolio careers, physical and emotional strain, stress, burnout, debt, income, work–life balance and antisocial working patterns. Definitions of key terms were used inconsistently. No factors clearly dominated; studies of correlation between factors were common. There were minimal research reporting interventions.Many factors have been linked to retention of doctors in EM, but the research lacks an appreciation of the complexity inherent in career decision-making. A broad approach, addressing multiple factors rather than focusing on single factors, may prove more informative.
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This article critically reviews the latest evidence to guide the use of biomarkers for the diagnosis of acute coronary syndromes in practice. It shows how modern cardiac troponin assays can enable diagnoses to be ruled in or ruled...
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This article critically reviews the latest evidence to guide the use of biomarkers for the diagnosis of acute coronary syndromes in practice. It shows how modern cardiac troponin assays can enable diagnoses to be ruled in or ruled out with a single blood test, with many more diagnoses confirmed or refuted in as little as 1?hour later. Finally, this article appraises the latest evidence for other cardiac biomarkers, such as heart-type fatty acid-binding protein and copeptin.
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VTE disease is a topical and costly health-care burden. Diagnosis is associated with significant morbidity and mortality despite modern advances in care.
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Background: D-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic accuracy performance of the Tina-quant ? D-Dimer Gen.2 assay (Roche Diag...
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Background: D-Dimer testing is a diagnostic tool for exclusion of deep vein thrombosis (DVT) and pulmonary embolism (PE). This study evaluated the diagnostic accuracy performance of the Tina-quant ? D-Dimer Gen.2 assay (Roche Diagnostics International Ltd, Rotkreuz, Switzerland) in patients with low/intermediate pre-test probability of DVT/PE using standard, age-, and clinical probability-adjusted cut-offs.In this prospective, observational, multicenter study (July 2017-August 2019), plasma samples were collected from hospital emergency departments and specialist referral centers. DVT/PE was diagnosed under hospital standard procedures and imaging protocols. A standard D-Dimer cut-off of 0.5 μg fibrinogen equivalent units (FEU)/mL was combined with the three-level Wells score; cut-offs adjusted for age (age ? 0.01 μg FEU/mL for patients >50 years) and clinical probability (1 μg FEU/mL for low probability) were also evaluated. An assay comparison was conducted in a subset of samples using the Tina-quant D-Dimer Gen.2 assay and the previously established routine laboratory assay, STA-Liatest D-Di Plus assay (Stago Deutschland GmbH, Düsseldorf, Germany).Results: 2,897 patients were enrolled; 2,516 completed the study (1,741 DVT cohort; 775 PE cohort). Clinical assessment plus D-Dimer testing using the standard cut-off resulted in 317 (DVT) and 230 (PE) false positives, and zero (DVT) and one (PE) false negatives. Negative predictive value (NPV) was 100.0% (95% confidence interval [CI]: 99.7-100.0%) and 99.8% (95% CI: 98.8-100.0%) for DVT and PE, respectively. After age-adjustment, NPV was 99.9% (95% CI: 99.6-100.0%) and 99.1% (95% CI: 97.8-99.7) for DVT and PE, respectively. False positive rates decreased (>50%) in clinical probability-adjusted analyses versus primary analysis. In the assay comparison, the performances of the two assays were comparable.The Tina-quant D-Dimer Gen.2 assay and standard D-Dimer cut-off level combined with the three-level Wells score accurately identified patients with a very low probability of DVT/PE.
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The COVID-19 pandemic has given rise to numerous commercially available antigen rapid diagnostic tests (Ag-RDTs). To generate and to share accurate and independent data with the global community requires multisite prospective diag...
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The COVID-19 pandemic has given rise to numerous commercially available antigen rapid diagnostic tests (Ag-RDTs). To generate and to share accurate and independent data with the global community requires multisite prospective diagnostic evaluations of Ag-RDTs. This report describes the clinical evaluation of the OnSite COVID-19 rapid test (CTK Biotech, CA, USA) in Brazil and the United Kingdom. A total of 496 paired nasopharyngeal (NP) swabs were collected from symptomatic health care workers at Hospital das Clínicas in S?o Paulo, Brazil, and 211 NP swabs were collected from symptomatic participants at a COVID-19 drive-through testing site in Liverpool, United Kingdom. Swabs were analyzed by Ag-RDT, and results were compared to quantitative reverse transcriptase PCR (RT-qPCR). The clinical sensitivity of the OnSite COVID-19 rapid test in Brazil was 90.3% (95% confidence interval [CI], 75.1 to 96.7%) and in the United Kingdom was 75.3% (95% CI, 64.6 to 83.6%). The clinical specificity in Brazil was 99.4% (95% CI, 98.1 to 99.8%) and in the United Kingdom was 95.5% (95% CI, 90.6 to 97.9%). Concurrently, analytical evaluation of the Ag-RDT was assessed using direct culture supernatant of SARS-CoV-2 strains from wild-type (WT), Alpha, Delta, Gamma, and Omicron lineages. This study provides comparative performance of an Ag-RDT across two different settings, geographical areas, and populations. Overall, the OnSite Ag-RDT demonstrated a lower clinical sensitivity than claimed by the manufacturer. The sensitivity and specificity from the Brazil study fulfilled the performance criteria determined by the World Health Organization, but the performance obtained from the UK study failed to do. Further evaluation of Ag-RDTs should include harmonized protocols between laboratories to facilitate comparison between settings. IMPORTANCE Evaluating rapid diagnostic tests in diverse populations is essential to improving diagnostic responses as it gives an indication of the accuracy in real-world scenarios. In the case of rapid diagnostic testing within this pandemic, lateral flow tests that meet the minimum requirements for sensitivity and specificity can play a key role in increasing testing capacity, allowing timely clinical management of those infected, and protecting health care systems. This is particularly valuable in settings where access to the test gold standard is often restricted.
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