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IntroductionCurrent guidelines on clinical nutrition of ventilated patients in the intensive care unit (ICU) recommend initiating continuous enteral nutrition within 48 hours of ICU admission when feasible. However, discontinuous feeding regimens, alternating feeding and fasting intervals, may have an impact on clinical and patient centred outcomes. The ongoing \"Impact of daily cyclic enteral nutrition versus standard continuous enteral nutrition in critically ill patients\" (DC-SCENIC) trial aims to compare standard continuous enteral feeding with daily cyclic enteral feeding over 10 hours to evaluate if implementing a fasting-mimicking diet can decrease organ failure in ventilated patients during the acute phase of ICU management.Methods and analysisDC-SCENIC is a randomised, controlled, multicentre, open-label trial comparing two parallel groups of patients 18 years of age or older receiving invasive mechanical ventilation and having an indication for enteral nutrition through a gastric tube. Enteral feeding is continuous in the control group and administered over 10 hours daily in the intervention group. Both groups receive isocaloric nutrition with 4 g of protein per 100 mL, and have the same 20 kcal/kg/day caloric target. The primary endpoint is the change in the Sequential Organ Failure Assessment score at 7 days compared with the day of inclusion in the study. Secondary outcomes include daily caloric and protein delivery, digestive, respiratory and metabolic tolerance as well as 28-day mortality, duration of mechanical ventilation and ventilator-free days. Outcomes will be analysed on an intention-to-treat basis. Recruitment started in June 2023 in 3 French ICU’s and a sample size of 318 patients is expected by February 2026.Ethics and disseminationThis study received approval from the national ethics review board on 8 November 2022 (Comité de Protection des Personnes Sud-Est VI, registration number 2022-A00827-36). Patients are included after informed consent. Results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT05627167.

Background Primary care patients are often cited as a cause of Emergency Department overcrowding (ED). The aim of this study was to evaluate a physician led redirection procedure of selected patients towards an out of hours general practice (OHGP) in an Emergency Department with 55,000 admissions per year. Methods Observational monocentric study over a period of 2 months. Every patient redirected to the OHGP was included and subsequently contacted by telephone to answer a standardized questionnaire, in order to measure: Redirection rate over the entire period and during weekdays or weekends/holiday Rate of redirected patients who went to the OHGP Rate of redirected patients who consulted in an ED in the next 72 h for the same reason Redirected patients’ satisfaction rate Results During the study period 9551 patients presented to the ED, of which 288 were redirected towards the OHGP (3%). The redirection rate was 1.9% during weekdays and 5.7% during weekends/holiday ( p  < 0.001). Of the redirected patients, 77% answered the telephone interview. Ninety percent of these patients consulted the OHGP. The main reasons for not consulting were: unduly long wait, opening hours not suitable, too costly. The rate of redirected patients who consulted in an ED in the following 72 h for the same reason was 4.1%. The satisfaction rate was 79.6% among interviewed patients. Conclusions A physician led procedure to redirect selected patients from the ED towards an OHGP results in a low redirection rate, unlikely to have a significant effect on ED patient flow. However, the procedure is safe and well accepted by a majority of patients.

IntroductionPatients in intensive care units (ICUs) frequently require mechanical ventilation, with approximately half needing invasive ventilation through an orotracheal tube. For these patients, gastric tube (GT) insertion is routinely performed to administer nutrition and medications or to drain gastric contents. The insertion route (oral or nasal) may affect the incidence of ventilator-associated pneumonia (VAP), a significant ICU care complication. This study aims to compare the impact of oral versus nasal GT insertion on the incidence of VAP in intubated ICU patients.Methods and analysisThe SONG trial (NCT 05915663) is a multicentre, open-label, two-period, two-intervention, cluster randomised crossover superiority trial. 16 French ICUs will participate. ICUs will be randomised to periods of nasogastric or orogastric tube placement. The trial includes a practice standardisation period, followed by two 12-month inclusion periods separated by a monitoring and washout period. The primary endpoint is the incidence rate of VAP at day 28, confirmed by three independent physicians. Secondary endpoints include the ease of GT insertion, measured by the number of attempts.Ethics and disseminationThis study received approval from a central ethical review board on 12 April 2024 (CPP Sud-est VI, registration number 23.00943.000175). Patients are included after informed consent or, when not possible, from next of kin. If none are available, the investigator will proceed with emergency inclusion, following French law. When consent is initially obtained from the next of kin or through emergency inclusion, the investigator will seek consent from the patient as soon as possible. Data will be anonymised and patient confidentiality maintained. Results will be published in peer-reviewed journals and presented at scientific meetings.Trial registration numberNCT05915663.

Routine biological tests are frequently ordered in self-poisoning patients, but their clinical relevance is poorly studied. This is a prospective multicentric observational study conducted in the emergency departments and intensive care units of 5 university and nonuniversity French hospitals. Adult self-poisoning patients without severely altered vital status on admission were prospectively included. Routine biological test (serum electrolytes and creatinine, liver enzymes, bilirubin, blood cell count, prothrombin time) ordering and results were analyzed. A total of 1027 patients were enrolled (age, 40.2 ± 14 years; women, 61.5%); no patient died during the hospital stay. Benzodiazepine was suspected in more than 70% of cases; 65% (range, 48%-80%) of patients had at least 1 routine biological test performed. At least 1 abnormal test was registered in 23% of these patients. Three factors were associated with abnormal test results: age older than 40 years, male sex, and poisoning with a drug known to alter routine tests (ie, acetaminophen, NSAIDs, metformine, lithium). Depending on these factors, abnormal results ranged from 14% to 48%. Unexpected severe life-threatening conditions were recorded in 6 patients. Only 3 patients were referred to the intensive care unit solely because of abnormal test results. Routine biological tests are commonly prescribed in nonsevere self-poisoning patients. Abnormal results are frequent but their relevance at bedside remains limited.

BackgroundThe aim of this study was to determine whether: (1) the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and National Early Warning Score (NEWS) clinical prediction tools alone, (2) modified versions of these prediction tools that integrate lactate into their scores, or (3) use of the two tools in tandem with lactate better predicts in-hospital 28-day mortality among adult EDpatients with suspected infection.MethodsFrom 1 January through 31 December 2018, this retrospective cohort study enrolled consecutive adult patients with suspected infection evaluated at two EDs in France. Patients were included if blood cultures were obtained and non-prophylactic antibiotics were administered in the ED. qSOFA, NEWS criteria and lactate measurements were recorded when patients were clinically suspected of having an infection. Two composite scores (lactate qSOFA (LqSOFA) and lactate NEWS (LNEWS)) integrating lactate were created. Diagnostic test performances for predicting in-hospital mortality within 28days were assessed for qSOFA≥2, LqSOFA≥2, qSOFA≥2 or lactate≥2 mmol/L, and for NEWS≥7, LNEWS≥7, and NEWS≥7 or lactate≥2 mmol/L.Results1003 patients were included, 130 (13%) of whom had died by day 28. Sensitivities for 28-day mortality were 50% (95%CI41% to 59%) for qSOFA≥2,69% (95% CI60% to 77%) for LqSOFA≥2,77% (95% CI69% to 84%) for qSOFA or lactate≥2 mmol/L; and 69% (95% CI60% to 77%) for NEWS≥7, 80% (95% CI72% to 86%) for LNEWS≥7, 87% (95% CI80% to 92%) for NEWS≥7 or lactate≥2 mmol/L.ConclusionLactate used in tandem with qSOFA or NEWS yielded higher sensitivities in predicting in-hospital 28-day mortality, as compared with integration of lactate into these prediction tools or usage of the tools independently.

BackgroundThe aim of this study was to determine whether: (1) the quick Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) and National Early Warning Score (NEWS) clinical prediction tools alone, (2) modified versions of these prediction tools that integrate lactate into their scores, or (3) use of the two tools in tandem with lactate better predicts in-hospital 28-day mortality among adult EDpatients with suspected infection.MethodsFrom 1 January through 31 December 2018, this retrospective cohort study enrolled consecutive adult patients with suspected infection evaluated at two EDs in France. Patients were included if blood cultures were obtained and non-prophylactic antibiotics were administered in the ED. qSOFA, NEWS criteria and lactate measurements were recorded when patients were clinically suspected of having an infection. Two composite scores (lactate qSOFA (LqSOFA) and lactate NEWS (LNEWS)) integrating lactate were created. Diagnostic test performances for predicting in-hospital mortality within 28days were assessed for qSOFA≥2, LqSOFA≥2, qSOFA≥2 or lactate≥2 mmol/L, and for NEWS≥7, LNEWS≥7, and NEWS≥7 or lactate≥2 mmol/L.Results1003 patients were included, 130 (13%) of whom had died by day 28. Sensitivities for 28-day mortality were 50% (95%CI41% to 59%) for qSOFA≥2,69% (95% CI60% to 77%) for LqSOFA≥2,77% (95% CI69% to 84%) for qSOFA or lactate≥2 mmol/L; and 69% (95% CI60% to 77%) for NEWS≥7, 80% (95% CI72% to 86%) for LNEWS≥7, 87% (95% CI80% to 92%) for NEWS≥7 or lactate≥2 mmol/L.ConclusionLactate used in tandem with qSOFA or NEWS yielded higher sensitivities in predicting in-hospital 28-day mortality, as compared with integration of lactate into these prediction tools or usage of the tools independently.

Our ageist attitudes toward sex in old age impede the quality of life and the detection and prevention of elder sexual abuse. When sexual abuse is alleged or suspected, responders rarely ask the right questions or take the appropriate steps to assist victims, preserve evidence, or comply with reporting requirements. The legal, medial, social, ethical, and practical issues at the intersection of aging and cognitive incapacity are rarely addressed, so practitioners and families have little guidance. Recent studies demonstrate a far greater interest in intimacy among elders than is assumed. Elder abuse prevalence studies also show more incidences than has been assumed. Once all parties accept that there is both intimacy between elders and abuse in facilities and elsewhere, they will be better able to pursue perpetrators and ensure quality of life for all elders.

Traditional computational phenotypes (CPs) identify patient cohorts without consideration of underlying pathophysiological mechanisms. Deeper patient-level characterizations are necessary for personalized medicine and while advanced methods exist, their application in clinical settings remains largely unrealized. This thesis advances deep CPs through several experiments designed to address four requirements.Stability was examined through three experiments. First, a multiphase study was performed and identified resources and remediation plans as barriers preventing data quality (DQ) assessment. Then, through two experiments, the Harmonized DQ Framework was used to characterize DQ checks from six clinical organizations and 12 biomedical ontologies finding Atemporal Plausibility and Completeness and Value Conformance as the most common clinical checks and Value and Relation Conformance as the most common biomedical ontology checks.Scalability was examined through three experiments. First, a novel composite patient similarity algorithm was developed that demonstrated that information from clinical terminology hierarchies improved patient representations when applied to small populations. Then, ablation studies were performed and showed that the combination of data type, sampling window, and clinical domain used to characterize rare disease patients differed by disease. Finally, an algorithm that losslessly transforms complex knowledge graphs (KGs) into representations more suitable for inductive inference was developed and validated through the generation of expert-verified plausible novel drug candidates.Interoperability was examined through two experiments. First, 36 strategies to align five eMERGE CPs to standard clinical terminologies were examined and revealed lower false negative and positive counts in adults than in pediatric patient populations. Then, hospital-scale mappings between clinical terminologies and biomedical ontologies were developed and found to be accurate, generalizable, and logically consistent.Multimodality was examined through two experiments. A novel ecosystem for constructing ontologically-grounded KGs under alternative knowledge models using different relation strategies and abstraction strategies was created. The resulting KGs were validated through successfully enriching portions of the preeclampsia molecular signature with no previously known literature associations.These experiments were used to develop a joint learning framework for inferring molecular characterizations of patients from clinical data. The utility of this framework was demonstrated through the accurate inference of EHR-derived rare disease patient genotypes/phenotypes from publicly available molecular data.

My dissertation explores how the so-called \"fleshliness\" of the writing of Pater, Swinburne and D. G. Rossetti, engages with poetic and epistemological structures perceived as vitiating the experience of the bourgeois masculine subject. The aesthetic writers resist the construction of an aesthetic realm and a true self that depends on the repression of the individual's continuity with the commodifiable material realm; instead of the disavowal of the body, their writings value mastery over matter through aesthetic form (\"craftsmanship\") as a means of establishing masculine identity and producing poems. In Pater, aestheticism (as love of the artificial) enables history to be transmitted through a subject's vicarious identifications with past masculine signifiers and their desire, identifications which displace the subject-object and soul-body relationships that seem to structure Romantic and sentimental epistemology. Swinburne creates a form of ironic aesthetic autonomy that enables the normally suppressed historical and material conditions of meaning to re-emerge. Rossetti's religion of love is not only his private esoteric reaction to modern life, but also reproduces the bourgeois ideology of love, enacting a social injunction to seek the \"meaning\" of life and one's individuality through sexual love constructed as masculine eye looking upon woman-as-image.

There are more children in Edmonton who could use a teddy bear to hug, a warm jacket and a good breakfast than [John Kirkman] will ever know, and this is a pity, because his thinking is also that of thousands of Edmontonians.