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As the department's team had been renewed in less than two years, it was necessary to invent a method to improve cohesion and communication, and to enhance the skills of professionals. This led to the creation of a training program using a variety of methods (theoretical training, care approaches and quality coffees)., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Objectives: Assay of sex hormone binding globulin (SHBG), the main carrier protein for sexual steroids, is prescribed mainly by endocrinologists and performed in specialized laboratories. This study aimed to evaluate the analytic performance of an automated immunochemiluminescent assay (ImmunoDiagnostic Systems (IDS), Boldon, United Kingdom) compared to a manual radioimmunoassay (Cisbio Bioassays, Codolet, France). It further aimed to assess the suitability of the reference values proposed by IDS., Materials and Methods: One hundred and forty sera were used to assess the analytic performance of the IDS kit. The coefficients of variation (CV%) for within- and between-run precision were calculated. The reference values provided by IDS were recalculated based on the regression curve equation obtained by comparing the IDS and Cisbio values on Passing-Bablok regression. The new sex-based reference values were then established and their concordance with clinical status was evaluated on Kappa coefficient., Results: The new kit correlated strongly with the reference technique (R 2 =0.96). Based on the regression line equation, the new reference values for IDS were [20.9-50.6] nmol/L for men and [33.8-71.1] nmol/L for women. Agreement with the reference values we established was 0.933 for men and 0.825 for women, compared with 0.606 and 0.286 for the supplier's values., Conclusion: The performance of the IDS kit met the current recommendations and correlated strongly with the Cisbio method. The calculation of new sex-based reference values was needed to correctly classify patients according to androgen status, underlining the importance of systematically checking the reference values provided by suppliers., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Objective: To determine whether observed and predicted mortality for intensive care unit (ICU) transfer admissions is different from non-ICU transfer admissions and how that might affect ICU performance evaluation., Design, Setting, and Patients: We retrospectively analyzed the charts of 3,416 patients admitted to our tertiary referral ICU from January 1995 to December 2001 and evaluated the effect on our performance (based on the Simplified Acute Physiology Score II risk model) of accepting patients transferred from another hospital's ICU., Main Results: During the study period, 597 patients (17%) had been transferred from a non-ICU setting in another hospital (hospital transfer) and 408 (12%) from another hospital's ICU (ICU transfer). ICU mortality and standardized mortality ratios were significantly higher for ICU-transfer patients than for hospital-transfer or directly admitted patients: 34% vs. 23% vs. 17% (p < .0001) and 0.95 (95% confidence interval, 0.83-1.08), 0.82 (95% confidence interval, 0.71-0.95), and 0.62 (95% confidence interval, 0.55-0.68), respectively. ICU-transfer patients had 3.6-fold longer mean ICU stays and 1.9-fold longer durations of mechanical ventilation than directly admitted patients. Hospital-transfer (odds ratio = 1.89) and ICU-transfer patients (odds ratio = 2.41) had significantly higher mortality rates, even after adjustment for case mix and disease severity. Consequently, a benchmarking program adjusting only for these latter variables, but not admission source, would penalize our ICU by 39 excess deaths per 1,000 admissions as compared with another ICU admitting no transfer patients. Finally, patients transferred from the ward of another hospital had significantly higher mortality rates (odds ratio = 1.56) as compared with patients directly admitted from the ward of our hospital, confirming the "transfer effect" for this homogeneous patients' subgroup., Conclusions: Admission source remains a strong and independent predictor of ICU death, despite adjustment for case mix and disease severity at ICU admission. Specifically, accepting numerous ICU-transfer patients, for whom the probability of ICU death is the most underestimated by a system adjusting only for case mix and disease severity, can adversely affect the evaluation of referral centers' performance. Future benchmarking and profiling systems should evaluate and adequately account for the ICU-transfer factor to provide healthcare payers and consumers with more accurate and valid information on the true performance of referral centers.

Background and Aims: A model of fruit surface conductance to water vapour diffusion driven by fruit growth is proposed. It computes the total fruit conductance by integrating each of its components: stomata, cuticle and cracks., Methods: The stomatal conductance is computed from the stomatal density per fruit and the specific stomatal conductance. The cuticular component is equal to the proportion of cuticle per fruit multiplied by its specific conductance. Cracks are assumed to be generated when pulp expansion rate exceeds cuticle expansion rate. A constant percentage of cracks is assumed to heal each day. The proportion of cracks to total fruit surface area multiplied by the specific crack conductance accounts for the crack component. The model was applied to peach fruit (Prunus persica) and its parameters were estimated from field experiments with various crop load and irrigation regimes., Key Results: The predictions were in good agreement with the experimental measurements and for the different conditions (irrigation and crop load). Total fruit surface conductance decreased during early growth as stomatal density, and hence the contribution of the stomatal conductance, decreased from 80 to 20 % with fruit expansion. Cracks were generated for fruits exhibiting high growth rates during late growth and the crack component could account for up to 60 % of the total conductance during the rapid fruit growth. The cuticular contribution was slightly variable (around 20 %). Sensitivity analysis revealed that simulated conductance was highly affected by stomatal parameters during the early period of growth and by both crack and stomatal parameters during the late period. Large fruit growth rate leads to earlier and greater increase of conductance due to higher crack occurrence. Conversely, low fruit growth rate accounts for a delayed and lower increase of conductance., Conclusions: By predicting crack occurrence during fruit growth, this model could be helpful in managing cropping practices for integrated plant protection.

Background: Autopsy rates have declined worldwide, but recent retrospective intensive care unit (ICU) data indicate major discrepancies between more than 25% of clinical and autopsy diagnoses., Methods: We conducted a 3-year prospective study of all consecutive autopsies performed on patients who died in a university hospital medical-surgical ICU to determine how many might have benefited from a different level of care, had the autopsy diagnosis been made before death. All clinical diagnoses were compared with autopsy findings at monthly clinical-pathological meetings. Major and minor diagnostic discrepancies were categorized according to the criteria of Goldman et al., Results: Of 1492 patients admitted to the ICU, 315 died, of whom 167 (53.0%) were autopsied. The most common reason (79.7%) for not obtaining an autopsy was family refusal. The mean +/- SD clinical characteristics were similar for autopsied vs nonautopsied patients, except for shorter length of ICU stay (13 +/- 17 vs 20 +/- 27 days, P =.006), shorter duration of mechanical ventilation (13 +/- 16 vs 19 +/- 25 days, P =.01), and lower percentage of postcardiac surgery patients (38.9% vs 50.0%, P =.05). Among the intensivists' 694 clinical diagnoses, 33 (4.8%) were refuted and 13 (1.9%) were judged incomplete by autopsy findings. Autopsies revealed 171 missed diagnoses, including 21 cancers, 12 strokes, 11 myocardial infarctions, 10 pulmonary emboli, and 9 endocarditis, among others. Major diagnostic errors (class I and class II discrepancies) were made in 53 (31.7%) of 167 patients, with a high percentage of immunocompromised patients also observed among these. Similar percentages of patients with class I and class II errors vs other patients had undergone modern diagnostic techniques during their ICU stay., Conclusion: Even in the era of modern diagnostic technology, regular comparisons of clinical and autopsy diagnoses provide pertinent information that might improve future management of ICU patients.

Objective: To determine the outcome and health-related quality of life of patients requiring >or=14 days of mechanical ventilation in the intensive care unit (ICU)., Design: Prospective cohort study with post-ICU, cross-sectional, health-related quality-of-life survey., Setting: A 17-bed ICU in a university hospital., Patients: A consecutive cohort of 347 patients receiving mechanical ventilation for >or=14 days., Interventions: None., Measurements and Main Results: Of the patients enrolled in the study, 150 (44%) died in the ICU and 197 were discharged (58 of 197 died 1-57 months after discharge). Factors associated with ICU death according to multivariate logistic regression analysis were age >or=65 yrs, preadmission New York Heart Association functional class of >or=3, a preadmission immunocompromised status, septic shock at ICU admission, renal replacement therapy in the ICU, and nosocomial septicemia. Cox proportional hazards multivariate analysis identified age of >or=65, a preadmission immunocompromised status, and duration of mechanical ventilation for >35 days as independent predictors of death after ICU discharge. By contrast, postcardiac surgery patients had a better outcome. Health-related quality of life was evaluated for 87 of the 99 long-term survivors after a median follow-up of 3 yrs by using the Nottingham Health Profile and St. George's Respiratory questionnaires. Compared with those of a general French population, their scores were significantly worse for each of the Nottingham Health Profile domains, except social isolation. Nottingham Health Profile scores did not significantly differ between postcardiac and nonpostcardiac surgery patients, men and women (except that women felt more socially isolated), and patients with and without acute respiratory distress syndrome (except for more sleep disorders in those with acute respiratory distress syndrome). Finally, pulmonary-specific St. George's Respiratory Questionnaire global score was worse for acute respiratory distress syndrome survivors., Conclusions: Prolonged mechanical ventilation is associated with impaired health-related quality of life compared with that of a matched general population. Despite these handicaps, 99% of the patients evaluated were independent and living at home 3 yrs after ICU discharge. Future studies should focus on physical or psychosocial rehabilitation that could lead to improved management of patients after their ICU stay.

Objective: To evaluate the role that nosocomial pneumonia plays in the outcome of intensive care unit (ICU) patients., Design: Cohort study., Setting: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center., Patients: A total of 1978 consecutive patients admitted to the ICU for at least 48 hours., Main Outcome Measures: Various parameters known to be strongly associated with death of ICU patients were recorded: age, location before admission to the ICU, diagnostic categories, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiologic Score, McCabe score, number and type of dysfunctional organs, and the development of nosocomial bacteremia and nosocomial urinary tract infection. These variables and the presence or absence of nosocomial pneumonia were compared between survivors and nonsurvivors and entered into a stepwise logistic regression model to evaluate their independent prognostic roles., Results: Nosocomial pneumonia developed in 328 patients (16.6%) whose mortality was 52.4% compared with 22.4% for patients without ICU-acquired pneumonia (P < .001), APACHE II score (odds ratio [OR] = 1.08; 95% confidence interval [CI], 1.06 to 1.10; P < .001), number of dysfunctional organs (OR = 1.54; 95% CI, 1.36 to 1.74; P < .001), nosocomial pneumonia (OR = 2.08; 95% CI, 1.55 to 2.80; P < .001), nosocomial bacteremia (OR = 2.51; 95% CI, 1.78 to 3.55; P < .001), ultimately or rapidly fatal underlying disease (OR = 1.76; 95% CI, 1.38 to 2.25; P < .001), and admission from another ICU (OR = 1.30; 95% CI, 1.01 to 1.68; P =.04) were significantly associated with mortality., Conclusion: These data suggest that, in addition to the severity of underlying medical conditions and nosocomial bacteremia, nosocomial pneumonia independently contributes to ICU patient mortality.

The infectious complications after lung transplantation have been studied in 26 patients suffering from mucoviscidosis who had transplants in the Ile-de-France between July 1987 and October 1990. We counted 99 infections (74 bacterial infections, 23 viral infections and two fungal infections) during a cumulative observation period of 127 months. The majority of the infections (48%) were localised to the grafted lung. These infections were responsible for 61% of deaths (50% secondary to bacterial infections and 11% to viral infections). The risk of infection remains even after a considerable time after transplantation in this series. These studies underline the importance of infectious complications in the mortality and morbidity of lung transplant patients suffering from mucoviscidosis.

Forty-seven nosocomial cases of legionellosis due to Legionella pneumophila serogroup 1 were diagnosed in one major outbreak from November 1982 to March 1983 in a 960-bed teaching hospital. Contaminated water was considered to be a possible source of infection because, during that period, monthly samples were found to be positive with averages of 10(4) CFU/l. After chlorination of hot water associated with flushing of outlets, nearly all samples taken in the next two years were found to be negative. A case-control study was performed to examine potential risk factors. Three groups of controls were randomly selected among eligible patients. In a multivariate analysis, only three clinical factors were found to be associated with legionellosis patients: malignant illness (relative risk, RR = 3.5), presence of an ultimately fatal disease (RR = 2.6), and exposure to corticosteroids prior to admission (RR = 7.9). Investigations of in-hospital exposures suggest that during this nosocomial outbreak diagnostic or therapeutic respiratory procedures had not increased the risk of illness. Although the epidemiological association between water contamination and disease remains unclear, the eradication of L. pneumophila from the identified supply seems to have been effective in preventing disease in this hospital.