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International audience; ObjectiveMost studies showed no or little effect of pay-for-performance (P4P) programs on different outcomes. In France, the P4P program IFAQ was generalized to all acute care hospitals in 2016. A pilot study was launched in 2012 to design, implement and assess this program. This article aims to assess the immediate impact of the 2012–14 pilot study.Design and settingFrom nine process quality indicators (QIs), an aggregated score was constructed as the weighted average, taking into account both achievement and improvement. Among 426 eligible volunteer hospitals, 222 were selected to participate. Eligibility depended on documentation of QIs and results of hospital accreditation. Hospitals with scores above the median received a financial reward based on their ranking and budget. Several characteristics known to have an influence on P4P results (patient age, socioeconomic status, hospital activity, casemix and location) were used to adjust the models.InterventionTo assess the effect of the program, comparison between the 185 eligible selected hospitals and the 192 eligible not selected volunteers were done using the difference-in-differences method.ResultsWhereas all hospitals improved from 2012 to 2014, the difference-in-differences effect was positive but not significant both in the crude (2.89, P = 0.29) and adjusted models (4.07, P = 0.12).ConclusionThese results could be explained by several reasons: low level of financial incentives, unattainable goals, too short study period. However, the lack of impact for the first year should not undermine the implementation of other P4P programs. Indeed, the pilot study helped to improve the final model used for generalization.

International audience; PURPOSE:Referrals to the Emergency Department can be distressing to patients with advanced cancer and may be a non-optimizing health care service. We aimed to describe the appropriateness and potential avoidability of Emergency Department referrals in a tertiary cancer care center where only physician referrals are allowed.METHODS:We prospectively reviewed the electronic medical charts of patients consecutively checked into the Emergency Department in August 2015. The appropriateness of referrals was assessed using a nationally validated classification (Classification Clinique des Malades aux Urgences) and local criteria. Potentially avoidable referrals were assessed using international classifications (Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations diagnostic tool according to Kosecoff's criteria) and local criteria.RESULTS:We included 500 referrals related to 423 patients. The mean age was 59 years, and 74% of cancers were progressive. The referrals were appropriate in 61% of cases. They were deemed potentially avoidable "with a high likelihood" in 33.4% (CI95% [29.3-37.5]) of cases, potentially avoidable "with a moderate likelihood" in 14.4% (CI95% [11.3-17.5]) of cases, and "non-avoidable" in 52% (CI95% [47.6-56.4]) of cases. Opportunities to avoid referrals after an index stay involved this hospital stay or discharge process in 66 cases (28%), the follow-up period in 59 cases (25%), or both in 66 cases (28%).CONCLUSIONS:Potentially avoidable ED referrals are common in patients with cancer. These potentially avoidable ED referrals underline the importance of several domains of care coordination.Comment inResponse to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018]Response to the response by Lahbib et al. to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018]

International audience; Despite a wide implementation of pay-for-performance (P4P) programs, evidence on their impact in hospitals is still limited. Our objective was to assess the implementation of the French P4P pilot program (IFAQ1) across 222 hospitals. The study consisted of a questionnaire among four leaders in each enrolled hospital, combined with a qualitative analysis based on 33 semi-structured interviews conducted with staff in four participating hospitals. For the questionnaire results, descriptive statistics were performed and responses were analyzed by job title. For the interviews, transcripts were analysed using coding techniques. Survey results showed that leaders were mostly positive about the program and reported a good level of awareness, in contrast to the frontline staff, who remained mostly unaware of the program's existence. The main barriers were attributed to lack of clarity in program rules, and to time constraints. Different strategies were then suggested by leaders. The qualitative results added further explanations for low program adoption among hospital staff, so far. Ultimately, although paying for quality is still an intuitive approach; gaps in program awareness within enrolled hospitals may pose an important challenge to P4P efficacy. Implementation evaluations are therefore necessary for policymakers to better understand P4P adoption processes among hospitals.

Background— In acute myocardial infarction, the relationship between volume and quality indicators (QIs) is poorly documented. Through a nationwide assessment of QIs at discharge repeated for 3 years, we aimed to quantify the relationship between volume and QIs in survivors after acute myocardial infarction. Methods and Results— Almost all healthcare centers in France participated. Medical records were randomly selected. Data collection was performed by an independent group. QIs for acute myocardial infarction were defined by an expert consensus group as appropriate prescription at discharge of aspirin, clopidogrel, β-blocker, statin, and an angiotensin-converting enzyme inhibitor in patients with left ventricular ejection fraction 300, a significantly lower rate of all QIs was observed in centers with the lowest volume. Odds ratios progressively decreased with increasing volume. Despite a significant increase in the composite QI over the 3 years, a significant relationship persisted between volume and quality of care. Conclusions— Analysis of QIs at discharge demonstrates the existence of a relationship between volume and appropriate prescriptions at discharge. Centers with the highest volume perform better on quality measures than centers with lower volumes. Temporal analysis over 3 consecutive years confirms this relationship and shows that it persists despite improvement in QIs between 2008 and 2010.

Nocardia farcinica is an emerging pathogen in immunosuppressed patients causing both localized and disseminated infections. Many strains of this species are multidrug-resistant and require long-term antibiotic therapy, and consequently the choice of an oral treatment can be problematic. We report here the first case of successful treatment of N. farcinica brain abscess in a renal transplant recipient with an extended-spectrum fluoroquinolone, moxifloxacin.

Study objectives To assess incidence, outcome, and early predictors of mortality for patients with primary graft failure (PGF) following lung transplantation (LTx), and to develop an injury severity score able to accurately predict ICU mortality for these patients. Design Retrospective cohort analysis. Setting Two LTx centers in Paris. Patients Two hundred fifty-nine patients who underwent LTx over a 12-year period. Measurements and results One hundred thirty-one patients (50.6%) met PGF criteria: radiographic graft infiltrate within the first 3 days following LTx associated with gas exchange impairment (Pao 2 /fraction of inspired oxygen ratio Conclusion PGF following LTx is a frequent event, with significant ICU morbidity and mortality. We demonstrate that four simple factors allow prediction of ICU mortality with good accuracy.

Resume L'insuffisance renale aigue (IRA) est responsable d'anomalies metaboliques qui lui sont propres mais qui restent mal connues, en partie en raison des difficultes a individualiser ce qui revient a l'IRA et ce qui revient a la maladie sous-jacente causale. Il semble que l'IRA n'a que peu de retentissement sur le metabolisme energetique. Elle est associee a une insulinoresistance et a une augmentation de la neoglucogenese hepatique, les deux mecanismes tendant a favoriser l'intolerance glucidique. Les anomalies du metabolisme proteique entrainent un hypercatabolisme multifactoriel : en sont responsables a la fois la maladie sous-jacente et l'IRA, soit directement par le biais de l'acidose metabolique associee, soit indirectement (secretion d'hormones cataboliques, defaut de synthese proteique musculaire, diminution de la production d'acides amines par le rein, deperdition proteique liee a la dialyse...). Enfin, l'IRA est egalement responsable d'alterations du metabolisme lipidique principalement secondaires a une diminution de la lipolyse, avec hypertriglyceridemie, hypocholesterolemie et anomalies qualitatives et quantitatives des lipoproteines. Ces diverses anomalies peuvent entrainer une denutrition dont le role, dans la gravite de l'IRA, devrait pouvoir etre precise par des etudes prospectives faisant appel a une analyse multivariee.

Objectives Accreditation in France relies on a mandatory 4-year cycle of self-assessment and a peer review of 82 standards, among which 14 focus priority standards (FPS). Hospitals are also required to measure yearly quality indicators (QIs—5 in 2010). On advice given by the accreditation committee of HAS (Haute Autorite en Sante), based on surveyors proposals and relying mostly on compliance to standards, accreditation decisions are taken by the board of HAS. Accreditation is still perceived by hospitals as a burdensome process and a simplification would be welcomed. The hypothesis was that a more limited number of criteria might give sufficient amount of information on hospitals overall quality level, appraised today by accreditation decisions. Design The accuracy of predictions of accreditation decisions given by a model, Partial Least Square-2 Discriminant Analysis (PLS2-DA), using only the results of FPS and QIs was measured. Accreditation decisions (full accreditation (A), recommendations or reservation (B), remit decision or non-accreditation (C)), results of FPS and QIs were considered qualitative variables. Stability was assessed by leave one out cross validation (LOOCV). Setting and participants All French 489 acute care organisations (ACO) accredited between June 2010 and January 2012 were considered, 304 of them having a rehabilitation care sector (RCS). Results Accuracy of prediction of accreditation decisions was good (89% of ACOs and 91% of ACO-RCS well classified). Stability of results appeared satisfactory when using LOOCV (87% of ACOs and 89% of ACO-RCS well classified). Identification of worse hospitals was correct (90% of ACOs and 97% of ACO-RCS predicted C were actually C). Conclusions Using PLS2-DA with a limited number of criteria (QIs and FPS) provides an accurate prediction of accreditation decisions, especially for underperforming hospitals. This could support accreditation committees which give advices on accreditation decisions, and allow fast-track handling of ‘safe’ reports.

OBJECTIVE To investigate the role of metformin accumulation in the pathophysiology of metformin-associated lactic acidosis. RESEARCH DESIGN AND METHODS We used high-performance liquid chromatography to measure plasma metformin concentrations in 14 patients who experienced lactic acidosis (pH 5 mmol/l) while receiving chronic metformin treatment. Their treatment was generally based on alkalinization and dialysis therapy. RESULTS Clinical shock and/or evidence of tissue hypoxia was found in all patients with the exception of one who had a nonsteroidal anti-inflammatory drug-induced anuria. Ten patients had significant metformin accumulation (plasma metformin concentrations 4.1-84.9 mg/l, normal value 0.6 ± 0.5 mg/l before drug intake), generally because of failure to withdraw metformin despite intercurrent pathological conditions affecting its renal elimination (serum creatinine concentrations ranging from 269 to 1,091 μmol/l). There was no metformin accumulation (plasma metformin 0.03–0.7 mg/l) in the four other patients, who had less severe renal failure (serum creatinine 140–349 mumol/l). The severity of the patient's general condition did not predict early hospital mortality (death before discharge from the intensive care unit) even in patients in shock. Whereas it was high in those without metformin accumulation (only 1 of 4 patients recovered), early hospital mortality was low in the 10 patients with metformin accumulation and was not related to its extent (3 patients died with end-stage hepatic failure or cardiac failure). Correlation studies showed a positive correlation between serum creatinine and plasma metformin and between plasma metformin and arterial lactate but, for the latter correlation, only in patients with metformin accumulation. CONCLUSION Metformin-associated lactic acidosis is not necessarily due to metformin accumulation; true type B (aerobic) lactic acidosis, i.e., without an apparent associated hypoxic factor, seems exceptional. Neither the severity of the clinical picture nor the degree of metformin accumulation predicted survival; rather, the prognosis was dependent upon the severity of the associated pathological conditions.

The present case describes an acute respiratory-related hemodynamic failure during a single left lung transplantation in a 32-year-old woman suffering from end-stage pulmonary lymphangiomyomatosis. During the first 5 min of single right lung ventilation, a progressive increase in airway pressure and decrease in tidal volume associated with a decrease in arterial pressure and Spo2 occurred that were successfully countered by reventilation of the left lung. Proper positioning of the double-lumen tube was confirmed with a fiberoptic bronchoscope. Despite deliberate hypoventilation, within a few respiratory cycles, each further attempt at single lung ventilation was followed by abrupt hypotension, increase in pulmonary artery pressure, while airway pressure rose and tidal volume collapsed. The surgical team saw no signs of right pneumothorax. In these circumstances, cardiopulmonary bypass was required to perform pneumonectomy and grafting. Postoperatively a right anterior pneumothorax remained undiscovered on standard radiograph but was later revealed on soft radiograph. This acute intraoperative respiratory failure could equally well have been related to air trapping, in which case, however, deliberate hypoventilation would have been effective. In addition, the striking difference between the progressive onset of the first episode of hemodynamic failure and the immediate onset of the others argues in favor of a pneumothorax being at cause. Patients with pulmonary lymphangiomyomatosis are at high risk for intraoperative pneumothorax, but in our case, it could not be confirmed and treated during the surgical procedure without putting the patient at high risk for lung injury because of pleurodesis due to earlier pleural abrasion. This case again clearly shows the need to have cardiopulmonary bypass whenever single lung transplantation is performed.

Objective To determine the impact on hospital ranking of different aggregation methods when creating a composite score from a set of quality indicators relating to a single clinical condition. Design The analysis was based on 14966 medical records taken from all French hospitals that treated over 30 patients with acute myocardial infarction in 2008 (n=275). Five quality indicators measuring the quality of care delivered to patients with acute myocardial infarction at hospital discharge were aggregated by 5 methods issued from a variety of activity sectors (indicator average, all-or-none, budget allocation process, benefit of the doubt, and unobserved component model). Main outcome measures Each aggregation method was used to rank hospitals into 3 categories depending on the position of the 95% confidence interval of the composite score relative to the overall mean. Variations in rank according to method were estimated using weighted κ coefficients. Results Agreement between methods ranged from poor (κ=0.20) to almost perfect (κ=0.84). A change of method led to a change in rank for 71% (196 of 275) of hospitals. Only 14 of 121 hospitals which were ranked top and 20 of 118 which were ranked bottom, by at least 1 of the 5 methods, held their rank on a switch to the 4 other methods. Conclusion Hospital ranking varied widely according to 5 aggregation methods. If one method has to be chosen, for instance for reporting to governments, regulatory agencies, payers, health care professionals, and the public, it is necessary to provide its rationale and characteristics, and information on score uncertainty.

Background Coordination within hospitals is a major attribute of medical care and influences quality of care. This study tested the validity of 3 indicators covering two key aspects of coordination: the transfer of written information between professionals (medical record content, radiology exam order) and the holding of multidisciplinary team meetings during treatment planning. Methods The study was supervised by the French health authorities (COMPAQH project). Data for the three indicators were collected in a panel of 30 to 60 volunteer hospitals by 6 Clinical Research Assistants. The metrological qualities of the indicators were assessed: (i) Feasibility was assessed using a grid of 19 potential problems, (ii) Inter-observer reliability was given by the kappa coefficient () and internal consistency by Cronbach's alpha test, (iii) Discriminatory power was given by an analysis of inter-hospital variability using the Gini coefficient as a measure of dispersion. Results Overall, 19281 data items were collected and analyzed. All three indicators presented acceptable feasibility and reliability (, 0.59 to 0.97) and showed wide differences among hospitals (Gini, 0.08 to 0.11), indicating that they are suitable for making comparisons among hospitals. Conclusion This set of 3 indicators provides a proxy measurement of coordination. Further research on the indicators is needed to find out how they can generate a learning process. The medical record indicator has been included in the French national accreditation procedure for healthcare organisations. The two other indicators are currently being assessed for inclusion.

Background Intensive care unit (ICU) admission of adults with cystic fibrosis (CF) is controversial because of poor outcome. This appraisal needs re-evaluation following recent changes in both CF management and ICU daily practice. Objectives were to determine long-term outcome of adults with CF admitted in ICU and to identify prognostic factors. Methods Retrospective multicenter study of 60 ICU hospitalizations for 42 adult CF patients admitted between 2000 and 2003. Reason for ICU admission, ventilatory support provided and one-year survival were recorded. Multiple logistic analysis was used to determine predictors of mortality. Results Prior to ICU admission, all patients (mean age 28.1 ± 8 yr) had a severe lung disease (mean FEV1 28 ± 12% predicted; mean PaCO2 47 ± 9 mmHg). Main reason for ICU hospitalization was pulmonary infective exacerbation (40/60). At admission, noninvasive ventilation was used in 57% of cases and was successful in 67% of patients. Endotracheal intubation was implemented in 19 episodes. Overall ICU mortality rate was 14%. One year after ICU discharge, 10 of the 28 survivors have been lung transplanted. Among recognized markers of CF disease severity, only the annual FEV1 loss was associated with a poor outcome (HR = 1.47 [1.18–1.85], p = 0.001). SAPSII (HR = 1.08 [1.03–1.12], p < 0.001) and endotracheal intubation (HR = 16.60 [4.35–63.34], p < 0.001) were identified as strong independent predictors of mortality. Conclusion Despite advanced lung disease, adult patients with CF admitted in ICU have high survival rate. Endotracheal intubation is associated with a poor prognosis and should be used as the last alternative. Although efforts have to be made in selecting patients with CF likely to benefit from ICU resources, ICU admission of these patients should be considered.

Cerebellar syndromes and radiologic cerebellar atrophy after hyperpyrexia have occasionally been reported, mostly in neuroleptic malignant syndromes, but neuropathologic studies are extremely rare. We studied 3 patients (a 74-year-old woman, a 63-year-old man, and an 80-year-old man) who had heat stroke during heat waves in France. One patient had generalized seizures and died 28 hours after admission. The other patients survived one month and 2 months after admission; both had palatal myoclonus, and in one case, magnetic resonance imaging showed high signal intensity in the cerebral peduncles. The main neuropathology in the 3 cases was severe diffuse loss of Purkinje cells associated with heat shock protein 70 expression by Bergmann glia. In situ end labeling was negative in surviving Purkinje cells, suggesting that the mechanism of neuronal death was not apoptosis. Degeneration of Purkinje cells axons resulted in myelin pallor of the white matter of the folia and of the hilum of the dentate nuclei. DNA internucleosomal breakages were identified by in situ end labeling in the dentate nuclei and centromedian nuclei of the thalamus and were associated with degeneration of the cerebellar efferent pathways: superior cerebellar peduncles, decussation of the superior cerebellar peduncles (Wernekinck commissure), and dentatothalamic tract. These findings suggest that the mechanisms of neuronal death in the dentate nuclei and centromedian nuclei of the thalamus was different from that in Purkinje cells and more likely resulted from deafferentation. Ammon's horn and other areas susceptible to hypoxia were spared. These observations confirm the selective vulnerability of Purkinje cells to heat-induced injury and involvement of the cerebellar efferent pathways in palatal myoclonus.

Objective: The use of cardiopulmonary bypass (CPB) for lung transplantation (LTx) has been reported previously. This study reports the authors’ experience of planned and unplanned use of cardiopulmonary bypass for LTx. Design: Case series. Setting: A university teaching hospital. Participants: Patients undergoing LTx. Interventions: A retrospective analysis of the charts of all patients having undergone LTx over the last 10 years. Measurements and Main Results: Among 140 LTx, 23 (16%) were performed with the use of CPB. CPB was planned in 11 cases and unplanned in the 12 other cases. The use of CPB is associated with a longer period of postoperative mechanical ventilation, more pulmonary edema, more blood transfusion requirement, and an increase in postoperative mortality at 48 hours and 1 month. Surgical difficulties related to the dissection of the native left lung and acute right ventricular failure are the main reasons for unscheduled use of CPB. Conclusion: Scheduled and unscheduled CPB for LTx are associated with an increased mortality at 1 month and 1 year.

The effect of graft ischemic time on early graft function and long-term survival of patients who underwent lung transplantation remains controversial. Consequently, graft ischemic time has not been incorporated in the decision-making process at the time of graft acceptance.To investigate the relationship between graft ischemic time and (1) early graft function and (2) long-term survival after lung transplantation.The data from 752 patients who underwent single lung transplantation (n = 258), bilateral lung transplantation (n = 247), and heart-lung transplantation (n = 247) in seven French transplantation centers during a 12-year period were reviewed. Independent data quality control was done to ensure the quality of the collected variables. Mean graft ischemic time was 245.8 +/- 96.4 minutes (range 50-660). After adjustment on 11 potential confounders, graft ischemic time was associated with the recipient Pa(O2)/FI(O2) ratio recorded within the first 6 hours and with long-term survival in patients undergoing single or double lung transplantation but not in patients undergoing heart-lung transplantation. The relationship between graft ischemic time and survival appears to be of cubic form with a cutoff value of 330 minutes. These results were unaffected by the preservation fluid employed.The results of this large cohort of patients suggest a close relationship between graft ischemic time and both early gas exchange and long-term survival after single and double lung transplantation. Such relationship was not found in patients undergoing heart-lung transplantation. The expected graft ischemic time should be incorporated in the decision-making process at the time of graft acceptance.

International audience; Background: The liberalization of lung-donor criteria and the use of marginal donors have been advocated to face the current shortage of donors in lung transplantation. However, the impact of donor characteristics on the outcome of lung transplantation is still largely unknown. We aimed to determine, on a large cohort of patients, the effect of donors characteristics on short- and long-term outcome of lung transplantation. Methods: Between 1988 and 1998, a total of 785 adult patients underwent single-lung transplantation (n 270), bilateral-lung transplantation (n = 251), and heart-lung transplantation (n = 264) in 7 centers in France. We constructed several multivariate models to assess the relationship between donor characteristics and early gas exchange, duration of mechanical ventilation, and long-term survival after lung transplantation. Results: Among donor characteristics, donor gas exchange before harvest was found to be significantly associated with recipient early gas exchange, duration of mechanical ventilation, and long-term survival after adjustment for potential confounding variables. Moreover, nonlinear modeling showed a steep increase in the relative risk of death when donor Pao(2)/Fio(2) before harvest was below 350 (hazard ratio 1.43; 95% confidence interval 1.10 - 1.85; p = 0.01). Donor and recipient sex mismatch were also found to be significantly associated with long-term survival. Conclusions: Although liberalization of lung-donor criteria may be considered to overcome the shortage of lung donors, our data suggest that the violation of the gas-exchange criterion should be avoided.

The aim of this study was to assess the influence of preservation solution type and extra- or intracellular composition on the occurrence of early graft dysfunction after clinical lung transplantation. For 170 patients who underwent a single (n = 124) or bilateral (n = 46) lung transplantation in two centers in Paris between 1988 and 1999, the preservation technique applied to the donor lung was single-flush perfusion of the pulmonary artery with one of several solutions of intracellular (Euro-Collins, n = 61; University of Wisconsin, n = 24) or extracellular composition (Cambridge, n = 64; Celsior, n = 21). The early postoperative outcome of these patients was reviewed. Reimplantation edema occurred in 48% of all patients, and the overall 1-mo survival rate was 84%. No significant difference in the incidence of edema, duration of mechanical ventilation, and 1-mo survival rate was observed between the four groups or between intra- and extracellular groups. After adjustment for graft ischemic time by means of multivariate analysis, the use of extracellular preservation fluid was associated with a lower incidence of reimplantation edema without effect on 1-mo mortality. Graft ischemic time was associated with both edema occurrence and 1-mo survival rate (p = 0.02 and p = 0.01, respectively). We conclude that extracellular-type solutions are associated with better lung preservation than intracellular-type solutions in clinical transplantation.

Objectives To assess the efficacy of the Simplified Acute Physiology Score (SAPS II) in intermediate care units. A number of patients hospitalized in the intensive care unit (ICU) could be hospitalized in alternative structures, intermediate care units, which are equipped to handle their monitoring needs and able to provide adequate treatment at a lower cost. Characterization of the patients relies on the assessment of their severity of illness by severity scores. The efficiency of severity scores has been established in ICU patients, but not in the setting of intermediate care units. Design Prospective study. Setting Intermediate care unit of a multidisciplinary hospital. Patients Four hundred thirty-three patients admitted to the intermediate care unit. Interventions None. Measurements and Main Results Of 561 consecutive patients admitted to the intermediate care unit during a 12-mo period, 433 patients could be included in the analysis. Patients were admitted from the emergency ward (60.9%). Of the study patients, 60.9% were admitted from the emergency ward for mostly (96%) medical reasons. Average length of stay was 3.1 +/- 2.3 (SD) days. Death rate in the intermediate care unit was 2.7% (n = 11). Average SAPS II was 22.3 +/- 12.0 (range 6 to 73). Hospital death rate was 8.1%, whereas the expected mortality rate derived from SAPS II was 8.7%. To assess the performance of the system, a formal goodness-of-fit test was performed to evaluate calibration. Calibration was accurate using the C coefficient of Hosmer-Lemeshow statistics (C = 2.4; p > 0.5). The discriminant power of SAPS II, measured by the area under the receiver operating characteristic curve was excellent (0.85 +/- 0.04). Conclusions The SAPS II assessment of severity of illness in patients admitted to an intermediate care unit is reliable. These results will need to be confirmed, using different patient samplings from intermediate care units. (Crit Care Med 1998; 26:1368-1371)

To the Editor, In a recent article, Glasgow et al assessed the impacts of organizational context on quality improvement (QI). In their study of organizational characteristics of 100 hospitals participating in a national QI collaborative, they did not find any predictive associations with QI performance. Using a different approach, we conducted a study of 505 French hospitals that are subject to mandatory annual measurements of quality indicators in a national program aimed at promoting continuous quality improvement (CQI). This program is driven by the French Ministry of Health, the French Health Authority, and our research group (COMPAQ-HPST). From an analysis of the literature, we developed a theoretical frame that ranged potential factors of success for a CQI program along 2 axes. One concerned contextual factors (eg, staff stability, QI information), which covered the same organizational characteristics as described by Glasgow et al. The other included managerial factors (eg, managers use quality indicator results to define the hospi-tal's strategy, managers favor multiprofessional commitment when analyzing quality indicator results), which do not seem to have been considered in that article. Seventeen factors were identified and considered to be relevant by a panel of 22 health care professionals, using a consensus method. The relevance of these 17 factors was thereafter confirmed in 505 hospitals by assessing the correlation between the presence/absence of these factors and the results of 3 quality indicators (quality of patient medical records, pain assessment, and delay in sending information at patient discharge). A factorial analysis showed that the managerial axis included 6 factors and the contextual axis included 11. Cronbach α for the 2 axes were .78 and .82, respectively. A multivariate analysis showed a link between managerial score and the results of an indicator assessing the quality of patients' medical records (P = .02) and an indicator measuring the delay in sending information at patients' discharge (P = .03). We believe that managerial capacity is an important factor in the success of QI programs and should be analyzed more precisely.

Bilateral lung transplantation (BLT) is a recently described procedure based on two sequential single-lung transplantations (SLT), which are performed by a transverse sternobithoracotomy. It does not require either cardiac arrest or routine use of cardiopulmonary bypass (CPB). The intraoperative management of 10 patients suffering from end-stage pulmonary disease is reported. Implantation of the first graft is quite similar to a SLT. Problems encountered during this procedure (ie, hypoxemia, hypercapnia, or low cardiac output) were due to restricted pulmonary and cardiac reserve. Preoperative and intraoperative assessment of the recipient's respiratory and cardiac status was, therefore, of prime importance. Mild preoperative pulmonary hypertension, well-preserved right ventricular function, and removal of the less well-perfused lung limited these difficulties; no patient required partial CPB at this stage. During the second lung implantation, gas exchange was provided by the first grafted lung. Measurements of pulmonary vascular resistance (PVR), venous admixture (Qva/Qt), and dead space (VD/VT) assessed with the arterial-to-end-tidal CO2 difference were used to confirm the adequacy of perfusion and V/Q matching. In one patient, partial CPB was instituted because of surgical difficulty related to inadequate size matching of the lungs. In the other patients, first graft function was satisfactory and the second graft was implanted without CPB. With chest closure, PVR returned to nearly normal values (range, 57-293, mean 167 dynes.s.cm-5) and Qva/Qt increased (range, 3 to 36, mean 20%). This limited series demonstrates that CPB is optional during this procedure. Good selection of recipients and donors, good lung preservation methods, and a short duration of cold ischemia are essential to success.

The study objective was to describe the clinical, biologic, and hemodynamic features of adult overwhelming meningococcal purpura and to examine the prognostic factors by multivariate analysis at the time of admission to the intensive care unit. Thirty-five patients (greater than or equal to 13 years of age) with meningococcal infection, circulatory shock, and generalized purpuric lesions of abrupt onset were recorded in eight intensive care units from 1977 to 1989. The patients were young (mean age, 26.6 years; range, 13 to 68 years) and had been previously healthy. The female-to-male ratio was 3:1. Mortality was 54.3%, with most deaths occurring within the first 48 hours, usually secondary to irreversible shock with multiple organ failure. Ischemic complications (eight cases), prolonged heart failure (seven cases), and secondary septicemia (five cases) were the chief complications among survivors. Initial hemodynamic study after volume loading showed low stroke volume index (mean +/- SD, 29.4 +/- 13 mL/m2) and tachycardia (mean +/- SD, 138 +/- 16 beats per minute), a profile suggesting a greater myocardial depression than usually observed in gram-negative bacillary septic shock. Univariate prognostic analysis showed that four variables at the time of admission were associated with fatal outcome: a plasma fibrinogen level of 1.5 g/L or less, a factor V concentration of 0.20 or less, a platelet count lower than 80 x 10(9)/L, and a cerebrospinal fluid leukocyte count of 20 x 10(6)/L or less. Stepwise regression analysis showed that low fibrinogen level (less than or equal to 1.5 g/L) was the sole adverse prognostic variable (odds ratio = 2, 95% confidence interval, 1.5 to 2.7). Adult overwhelming meningococcal purpura is still associated with high mortality and morbidity. Low fibrinogen level at time of admission may permit early recognition of the most severely ill patients.

Many advances have been made in Intensive Care Medicine during the last few decades. Proper nutrition, adequate ventilatory support, fluid and electrolyte balance are better achieved than they were. Never-theless, ICU death rates remain high and it is difficult to measure and prove the benefits of Intensive Care as it treats increasingly more severely ill patients.

N euroleptic malignant syndrome is characterized by hyperthermia, frequently above 41°C, extrapyramidal symptoms, changes in consciousness, autonomic dysfunction, and rhabdomyolysis, with creatine phosphokinase levels rising as high as 100,000 IU/liter [1-3]. The incidence of this idiosyncratic reaction to neuroleptic drugs occurring either at the start of, or during treatment, is between 0.4 percent and 1.4 percent [4,5], and mortality is high, ranging from 16 to 24 percent [4,6]. Apyrexia usually occurs within two to 12 days but may be deferred as long as 24 to 36 days in the case of long-acting depot neuroleptics [4,6]. The increased mortality of 40 percent associated with longacting neuroleptics may be explained by persistence of symptomatology, itself an important sign of the seriousness of the situation, and the consequential risk of intercurrent complications. The following observation is of one such case in which the patient presented with a malignant syndrome over a period of several months following treatment with haloperidol decanoate. The final outcome was satisfactory, but several complications occurred during hospitalization, notably a necrotizing enterocolitis, which considerably jeopardized vital prognosis.

The clearance of endogenous creatinine in 20 burned patients, measured between the fourth and the 35th post-burn day, was a mean (+/- S.D.) of 172.1 p 48.4 ml per minute per 1.73 m2; in eight normal subjects the mean value was 125.4 g- 10.4 (P less than 0.02). Thirteen patients had values more than 2 S.D. above the normal mean. We confirmed this rise in glomerular filtration rate by measuring inulin or iothalamate clearance in nine patients. The pharmacokinetics of tobramycin were studied in 11 of the 20 patients and in eight normal subjects receiving continuous intravenous infusions of the drug. An inverse correlation was found between plasma half-life of the drug and creatinine clearance (r = 0.68, P less than 0.01). Increased creatinine clearances and shortened half-life of tobramycin occurred mainly in younger patients. Glomerular filtration rates in burned patients may rise to very high values and can be validly measured by creatinine clearance. The plasma half-lives of drugs with predominantly urinary excretion may decrease in patients with burns.