Secondary analysis of hand-offs in internal medicine using the I-PASS mnemonic.

BACKGROUND: Miscommunications account for up to 80% of preventable medical errors. Mnemonics like I-PASS (Illness severity, Patient summary, Actions list, Situation awareness, Synthesis) have demonstrated a positive impact on reducing error rates. Currently, physicians at our hospital do not follow a specific structure during hand-offs. We aimed to compare current hand-offs without prior training to a gold standard and the I-PASS tool in terms of content and sequence. METHODS: This study is a secondary analysis of data collected during a simulation study of a Friday evening hand-off to the night resident at University Hospitals of Geneva. Thirty physicians received a hand-off of four patients and managed two other patients through nursing pages at the start of the night shift, generating six sign-outs each, totaling 177 sign-outs. A focus group of three senior doctors defined the gold standard (GS) by consensus on the essential content of each sign-out. The analysis focused on the rates of relevance (ratio of information considered relevant by the GS) and completeness (proportion of transmitted elements out of all expected elements of the GS), and the distribution and sequence of the first four I-PASS categories. RESULTS: Relevance and completeness rates were 37.2% ± 0.07 and 51.9% ± 0.1, respectively, with no significant difference between residents and supervisors. There was a positive correlation between total hand-off time and relevance (residents: R2 = 0.62; supervisors: R2 = 0.67) and completeness (residents: R2 = 0.32; supervisors: R2 = 0.56). The distribution of I-PASS categories was highly skewed in both the GS (I = 2%, P = 72%, A = 17%, S = 9%) and participants (I = 6%, P = 73%, A = 14%, S = 7%), with significant differences in categories A (p = 0.046) and I (p ≤ 0.001). Sequences of I-PASS categories generally followed a P-A-S-I pattern. The first S category was frequently absent, and only one participant began by announcing the case severity as suggested by I-PASS. CONCLUSION: We identified gaps between current medical sign-outs in our institution's general internal medicine division and the I-PASS structure. We recommend implementing the I-PASS mnemonic, emphasizing the "I" category at the start and the "S" category to anticipate and prevent complications. Future studies should assess the impact of this recommendation, adapt the mnemonic elements to the context, and introduce specific hand-off training for senior medical students.

[How to manage hypertension after an ischemic or hemorrhagic stroke?] / Hypertension artérielle après un accident vasculaire cérébral: quelle prise en charge?

The sometimes-divergent results of studies on the management of blood pressure in the acute phase of stroke have not led to strong and generalizable recommendations. Indeed, an individualized approach seems to be necessary. Depending on the etiology of the stroke, the time to introduce blood pressure lowering therapy differs. In hemorrhagic stroke, it is recommended that intensive hypotensive therapy be started immediately aiming a systolic blood pressure of 130-140mmHg, whereas in the management of ischemic stroke, no hypotensive therapy should be introduced within the first 24 hours except if thrombectomy or thrombolysis are performed. No antihypertensive agent has clearly demonstrated superiority over other classes. However, abrupt changes in blood pressure should be avoided.

Les résultats, parfois divergents, des études évaluant la prise en charge de la tension artérielle en phase aiguë d'un accident vasculaire cérébral (AVC) n'ont pas permis d'établir avec certitude les stratégies thérapeutiques optimales. Néanmoins, ces études mettent en évidence des différences majeures selon le type d'AVC. En cas d'AVC hémorragique, il est recommandé de débuter immédiatement un traitement hypotenseur intensif en visant une tension artérielle systolique (TAS) entre 130 et 140 mmHg, alors que, lors de la prise en charge d'un AVC ischémique, aucun traitement hypotenseur ne devrait être instauré, sauf en cas de thrombectomie ou de thrombolyse. Aucun agent antihypertenseur n'a clairement démontré une supériorité sur les autres classes. Il faut toutefois éviter toute variation brutale de la tension artérielle.

Calcification Propensity (T50) Predicts a Rapid Decline of Renal Function in Kidney Transplant Recipients.

BACKGROUND: Serum creatinine level, proteinuria, and interstitial fibrosis are predictive of renal prognosis. Fractional excretion of phosphate (FEP)/FGF23 ratio, tubular reabsorption of phosphate (TRP), serum calcification propensity (T50), and Klotho's serum level are emerging as determinants of poor kidney outcomes in CKD patients. We aimed at analysing the use of FGF23, FEP/FGF23, TRP, T50, and Klotho in predicting the rapid decline of renal function in kidney allograft recipients. METHODS: We included 103 kidney allograft recipients in a retrospective study with a prospective follow-up of 4 years. We analysed the predictive values of FGF23, FEP/FGF23, TRP, T50, and Klotho for a rapid decline of renal function defined as a drop of eGFR > 30%. RESULTS: During a follow-up of 4 years, 23 patients displayed a rapid decline of renal function. Tertile of FGF23 (p value = 0.17), FEP/FGF23 (p value = 0.78), TRP (p value = 0.62) and Klotho (p value = 0.31) were not associated with an increased risk of rapid decline of renal function in kidney transplant recipients. The lower tertile of T50 was significantly associated with eGFR decline >30% with a hazard ratio of 3.86 (p = 0.048) and remained significant in multivariable analysis. CONCLUSION: T50 showed a strong association with a rapid decline of renal function in kidney allograft patients. This study underlines its role as an independent biomarker of loss of kidney function. We found no association between other phosphocalcic markers, such as FGF23, FEP/FGF23, TRP and Klotho, with a rapid decline of renal function in kidney allograft recipients.