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Majocchi granuloma was described naturally in situations of occlusion and later from superficial trauma such as shaving. More recently, the disease has occurred in the immunocompromised patient. Iatrogenic disease (tinea incognito) is a new and more subtle form.
Many general signs familiar to physicians can be found on the skin in cardiac patients. These include (a) cyanosis, central and peripheral, (b) erythremia, flushing and erythema, (c) digital clubbing and (d) alteration in texture. Specific cardiac conditions often have useful diagnostic cutaneous clues. Of these the association of coronary heart disease, hyperlipidemia and xanthomas is the most important. Rare syndromes such as the "leopard syndrome" often have distinctive skin signs. Multisystemic disorders may affect the heart and skin simultaneously or in sequence. They include collagen vascular diseases, amyloidosis, sarcoidosis and relapsing polychondritis. Finally iatrogenic disease arising from treatment of cardiac or cutaneous disease may induce changes in one or the other organ. The heart and the skin have much in common. These manifestations help elucidate the cause, evaluate the diagnosis, and follow the treatment and progress of these diseases.
Angiodysplasia or vascular ectasia of the intestine is a new pathological entity which was initially revealed by arteriography. More recently it has been found by coloscopy and is considered to be responsible for many cases of intestinal bleeding, especially in older patients The present study is based on eight patients including 2 cases of microscopic bleeding, 4 of massive hemorrhage, and 2 asymptomatic cases. There is a clear difference between intestinal angiodysplasia and other forms of vascular malformations, even though its pathogenesis is still in question. Whereas in older patients it is acquired, typically in the caecum. It can also exist congenitally in younger patients and in other locations. However, identical lesions may be observed at all levels of the digestive tract in association with certain diseases, most often vascular atheroma, but also diverse intestinal diseases (diverticulitis, colitis, polyps, cancer) and even iatrogenic diseases. Even though these malformations are frequent, the lesions often go unrecognized because special histological technics are required to reveal the arteriovenous fistulas. The major circumstance leading to this diagnosis is anemia due either to occult intestinal bleeding or massive hemorrhage (after exclusion of prevalent associated disease such as diverticulosis). Occasionally latent angiodysplasia is revealed during studies undertaken for associated disease. Positive diagnosis is based on selective angiography during massive bleeding and on endoscopic examination in case of anemia from occult bleeding. Surgical treatment should be undertaken in case of major blood loss. This usually consists of resection of the ascending colon, the most frequent site of the lesion. It is recommended that an even longer colonic segment be resected in case of associated diverticulosis. The preferred treatment of limited forms with few symptoms depends on more recent technics such as endoscopic electrocoagulation. In conclusion, many cases if occult intestinal bleeding can be explained by angiodysplasia which thus deserves better understanding and recognition.
Ovarian hyperstimulation syndrome is a severe and potentially fatal iatrogenic disease that affects 2% of women subjected to pharmacological induction of ovulation. The newest data on the clinical picture, risk factors, pathophysiology and management of this disease, are reviewed.
Classifications of iatrogenic diseases are presented for establishing their causes, their place in the pathology diagnosis and legal pathology. The quality of clinical diagnosis should be considered including the index of quality of clinical diagnosis of the deceased.
A case of hyperstimulation syndrome secondary to Pergonal therapy is presented. Successful management was based principally on severe sodium and fluid restriction without the use of volume expanders. The rationale for this therapeutic approach is presented and discussed. Although this iatrogenic disease should be virtually eliminated with the monitoring of daily urinary estrogens, severe hyperstimulation may still occur as a result of laboratory error.
The efficiency of the transfer of information among doctors about current drug therapy was examined in emergency, waiting list, and outpatients. Communication about the patient's recent medical history was established with the practitioner in 551 of 559 patients referred (99%). Four hundred and ninety-eight patients (89%) were currently taking 1,557 drugs either supplied by prescription or taken as self-medication. In 314 patients (56%) some information was supplied by the practitioner about 555 drugs (36%). Six hundred and thirteen (61%) of the 1,002 drugs not mentioned by the practitioner were drugs supplied by prescription, mainly hypnotics, sedatives, and analgesics. The transfer of information was unsatisfactory about drugs taken as self-medication and about the allergic status of patients.If iatrogenic disease due to drug therapy is to be recognized or prevented the communication of information about drugs must be improved.
The oral cavity is the site of diverse manifestations of iatrogenic disease. Mucosal pigmentations, gingival hypertrophy, ulcerations, mucositis and xerostomia are easily identifiable, but may simulate diseases that are well known to localise to the oral cavity, such as aphthous ulcers or lichen planus. Drug therapies are at the origin of the greatest number of these lesions. A rigorous inquiry into the characteristic oral lesions permits, in the majority of cases, the establishment of this relationship.
In order to investigate the clinical course and outcome of septicemia in urological patients, data were collected retrospectively from all patients admitted to a specialized urological department, in whom positive blood cultures were drawn. During a 5-year period 91 patients were registered with urosepsis corresponding to an incidence of 1.2%. In non-iatrogenic urosepsis due to ureteral obstruction women dominated over men, however, in iatrogenic disease--after investigative manoeuvres as well as after surgery--men by large dominated the material. Gram-negative bacteria were responsible for almost 75% of the septicemias and for 99% of the cases where septic shock was present. Where a urinary infection was demonstrated prior to septicemia (45%- identical bacteria were subsequently found in the blood, whether the focus had been successfully treated or not. Septic shock developed in 20 of the patients of whom 3 died. This overall mortality of 3% occurred only in patients with comcomitant serious disease. In general the course of septicemia was benign and the complication rate low. It is concluded that in urological patients septicemia is a less serious problem than in gastroenterological patients. The possible explanation for this is discussed in relation to the more discrete diagnostic and therapeutical procedures in the urological clinic.
Human immunodeficiency virus-infected patients are exposed to more or less specific iatrogenic diseases. The main characteristics of the risks encountered in this field are described: drug intolerance, mostly to sulfamethoxazole-trimethoprim, is extremely frequent; nucleoside analogue antiviral toxicity is reminiscent of that of chemotherapy; nosocomial infections, in general, are more prominent than in HIV-non infected patients. Intravenous line infections are particularly frequent, but these devices are necessary for prolonged intravenous therapies such as anti-CMV treatment of parenteral nutrition. An improved understanding of different etiopathogenic mechanisms and a better approach of the toxicity/efficacy ratio for each treatment would allow to reduce the excessive morbidity due to iatrogenicity.
The acute confusional state (delirium) is a common presentation for a wide variety of medical conditions in the elderly. This paper reports a prospective study of acute confusion in elderly people admitted to general medical services in two acute care hospitals in Edmonton, Alberta. Eighty patients were studied, ranging in age from 65-91. Acute confusion was seen in one-fourth of these patients, who tended to be older, more ill, more likely to have chronic cognitive impairment and a higher mortality rate. In patients admitted with confusion, infection and congestive heart failure predominated. In those who developed confusion after hospitalization, iatrogenic disease was more common. Confusion was a sensitive sign of physical illness, and its resolution accompanied recovery. A diagnosis of the cause of the confusion state could be made in 22 of 24 cases. These findings support the aggressive investigation and treatment of acute confusion in the elderly.
Six cases of methyldopa hepatitis, including two in which the patients died are reported; and 77 cases from the literature are reviewed. Patients in whom severe hepatotoxic reactions to methyldopa develop usually complain of prodromal symptoms typical of hepatitis, often with fever, one to four weeks after therapy is initiated. Jaundice, when it occurs, is usually manifest within three months. Asymptomatic, transient elevations of serum transaminase levels may occur in patients receiving methyldopa. However, since the clinical and histologic features of hepatic injury from methyldopa are indistinguishable from viral hepatitis, it is suggested that the incidence of this iatrogenic disease is higher than generally appreciated. Serum transaminase levels should be determined at the initiation of therapy with methyldopa and four weeks later. Moreover, any patient who has unexplained fever or the prodromal symptoms of hepatitis should undergo liver chemistry studies immediately.
Health-promotion/disease-prevention may--despite the best intentions--have mischievous effects and overlooked ethical implications. This article describes some consequences of health promotion when initiated by the medical profession as medicalization of the modern human being, problems with false test-results, iatrogenic disease, and the risk of "victim blaming". The responsibility of the medical profession includes the well-being of healthy people as well as the actually or future sick. Therefore, health promotion has to be based on the values and informed consent of the healthy part of the population.
Some of various iatrogenic diseases, during manual endodontic treatments, are analysed, from detailed clinical instances. Discussion leads to insist upon some classical and original ways of prevention. From general point of view, it is unavoidable to realize with gentleness, never forcing, endodontic proceedings. Deep perception of internal dental morphology is quite necessary and must be respected during treatment. Besides, histo-pathological modifications of parietal dentine have to be known, not only from intellectual but also from tactile point of view. Each practitioner will progressively improve.
The nosocomial pathology concept includes all the complications taking place while performing a prevention diagnosis or during a medical treatment, proved in relation with the treatment but independent from the original pathology and its course. This notion is acknowledged in the 2002-303 law which concerns the "medical accidents, iatrogenous disease and nosocomial infections" which aetiology and damages are being assessed in the same way by registered medical experts at country level Public and administrative liability relies on the proof of a prejudicial mistake. This mistake being a failure to comply with commitments and means to identify and limit potential risks as well as to limit access to the proved damage while complying with best practice rules and regulations in force. The security chain can be altered less by human failure (20%) than by a bad system organisation (80%). Security management is every one's concern among the medical team, the forensic mistake being a risk management failure.
The regional commission for conciliation and compensation for medical accidents, iatrogenic diseases and nosocomial infections (commission régionale de conciliation et d'indemnisation des accidents médicaux, affections iatrogènes et infections nosocomiales, CRCI) offers victims of such events the possibility of obtaining compensation without recourse to legal proceedings. We suggest various points of view about this commission set up by the French law no. 2002-303 of 4 March 2002: the composition, role and competence of the CRCI; the place of the expert's report; the opinion pronounced by the CRCI and its outcome, the compensation of victims and, finally, interaction with other procedures.
The whole spectrum of medicine consists of complex non-linear systems that are balanced and interact with each other. How non-linearity confers stability on a system and explains variation and uncertainty in clinical medicine is discussed. A major theme is that a small alteration in initial conditions may have a major effect on the end result. In the context of non-linearity, it is argued that 'evidence-based medicine' (EBM) as it exists today can only ever be relevant to a small fraction of the domain of medicine, that the 'art of medicine' consists of an intuitive 'tuning in' to these complex systems and as such is not so much an art as an expression of non-linear science. The main cause of iatrogenic disease is interpreted as a failure to understand the complexity of the systems being treated. Case study examples are given and analysed in non-linear terms. It is concluded that good medicine concerns individualized treatment of an individual patient whose body functions are governed by non-linear processes. EBM as it exists today paints with a broad and limited brush, but it does promise a fresh new direction. In this context, we need to expand the spectrum of scientific medicine to include non-linearity, and to look upon the 'art of medicine' as a historical (but unstated) legacy in this domain.
Drugs are a frequently cited cause of dementia. There is a paucity of data regarding the incidence of drug-induced dementia, but it has been estimated that over 10% of patients attending memory clinics have iatrogenic disease. Drugs may impair cognition indirectly via metabolic effects, such as hypoglycaemia, by alterations of immunological factors within the CNS, and by actions that interfere with synaptic transmission. Classes of drugs most frequently responsible are the benzodiazepines, antihypertensives and drugs with anticholinergic properties. Each of these classes is likely to produce a different pattern of neuropsychological deficits. Prevention of drug-induced dementia will be aided by: (i) minimising the number of drugs prescribed; (ii) using shorter-acting preparations; (iii) avoiding agents that cross the blood-brain barrier where possible; (iv) evaluating renal and hepatic function regularly; and (v) briefly assessing cognitive function before treatment.