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PubMed2006

Brachial artery thrombosis in infants: an algorithm for limb salvage.

BACKGROUND: Arterial occlusion in infants, although uncommon, is usually an iatrogenic event associated with arterial vascular access. Most common in the upper limb, the consequences of iatrogenic arterial occlusion may be gangrene and limb loss. Even if there is adequate collateral flow and limb loss is avoided, long-term growth disturbances may be seen. There are few published data to guide the management of arterial occlusion in premature or sick infants. In general, there is agreement regarding the importance of early diagnosis and the reestablishment of limb perfusion with the fewest risks, but the optimal choice and timing of treatment modalities remain unknown. METHODS: This article examines the authors' experiences at the Royal Children's Hospital, Melbourne, and provides their algorithm for the management of this complex iatrogenic disease. RESULTS: The management algorithm has successfully treated 11 limbs in 11 patients with arterial vascular access-associated thrombosis over the period 1995 to 2003, with no instances of limb loss. Five of these patients required surgical intervention. CONCLUSIONS: The authors recommend a multidisciplinary approach involving plastic surgeons and hematologists for all cases of suspected or confirmed arterial thrombosis. A consensus algorithm that determines the role of heparin, thrombolysis, and acute surgical interventions, and the sequence of such interventions, is useful in providing the framework of therapy. The early recognition of the limb at risk is a key factor in obtaining a successful outcome.

Algorithms↗
PubMed1990

Incidence and pattern of oesophageal perforations in Kenyatta National Hospital.

A retrospective study of 42 patients with perforations of the oesophagus during the period 1981-1987 indicated that 57.1% of the perforations were iatrogenic. Diseases of the oesophagus and in contiguous structures and foreign bodies in the oesophagus caused perforations in 31% of the cases. Perforations in 35.7% of the patients were located in the middle third of the oesophagus. The lower and upper thirds were affected in 31% of the patients in each site. The presenting physical signs included tachycardia (78.6%), fever (76.2%) and dyspnoea (59.5%). The main accompanying symptoms were chest pain and coughs in 100% and in 50% of the patients respectively. Radiographic findings showed hydropneumothorax in 40.5% of the cases and consolidation in 38.1% of the patients. Oesophagoscopy was positive in 78% of cases tested while thoracocentesis was positive in all cases that were tested.

Adolescent↗
PubMed1998

[Dealing with errors in medicine].

Iatrogenic disease is probably more commonly than assumed the consequence of errors and mistakes committed by physicians and other medical personnel. Traditionally, strategies to prevent errors in medicine focus on inspection and rely on the professional ethos of health care personnel. The increasingly complex nature of medical practise and the multitude of interventions that each patient receives increases the likelihood of error. More efficient approaches to deal with errors have been developed. The methods include routine identification of errors (critical incidence report), systematic monitoring of multiple-step processes in medical practice, system analysis, and system redesign. A search for underlying causes of errors (rather than distal causes) will enable organizations to collectively learn without denying the inevitable occurrence of human error. Errors and mistakes may become precious chances to increase the quality of medical care.

Cross-Cultural Comparison↗
PubMed2003

[Identification of drug misuse. Study of spontaneous notifications of adverse drug events in a regional safety reporting centre].

INTRODUCTION: The misuse of drugs, common practice for some, is a source of iatrogenic diseases and considerable supplementary costs in hospital budgets. The aim of this study was to quantify the number of adverse events (AE) related to the misuse of drugs. METHODS: This was a study conducted on 200 new validated AE case reports. In each report, we searched for the drug(s) responsible and checked whether the prescription respected the SPC (summary of product characteristics) and current guidelines or not. RESULTS: Among the 200 reports, 49 (24.5%) cases of AE were related to the misuse of a drug in 46 patients, with a mean age of 65.8 years [24 to 97]. Among these cases, 33 (67.3%) were at the origin of hospitalisation or prolongation of the latter. In 17 cases (34.7%), there was no therapeutic alternative to the drug used in the framework of misuse. DISCUSSION: The notion of good or bad use of a drug progresses with the life of the drug. We therefore selected as criterion of misuse the non-respect of the SCP but also other guidelines. Regarding the cases that could have been avoided, these concerned an AE related to poor surveillance and assessment of the benefit/risk ratio of treatments prescribed to elderly patients and also the commonplace use of non-steroidal anti-inflammatories, at the origin of digestive haemorrhages. CONCLUSION: The prevention of misuse implies all the actors of the health system. A reassessment of the prescription of certain therapeutic classes of drugs would avoid a great number of iatrogenic accidents and would lead to considerable economy in the field of health.

Adult↗
PubMed1997

Drug-related problems in elderly patients admitted to Tayside hospitals, methods for prevention and subsequent reassessment.

INTRODUCTION: although drug-related problems (DRPs) are known to be prevalent in elderly patients, the literature on prevention of iatrogenic disease is sparse. The present study addresses this requirement. OBJECTIVES: to assess the incidence of DRPs in elderly patients admitted to Tayside hospitals before (phase I) and after (phase II) implementation of preventive strategies. DESIGN: all elderly people admitted to hospital were screened by a pharmacist; individual case reviews were prepared for all those with a potential DRP and reviewed by a three-member panel which made a final decision on the presence of a DRP and its contribution to admission. SETTING: all hospital wards admitting elderly patients in the Tayside region of Scotland. SUBJECTS: 1011 elderly patient admissions over a 9-month period (phase I); 857 elderly patient admissions over an 8-month period (phase II). MAIN OUTCOME MEASURES: incidence of DRPs before and after targeted intervention strategies (information bulletin for general practitioners, patient information leaflet, oral presentation to trainee general practitioners). RESULTS: in phase I, the incidence of DRPs was 144/1011 (14.2%), with 54/1011 (5.3%) of the admissions identified as being definitely or probably drug-related. Non-steroidal anti-inflammatory drugs (NSAIDs) were the main drug group involved, being responsible for 15/54 (28%) of admissions primarily due to a DRP. Over 66% of admissions due to adverse effects of NSAIDs were considered to be definitely preventable. In phase II, after targeted intervention strategies, there was no significant reduction in total incidence of DRPs or incidence of DRPs related to NSAIDs. However, there appeared to be an improvement in the first 4 months, and a significant drop in NSAID prescribing in Tayside compared with the rest of Scotland was observed. CONCLUSION: DRPs remain a significant problem in elderly patients and NSAIDs are the major contributor. The intervention strategies used in the study were not demonstrably effective, but a continuous programme of education may be necessary to limit NSAID use.

Aged↗
PubMed1996

[Physiopathologic mechanisms of drug-induced lung diseases in man].

Iatrogenic lung disease in man is generated by very different and often complex pathology. This explains the great clinical diversity of these disorders which may manifest as eosinophilic pneumonia, intra-alveolar haemorrhage, bronchiolitis obliterans and diffuse interstitial pneumonia even with pulmonary fibrosis. The causes are also very varied such as direct cellular toxicity, cellular oedema, an alteration of the alveolar capillary membrane, the activation of inflammatory and/or immune cells, which are responsible for the production of soluble mediators whose effects are sometimes harmful to the pulmonary parenchyma. Rather than reporting on the different clinical types of iatrogenic lung disease and indicating for each one the hypothetical or known physiopathogenic mechanism, we have chosen to examine certain fundamental lesional mechanisms and to indicate the principal nosological groups which they cover. We have centered this review on the physiopathogenic models which are the most coherent and most fully elaborated based on observations made on man or on experimental animal models. Among those we have reported here is a case of bleomycin toxicity, with its direct toxic mechanism on the epithelial or endothelial cellular targets, amiodarone lung disease and with its associated alveolar oedema, inflammatory reactions and immunological reactions whose specificity is poorly understood; also there are some alveolitides whose specificity has been demonstrated, such as those to minocycline and to BCG and finally a complex model which is both inflammatory and disturbed immunology in radiation pneumonia.

Adjuvants, Immunologic↗
PubMed1985

Drug-induced lupus. Genetic, clinical, and laboratory features.

Drug-induced lupus is a disorder similar to idiopathic systemic lupus erythematosus in terms of manifestations. However, these entities have significant serologic and clinical differences, which call into question the concept that they represent an identical disease process. Nonetheless, further research into the drug-induced disease will enhance our understanding and management of this clinically significant iatrogenic disease and will likely contribute to our comprehension of the pathogenesis of autoimmunity.

Aged↗
PubMed1981

Hyperprolactinemia and galactorrhea: spontaneous versus iatrogenic hypothyroidism.

Although hyperprolactinemia and galactorrhea occur in primary hypothyroidism, factors influencing their presence are not well established. To further define these factors, the duration of illness and serum levels of PRL and TSH were investigated in a group of 50 patients with spontaneous (27 females and 7 males) and iatrogenic (16 females) primary hypothyroidism. To test the hypothesis of reduced hypothalamic dopamine content in over long-standing primary hypothyroidism, the percent increase in serum PRL after the administration of metoclopramide, a dopamine blocker (2.5 mg, iv bolus), was studied in 13 women with spontaneous primary hypothyroidism and compared with that in 10 euthyroid women. While 88.2% of the patients with spontaneous primary hypothyroidism were hyperprolactinemia, only 31% of those with iatrogenic disease had elevated PRL levels. Women with spontaneous primary hypothyroidism had a longer duration of illness (72 +/- 12 vs. 6.7 +/- 1.8 months; P less than 0.001) and higher serum TSH (189 +/- 32 vs. 68 +/- 14 microunits/ml; P less than 0.01) and PRL levels (49.8 +/- 5.6 vs. 20.9 +/- 0.8 ng/ml; P less than 0.001) than women with iatrogenic hypothyroidism. A linear correlation existed between PRL and duration of illness (r = 0.53; P less than 0.001), while a logarithmic correlation was found between PRL and TSH levels (r = 0.44; P less than 0.01). Even though the duration of illness and TSH levels were similar in women with spontaneous disease with (n = 7) or without (n = 20) galactorrhea, the former were significantly younger (39.3 +/- 1.8 vs. 56.6 +/- 3 yr; P less than 0.001), and their PRL levels were significantly higher (69.3 +2- 8.9 vs. 42.9 +/- 2.2 ng/ml; P less than 0.001). The PRL response to metoclopramide in women with spontaneous disease was significantly smaller than that in controls (194 +/- 39% vs. 446 +/- 40%; P less than 0.001) and inversely correlated with basal PRL levels (r = -0.55; P less than 0.05). These data indicate that in primary hypothyroidism 1) the duration of illness is important in the development of hyperprolactinemia, 2) galactorrhea is more common in young women with spontaneous disease and high PRL levels, and 3) hypothalamic dopamine appears reduced in spontaneous disease.

Adolescent↗
PubMed1998

The distribution of infectivity in blood components and plasma derivatives in experimental models of transmissible spongiform encephalopathy.

BACKGROUND: The administration of blood components from donors who subsequently develop Creutzfeldt-Jakob disease has raised the issue of blood as a possible vehicle for iatrogenic disease. STUDY DESIGN AND METHODS: We examined infectivity in blood components and Cohn plasma fractions in normal human blood that had been "spiked" with trypsinized cells from a scrapie-infected hamster brain, and in blood of clinically ill mice that had been inoculated with a mouse-adapted strain of human transmissible spongiform encephalopathy. Infectivity was assayed by intracerebral inoculation of the blood specimens into healthy animals. RESULTS: Most of the infectivity in spiked human blood was associated with cellular blood components; the smaller amount present in plasma, when fractionated, was found mainly in cryoprecipitate (the source of factor VIII) and fraction I+II+III (the source of fibrinogen and immunoglobulin); almost none was recovered in fraction IV (the source of vitamin-K-dependent proteins) and fraction V (the source of albumin). Mice infected with the human strain of spongiform encephalopathy had very low levels of endogenous infectivity in buffy coat, plasma, cryoprecipitate, and fraction I+II+III, and no detectable infectivity in fractions IV or V. CONCLUSION: Convergent results from exogenous spiking and endogenous infectivity experiments, in which decreasing levels of infectivity occurred in cellular blood components, plasma, and plasma fractions, suggest a potential but minimal risk of acquiring Creutzfeldt-Jakob disease from the administration of human plasma protein concentrates.

Animals↗
PubMed1985

[Pulmonary changes caused by cytostatic drugs].

About 80 drugs are known to cause lung disease. Cytostatic agents are the most common cause of this type of iatrogenic disease. In addition to the "intercalating" type of cytostatic, other groups, especially the alkylating (busulfan) and the antimetabolites groups (methotrexate), have also been incriminated. Cytostatic drug-induced lung disease is a difficult diagnosis based on the results of clinical, radiological, respiratory function, histopathological and biological investigations. The results of bronchoalveolar lavage are vital, especially in lung disease due to a drug hypersensitivity reaction; the diagnosis of drug-induced pulmonary fibrosis due to a toxic mechanism is much more difficult and risky. Early diagnosis of these drug-induced lung diseases is obviously important.

Alkylating Agents↗
PubMed1993

Pharmacologic considerations in the geriatric patient.

A physician has the primary responsibility of first causing no harm. Unfortunately, the myriad of pharmacologic agents available to the clinician at times may make this directive difficult. When the variable of age-related changes is introduced, the clinician's task may seem almost impossible. The most important aspect of gerontology is that there are no constants. Age-related changes are inconsistent. Although liver function may vary little among the general population, virtually every other system is affected by the aging process. Additional factors that complicate treatment of the geriatric patient are multiple organ diseases, the intervention of multiple practitioners, and nutritional variation. Multiple diseases require polypharmacy with its greater tendency for drug-drug interaction and iatrogenic disease exacerbation. Multiple clinician involvement frequently lacks appropriate communication between the various specialties. Aging is commonly associated with drastic changes in dietary habits. An older person living alone may tend to miss more meals than other groups. Meals that are consumed may be inadequate and lack proper balance, especially adequate amounts of protein. Mineral and vitamin depletion are additional problems, especially with patients on diuretics and chronic anti-infective therapy. In this article an attempt has been made to stimulate thought and generate an awareness in the podiatric practitioner of the considerations necessary when contemplating drug therapy in the geriatric population. Long lists of specific agents and recommended dosages, which quickly become outdated as newer drugs are introduced into the clinical arena, were intentionally not presented in this article. The author hopes that this article will generate interest in conducting additional research in podiatric applications of drugs.

Aged↗