Auswahl der wissenschaftlichen Literatur zum Thema „Multiple iatrogenic events“

Stroke is a rare but possible complication after atrial fibrillation (AF) ablation. However, its etiopathogenesis is far from being completely characterized. Here we report a case of stroke, with recurrent peripheral embolism after AF ablation procedure. In our patient, an in situ femoral vein thrombosis and iatrogenic atrial septal defect were simultaneously detected. A comprehensive review of multiple pathophysiological mechanisms of stroke in this context is provided. The case underlines the importance of a global evaluation of patients undergoing AF ablation.

The emergence of immune-based treatments for cancer has led to a growing field dedicated to understanding and managing iatrogenic immunotoxicities that arise from these agents. Immune-related adverse events (irAEs) can develop as isolated events or as toxicities affecting multiple body systems. In particular, this review details the neurological irAEs from immune checkpoint inhibitors (ICI) and chimeric antigen receptor (CAR) T cell immunotherapies. The recognition and treatment of neurological irAEs has variable success, depending on the severity and nature of the neurological involvement. Understanding the involved mechanisms, predicting those at higher risk for irAEs, and establishing safety parameters for resuming cancer immunotherapies after irAEs are all important fields of ongoing research.

Adverse events are a common and for the most part unavoidable consequence of therapeutic intervention. Nevertheless, available tomes of such data now provide us with an invaluable opportunity to study the relationship between human phenotype and drug-induced protein perturbations within a patient system. Deciphering the molecular basis of such adverse responses is not only paramount to the development of safer drugs but also presents a unique opportunity to dissect disease systems in search of novel response biomarkers, drug targets, and efficacious combination therapies. Inspired by the potential applications of this approach, we first examined adverse event circumstances reported in FAERS and then performed a molecular level interrogation of cancer patient adverse events to investigate the prevalence of drug-drug interactions in the context of patient responses. We discuss avoidable and/or preventable cases and how molecular analytics can help optimize therapeutic use of co-medications. While up to one out of three adverse events in this dataset might be explicable by iatrogenic, patient, and product/device related factors, almost half of the patients in FAERS received multiple drugs and one in four may have experienced effects attributable to drug interactions.

✓ A multimodality recording system was used in 14 ventilated patients with closed head injury to assess the potential use of near-infrared spectroscopy (NIRS) in the neurointensive care unit. Signals of intracranial pressure, cerebral perfusion pressure, peripheral oxygen saturation, jugular venous saturation, and NIRS-derived changes in the chromophores of oxy- and deoxyhemoglobin were digitized and recorded. After a review of 886 hours of continuous monitoring, 376 hours were considered free from artifact and were entered for final analysis. In nine of the patients 38 events were recorded that demonstrated clear changes in cerebral perfusion pressure accompanied by hemodynamic changes in middle cerebral artery flow velocity (transcranial Doppler) and cortical perfusion (laser Doppler flowmetry). Near-infrared spectroscopy showed correlated changes in 37 events (97%) whereas jugular venous saturation monitoring registered only 20 (53%). There was associated peripheral oxygen desaturation in eight cases (21%), intracranial hypertension in 10 (26%), and cerebral hyperemia in eight (21%). The remaining 12 events (32%) appeared to be complex changes of uncertain origin. Iatrogenic factors were identified as causative in 14 cases (37%). The potential application of NIRS in adults and the importance of using multiple parameter recording systems in the interpretation of cerebral events are discussed.

Attempted suicide and deliberate self-harm are common and challenging presentations in the emergency department. A proportion of these patients refuse interventions and this presents the clinical, legal, and ethical dilemma as to whether treatment should be provided against their will. Multiple factors influence this decision. It is difficult to foresee the multitude and magnitude of complications that can arise once it has been decided to treat individuals who do not consent. This case illustrates a particularly complex chain of events that occurred after treating someone against their will who presented with self-harm and suicidal ideation. These consequences are contrasted with those of not intervening when similar situations arose with the same patient.

The authors presented a case of a 50-year-old patient with multiple trauma who suffered from the inadvertent cannulation of the main pulmonary artery at the second attempt of left chest drainage. Pulmonary artery injury has been suspected because early chest tube production was 2300 mL of blood. CT scan showed injury of the trunk of the pulmonary artery, left hemothorax, and suspect damage of the right branch of the pulmonary artery. That chest tube touched the posterior wall of ascending aorta. Surgical approach was median sternotomy. Exploration showed a perforation of the trunk of pulmonary artery without lesion of the right pulmonary branch and the posterior wall of the ascending aorta. The lesion was repaired under normothermic partial cardiopulmonary bypass. Postoperative period was free of events. Review of the literatures for this rare case report has been done.

Abstract Nonobstructive coronary artery lesions are seen in two-thirds of patients with angina and verified ischemia using a stress test who undergo coronary angiography. Ischaemia with no obstructed coronary artery disease (INOCA) is becoming more well recognized as a significant medical illness due to its relationship to decreased quality of life and an increased risk of cardiac events. This association between acute coronary syndrome (ACS) and high levels of psychological stress has been thoroughly investigated, and it has been found to be substantial. The microvascular function of the coronary arteries is endothelium-dependent, and this plays a role in how the heart reacts to psychological stress. Although coronary artery spasm (CAS) is likely to play a role in the etiology of INOCA, it is frequently misdiagnosed and underreported. In this article, we discuss a case of a young woman who came with recurrent ACS related to CAS, which was exacerbated by iatrogenic coronary dissection due to the presence of arteria lusoria, an atherosclerotic coronary artery disease leading to in-stent restenosis of the previous stent.

Background. The risk of bleeding and thrombotic events should be weighed before, during and after surgery. To facilitate this process, it is advisable to ask yourself the following questions: if we start the operation now, will the bleeding develop? If we delay the intervention, will a thrombotic event occur? Are the patient’s antithrombotic drugs effective? Objective. To describe the blood coagulation monitoring system. Materials and methods. Analysis of literature sources on this topic. Results and discussion. Coagulopathy can be congenital and acquired, the latter including iatrogenic. The causes of congenital coagulopathies include hemophilia, von Willebrand factor deficiency, thrombocytopenia, and antiphospholipid syndrome. Antiplatelet drugs and direct oral anticoagulants are the main causes of iatrogenic coagulopathies. Other causes of acquired coagulopathies include hemostasis failure, disseminated intravascular coagulation syndrome, and post-surgical coagulopathies of various types. In order to treat bleeding in coagulopathies, desmopressin, tranexamic acid, coagulation factors, and protamine are administered. Laboratory tests needed to detect coagulopathies include prothrombin time, activated partial thromboplastin time, thrombin time, international normalized ratio, fibrinogen levels, and coagulation factors. The limitations of these tests include their non-dynamic nature, lack of ability to predict the risk of bleeding, time and financial costs, inability to understand the pathophysiological mechanism of bleeding. There may also be an error in the analysis due to the addition of citrate and calcium to the samples. Rapid tests to assess the hemostasis system include determination of activated coagulation time, Hepcon heparin monitoring system, thromboelastography and platelet mapping, platelet aggregometry using multiple electrodes, rotational thromboelastometry, and sonoreometry. Conclusions. 1. For best results, coagulopathy should be anticipated, detected, and treated in a timely manner. 2. The strength of blood clots depends on platelets and fibrinogen. 3. It is advisable to use rapid tests to assess hemostasis and repeat them regularly, as bleeding and blood clotting are dynamic processes. 4. The effects of hemodilution, acid-base balance and temperature should be kept in mind.

Schizophrenia is a psychotic disorder that exists at the more extreme end of a spectrum of diseases, and significantly affects daily functioning. Cardiovascular adverse effects of antipsychotic medications are well known, and include changes in blood pressure and arrhythmias. Sudden cardiac death is the leading cause of death worldwide, and antipsychotic medications are associated with numerous cardiac side effects. A possible link exists between antipsychotic medications and sudden cardiac death. Common prescribing patterns that may influence cardiovascular events include the use of multiple antipsychotics and/or additional drugs commonly prescribed to patients on antipsychotics. The results of this review reflect an association between antipsychotic drugs and increased risk of ventricular arrhythmias and sudden cardiac death by iatrogenic prolongation of the QTc interval. QTc prolongation and sudden cardiac death exist in patients taking antipsychotic monotherapy. The risk increases for the concomitant use of specific drugs that prolong the QTc interval, such as opioids, antibiotics, and illicit drugs. However, evidence suggests that QTc intervals may not adequately predict sudden cardiac death. In considering the findings of this narrative review, we conclude that it is unclear whether there is a precise association between antipsychotic polypharmacy and sudden cardiac death with QTc interval changes. The present narrative review warrants further research on this important potential association.

Abstract Transarterial radioembolization (TARE) with Yttrium-90 (Y90) is widely used for management of primary or secondary liver malignancies that are not amenable to surgery. Nevertheless, complications of Y90 treatment, including rare events of gastric and duodenal ulceration and cirrhosis, may be critical. Here we report a case of a 79-year-old man who received Y90 TARE for metastatic neuroendocrine tumor to liver from bronchial primary and developed multiple iatrogenic GI complications. Following TARE, a gastroduodenal artery (GDA) coil was instituted to prevent migration of Y90 beads. One year following TARE, the patient presented with cirrhosis of unknown etiology, thrombocytopenia, and multiple episodes of upper gastrointestinal bleeding (UGB). Endoscopy demonstrated GDA coil eroding into duodenum through mucosal ulcer base. Three years following TARE, an emergent esophagogastroduodenoscopy was performed due to upper GI bleeding. The histopathologic examination of stomach and duodenum revealed mucosal hemorrhage, submucosal and serosal fibrosis, and chronic inflammation associated with Y90 intravascular beads. A cholecystectomy was performed for fibrotic gallbladder that showed chronic cholecystitis with cholelithiasis and intravascular Y90 beads. GDA coil was removed, which showed attached food material, bacterial colonies, and Candida spp. A subsequent liver biopsy showed previously treated area with Y90 beads, inflammation, and fibrosis in adjacent parenchyma. Due to rich vascularity, TARE is considered an ideal treatment choice for neuroendocrine tumor. GI ulceration is the most common complication, which occurs in less than 4% patients, and usually can be managed with proton pump inhibitor. A surgery should be performed upon failure of medical treatment. Radiation-associated fibrosis has been reported mainly in hepatocellular carcinoma patients, who often have cirrhosis before the procedure. To conclude, this is the first case report of Y90 TARE complications in multiple GI organs in a metastatic NET patient.

Le taux de survie à 5 ans des cancers de l'enfant atteint aujourd'hui 80 %. Les survivants à 5 ans de cancer pédiatrique (CCS) ont cependant un risque accru d'occurrence de nombreux évènements. Beaucoup d'études ont été réalisé pour comprendre les liens entre ces évènements iatrogènes et les traitements pédiatriques, et un taux élevé d'évènements iatrogènes multiples a été observé. Cependant, ce taux d'évènements iatrogènes multiples est méconnu. Ce projet de thèse avait pour objectif d'étudier les causes et conséquences de ce taux élevé.La recherche présentée dans cette thèse est basée sur les données de la French Childhood Cancer Survivors Study, une cohorte rétrospective à suivi prospectif de 7670 CCS diagnostiqués avant l'âge de 21 ans entre 1945 et 2000 en France. La cohorte contient des données détaillées sur les traitements des cancers pédiatriques, et un important travail de validation des évènements iatrogènes a été réalisé.Nous avons utilisé la méthode de landmark combiné avec des pseudo-observations, afin de pouvoir étudier les effets des seconds cancers sur l'incidence cumulée d'évènement cardiaque et les années de vie perdues des patients.Nous avons constanté une augmentation de risque instantanné (csHR: 2.1, 95% CI: 1,5-2,9) et de l'incidence cumulée d'évènement cardiaque (CD) (+3,8%, 95% CI: 0,5-7,1) après un second cancer. Nous avons aussi constaté un impact de la radiothérapie, des seconds cancers, et des CD sur l'espérance de vie des patients, avec respectivement 6, 10,5 et 7,7 années de vie perdues à 16 ans. Nous avons trouvé un effet nul de l'interaction entre second cancer et CD, mais notre analyse de simulation a montré que ce résultat est biaisé par la corrélation entre seconds cancers et CD.En conclusion, dans cette thèse nous avons démontré que le risque accru de multi-morbidité chez les CCS est partiellement attribuable à l'occurrence d'un premier évènements iatrogène. Nous avons aussi montré un fort impact des seconds cancers et évènements cardiaques sur l'espérance de vie des patients. Ces résultats nous ammènent à recommander une forte surveillance des patients dévelopant l'une de ces maladies, et de poursuivre la recherche sur la multi-morbidité chez les CCS qui apapraît complexe et forte de conséquences pour les patients
5-years survival of childhood cancer exceeds 80% today. Nonetheless, 5-year childhood cancer survivors (CCS) are at increased risk of health-related late effects. Many studies have been conducted to investigate the link between those late effects and childhood cancer treatments. Furthermore, an elevated number of patients experiencing multiple iatrogenic event was observed. However, little is known about the causes of this multi-morbidity. This thesis aimed to study the causes et consequences of this elevated multi-morbidity.Research presented in this thesis is based on the French Childhood Cancer Survivors Study, a retrospective cohort with prospective follow-up, following 7,670 CCS diagnosed in France before 21 years old between 1945 and 2000. This cohort contains detailed data regarding childhood cancer treatments, and the iatrogenic event observed were validated by trained professionals.We used the landmark method combined with pseudo-observations to study the consequences of subsequent malignant neoplasm on the cumulative incidence of cardiac disease, and the life years lost by CCS.We found a subsequent malignant neoplasm (SMN) to cause a two-fold increase in the cause-specific hazard of cardiac disease (CD) and a 3.8% increase of its cumulative incidence. We found the use of radiotherapy to treat childhood cancer, the occurrence of SMN, and of CD to impact the life expectancy of CCS, with respectively 6, 10.5, and 7.7 life years lost at 16 years old. We found a nul effect of the interaction of SMN and CD on the life expectancy, although our simulation study suggested this was biased by the correlation between SMN and CD.In conclusion, we demonstrated that the increased risk of multi-morbidity among CCS is partially attributable to the occurrence of a first iatrogenic event. We also showed that subsequent malignant neoplasm and cardiac disease have a strong impact on the life expectancy of CCS. Therefore, we recommend to keep following in details the CCS developing either disease, and to pursue further research on the multi-morbidity among CCS which appears to be complex and consequentful for patients

Increasing life expectancy is a humanitarian achievement, however, rapid population aging brings numerous challenges. The increase in longevity is related to the growth of chronic non-communicable diseases, which are generally multicausal, and the concomitance of comorbidities, especially in the elderly, can lead to polypharmacy. The simultaneous use of several medications can cause adverse events and very harmful drug interactions in the elderly, generating new health problems or aggravations to existing ones, which can result in unnecessary hospitalizations and death. Deprescribing aims to reduce harm and costs to patients, in addition to increasing their quality of life, and borders on the performance of person-centered care. It is a practice that is part of the essential care of family and community medicine, both because of the mode of care provided and because of the large elderly population assisted by this specialty. The withdrawal of inappropriate medications in elderly patients with multiple comorbidities is part of comprehensive patient care and can only be performed without the occurrence of iatrogenic events and with a person-centered approach. Therefore, a shared decision of care is necessary, in addition to health education for patients and their families, as well as continuing education for health professionals.

Although the early outcome of acute coronary syndromes (ACS) has considerably improved in the last decade, cardiovascular diseases still represent the main cause of morbidity and mortality worldwide. The progression of coronary atherosclerosis can remain clinically silent even for life. In contrast, some patients at a certain point exhibit an ACS, followed by a period of stability, which can be short or last for years or decades. These clinical observations suggest that the mechanisms responsible for plaque growth and for plaque instability are different and that the causes of ACS are multiple and incompletely understood. Inflammation plays a key role in the pathogenesis of ACS. An outburst of the inflammatory process within the atherosclerotic plaque may lead to plaque fissure with thrombosis resulting in myocardial ischaemia and necrosis that is an additional source for a local and systemic inflammatory response. Furthermore, percutaneous coronary intervention may cause iatrogenic myocardial injury, a further source of inflammation. However, this notion is in contrast with the observation that about 40% of patients with an ACS have low or very low levels of high-sensitivity C-reactive protein, a very sensitive marker of inflammation. Moreover, coronary angiography fails to demonstrate obstructive atherosclerosis in up to one-third of patients with symptoms and signs suggestive of an ACS, suggesting that functional alterations of epicardial arteries and/or of coronary microcirculation play an important pathogenetic role. Thus, a better comprehension of the mechanisms responsible for coronary instability might lead to innovative preventive and therapeutic strategies.