Risk Of Iatrogenesis Research Articles

Migración de funduplicatura gástrica con perforación intratorácica

La cirugía antirreflujo mediante abordaje laparoscópico se considera el gold estándar para el tratamiento de la enfermedad por reflujo gastroesofágico y de la hernia de hiato. Los resultados postoperatorios presentan una morbimortalidad asociada baja y una buena satisfacción en el medio largo plazo. Presentamos el caso clínico de un paciente de 53 años intervenido de funduplicatura laparoscópica tipo Nissen-Rossetti que en el duodécimo día postoperatorio presenta clínica de mediastinitis asociada a sepsis por perforación intratorácica de la funduplicatura gástrica migrada a tórax. El paciente es intervenido de forma urgente, realizándose drenaje torácico, laparotomía media supra-umbilical y cierre primaria de la perforación. El postoperatorio se caracteriza por una estancia de 23 días en la unidad de cuidados intensivos y por neumonía necrotizante, abscesos pulmonares y empiema pleural izquierdo. A 10 años del episodio, el paciente se encuentra asintomático y sin signos de recidiva clínica. Aunque la incidencia de las complicaciones tempranas en la cirugía antirreflujo es relativamente baja, es obligatorio sospechar de ellas en un paciente con sepsis por mediastinitis y cirugía reciente. Antes situaciones de extrema gravedad es necesario intervenir de forma urgente aunque la re-exploración quirúrgica del hiato es considerada una cirugía compleja y de elevado riesgo de iatrogenia.

GnRHa (‘Puberty Blockers’) and Cross Sex Hormones for Children and Adolescents: Informed Consent, Personhood and Freedom of Expression

Ethical concerns have been raised about routine practice in paediatric gender clinics. We discuss informed consent and the risk of iatrogenesis in the prescribing of gonadotropin-releasing hormone analogues (GnRHas) and cross sex hormones to children and adolescents respectively. We place those clinical concerns in a wider societal context and invite consideration of two further relevant ethical domains: competing rights-based claims about male and female personhood; and freedom of expression about those claims. When reflecting on the assessment and medicalization of children and adolescents presenting at gender clinics, the matters of informed consent and iatrogenic risk should be the most pressing for clinicians. However, this is not just a matter of medical ethics, it also implies the need for a full ethical debate on competing notions of personhood and the defence of freedom of expression about transgender and its implications within contemporary democracies.

Decrease in prolactine levels after treatment with aripiprazole during a maniac episode: A case report

IntroductionHyperprolactinemia can produce clinical symptoms affecting the patient's quality of life and therefore limiting therapeutic approaches to bipolar disorder.Case reportWe report a case of a 46-year-old woman, with a 10 year history of type I bipolar disorder and a microprolactinoma, who was admitted to a psychiatry inpatient unit due to a maniac episode. Current symptoms at the moment of admission included hyperthymia, verbiage, flight of ideas and insomnia. Menstrual changes and galactorrea had been present previously. Aripiprazole was introduced, reaching a dose of 30 mg/day, in addition to her usual treatment with lithium and gabapentin. Response to treatment was good and euthymia was reached within 10 days. Moreover, gabapentin was substituted by Valproic acid, and the patient was discharged once therapeutic levels were attained. Prolactin levels were measured at the moment of admission (128.75 ng/mL) and after 11 days of treatment (92.93 ng/mL).DiscussionChoosing an adequate antipsychotic agent can reduce the risk of iatrogenesis and thus enhance adherence to treatment and quality of life. Aripiprazole had previously shown a high potential at decreasing levels of prolactine. In this case, clinical practice supports scientific evidence.ConclusionsAripiprazole is an effective treatment for type I bipolar disorder. Especially, it can be a treatment of choice in patients suffering from symptoms related to high levels of prolactine, even using a high dosage.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Communication with parents in neonatal intensive care

The psycho-relational problems in Neonatal Intensive Care Units (NICU) are complex and multifaceted and have only recently been properly addressed. Some specific factors make communication in NICU particularly problematic; the baby’s clinical condition, the emotional and working conditions of the medical staff, the emotional state of the parents and the setting of the NICU and the interaction of multiple professional figures with the parents. The purpose of communication in NICUs is not only to inform parents of their child’s clinical condition; the medical and nursing staff must also educate and guide parents so that they can actively participate in caring for their child and become true “partners” with the medical team in the decision-making process. Furthermore, the staff must also use their communication skills to understand and contain the anxieties and emotions of parents, supporting and comforting them through the most critical moments of their child’s illness and possibly even bereavement. Given the number and complexity of the interpersonal exchanges that take place in the NICU, the risk of misunderstanding, misinterpretation and conflict is high. One could say that the interpersonal aspect is an area where the risk of iatrogenesis is elevated. It is recognized that poor staff-family interactions not only reflect negatively on the baby’s care and are a source of distress and discontent for the parents, but are also a major cause of medico-legal litigation and increase the incidence of “burnout”. Therefore, specific training of the staff in communication is essential if the optimal results, obtained through modern technology, are not to be invalidated.

Primary care physicians’ behaviors towards risk of iatrogenesis in elderly patients

Iatrogenesis is common in elderly patients. This phenomenon could be reduced by improving awareness of general practitioners (GPs). We studied GPs' prescribing behavior to elderly patients, to identify GP and patient characteristics related to cautious prescribing behaviors. The observational study sampled 106 GPs who had consecutively recruited, on average, 12 patients over 75 years of age. GPs completed a questionnaire on their practice and a questionnaire for each patient they recruited, describing their usual care of elderly patients, and criteria for prescribing therapy. GPs' behaviors were studied with five scores and a global prescribing behavior (adequate/inadequate). The relationship between patients' risk of iatrogenesis and GPs' behaviors was studied with hierarchical logistic models. A total of 106 GPs recruited 1,318 patients (mean age 80.7 years, 36% males). A wide variety of behaviors was observed among GPs. Only 40% of GPs had specific prevention-oriented visits, while only 19.2% considered that prevention was optimally implemented in their practice. On average, GPs had behaviors considered adequate in about half of encounters. GPs' global behaviors were more likely to be adequate for patients at higher risk (OR=1.47, 95%CI: 1.10-1.95). Likewise, before prescribing to patients at higher risk of iatrogenesis, GPs were more likely to collect data on financial autonomy, on clinical/biological data, and to adopt good prescription practices, while less attention was paid to patients' physical and psychological autonomy. GPs tended to be more cautious when prescribing to patients at higher iatrogenesis risk. However, overall prescribing behaviors were not optimal. Efforts are needed to improve the quality of care in elderly patients.

Special Features: Workers' Compensation Benefits

Abstract The AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) specifies that impairment evaluation may be conducted by a treating or nontreating physician. A treating physician who is knowledgeable about the use of the AMA Guides may be the appropriate professional to evaluate impairment, but in cases that involve pain, disability, and medicolegal (forensic) issues, a truly independent medical examiner typically is most appropriate. All specialties share the same elevated risk of iatrogenesis when treating and evaluating/forensic roles are mixed because mixing compromises the quality of care and threatens the viability of the therapeutic relationship. Further, all treating specialties share the same bias toward offering treatment for most complaints—rather than engaging in the type of cautious skepticism that is required for competent impairment evaluation and other forensic duties. Finally, no treating clinician, regardless of specialty, can offer allegiance to judicial and administrative decision-makers. Treating clinicians often find themselves in a position in which they would be cutting off a source of their own income if they were to offer opinions that the clinical presentation is not valid, work related, or injury related, nor is the patient in need of further treatment. Such a financial conflict of interest can be eliminated only by referral to independent examiners and restricting treating clinicians from becoming involved in such decisions.