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We have compared the clinical and laboratory features as well as treatment complications observed in 6 patients with iatrogenic acute myelogenous leukemia (I-AML) with those of 26 patients with idiopathic acute myelogenous leukemia (AML). I-AML patients were significantly younger and their disease appeared less virulent on admission than in the AML patients. Following identical chemotherapy, hemorrhagic complications and the need for platelet support were found to be similar for both groups. Major infections, including systemic candidiasis and Gram-negative septicemias, occurred 3 times more frequently among I-AML than AML patients. More marked suppression and delayed regeneration of the bone marrow also occurred in I-AML patients. These observations and other factors, such as post-splenectomy state and inherent immune deficiency among surgically staged lymphoma patients as well as radiation induced immunologic impairment, may have contributed to the increased propensity to develop infection observed in this group of patients. Five of the 6 I-AML and 17 of the 26 AML patients achieved remission. We attribute the satisfactory outcome in our I-AML patients to treatment in a protective environment and availability of facilities for hematologic supportive care.

After more than 25 years of tympanoplasty for cholesteatomata, it is time to reconsider the origin of this pathological finding. The pathogenesis has not changed, it is the aspects of the disease which have shifted. There are two reasons for this: (a) much improved conditions of living, housing, nutrition and epidemiology, especially during childhood, and (b) discontinuation of the indication for radical surgery, only in the case of threatening complications is tympanoplasty used as a prophylactic operation. In the meantime a new and numerously large group of cholesteatomata has come up which was previously unknown, namely the so-called 'iatrogenic cholesteatomata'. Under these aspects the nomenclature of the cholesteatomata has to be newly defined, according to its etiology and form of disease.

Three to 15% of the whole population of patients with small cell lung carcinoma are long-term survivors. In a view of preventing iatrogenic sequellae and obtaining a better definition of therapeutic indications, the prognostic factors in this population will be defined.

This report reviews morphologic aspects of pericardial heart disease. A morphologic classification for this condition is presented. An ideal classification of pericardial heart disease obviously would take into account clinical, etiologic and morphologic features of this condition but a single classification combining these three components is lacking. Pericardial heart disease is relatively uncommon clinically, and when present at necropsy it usually had not been recognized during life. The term "pericarditis" is inaccurate because most pericardial diseases are noninflammatory in nature. Morphologically chronic pericardial heart disease may present clinically as an acute illness. Even when clinical symptoms are present, however, few patients develop evidence of cardiac dysfunction (constriction). When pericardial constriction occurs, it is the result of increased pericardial fluid or increased pericardial tissue or both. Increased fluid is treated by drainage; increased tissue is treated by excision. In most patients with chronic constrictive pericarditis the etiology is not apparent even after histologic examination of pericardia.

A major cause for failure of krypton red laser photocoagulation in patients with exudative age-related macular degeneration has been the development of recurrent choroidal neovascularization adjacent to the previously treated areas. After reviewing the possible causes of recurrences, it is apparent that a certain number are iatrogenic, ie, induced by krypton red laser causing disruption and damage to the pigment epithelium-Bruch's membrane-choroidal complex. We describe three separate episodes in two patients of iatrogenic recurrent choroidal neovascularization after krypton red laser photocoagulation.

During a combined acupuncture-neural therapy-treatment on account of a gastric ulcer several lesions with vast haemorrhages in the abdominal cavity and in the retroperitoneal space on the right (lesions of the kidney) were produced. At the operation a duodenal ulcer without perforation was found. The competence of the neural therapy in its relation to the complications is discussed, the indication to the application of these forms of therapy in such cases is refused.

Iatrogenic, or medically induced, drug addiction is a problem affecting both patients and physicians. We describe the function of a new center devoted solely to managing iatrogenic addiction. The center accepts patients on physician referral only. The addiction usually arises as a complication of a medical disorder that is accompanied by pain and requires comprehensive and multidisciplinary evaluation and treatment. Detoxification from the offending medication, provision of chronic analgesia, and maintenance are managed with methadone. All appropriate modalities of treatment including psychotherapy, physical therapy, and relaxation techniques are employed.

In recent years it has become evident that partial obstruction of bronchi can be acquired postnatally secondary to mechanical trauma caused during prolonged endotracheal intubation. In the presented case, a complete obstruction of the right main stem bronchus developed during the neonatal period despite a relatively short time of intubation. The etiological background is discussed.

We encountered a case of right internal mammary artery to innominate vein fistula following subclavian vein catheterization and the projection of the coil spring was projected after transcatheter intravascular coil occlusion. We were worried about both distal thromboembolism from small thrombi forming on a portion of the coil spring and stenosis of the subclavian artery. However, there was no evidence of thromboembolism of the distal artery, and good patency of the right subclavian artery was shown by an angiogram performed six months later. The patient has been receiving heparin therapy during hemodialysis, which should help prevent thromboembolism of the distal artery.

The kinesio, phychopathologic and psychosocial effects of prolonged immobilization of the ill aged are outlined. The iatrogenic (physician-induced) and nurisgenic (nurse-induced) factors related to such functional disabilities are described. Illustrative case histories are given. The syndrome is reversible. Thus physicians and nurses have a continued responsibility to support a sustained rehabilitation program for these patients. The biochemical effects of prolonged inactivity indicate that immobilization of the elderly patient results in adverse physical and psychologic phenomena.

The case is presented of a patient who developed a disseminated infection caused by M. chelonei which arose from a fragment of intravascular polyethylene catheter that had been inserted six months earlier.

Colon carcinomas develop at the site of implantation in approximately 6% of patients who undergo ureterosigmoidostomy for benign conditions. Generally, the obstruction of a long-functioning ureterosigmoidostomy heralds the presentation of the malignancy. The development of a carcinoma of the colon at the site of the ureteral stump 22 years after conversion to ileal conduit in a ureterosigmoidostomy, which had been in place for only nine months, raises fundamental questions about the pathogenesis of the tumor. The long-assumed role of urine in the induction of these iatrogenic tumors must be questioned. This issue and suggestions for management and prevention are discussed.

Although operative injury to the spleen continues to account for a large number of splenectomies, the incidence of injury during operations upon the colon and rectum has not previously been reported. Of 993 consecutive colonic and rectal excisions, the spleen was injured in eight and splenectomy resulted in three. Two hundred and sixty patients had the splenic flexure of the colon mobilized. All splenic injuries occurred in this group (3.1 per cent) for an incidence of splenectomy during splenic flexure mobilization of 1.15 per cent. In all patients, splenic injury consisted of a capsular tear and was a result of traction on spleno-omental peritoneal bands in 50 per cent. The spleen was salvaged using topical hemostatic agents in 63 per cent of the injuries. A method of splenic flexure mobilization which improves visualization of splenic attachments and avoids traction injuries is discussed. The morbidity and mortality from traumatic splenectomy are also reviewed.

Reoperations in strabismus are done for overcorrection, undercorrections, and new strabismus problems such as dissociated vertical deviation and ptosis. Each patient requiring reoperation should be thoroughly evaluated on the basis of current findings with the understanding that some alteration in anatomy will be found. Restrictions must be freed and muscle force balanced to first provide straight eyes in the primary position and secondly the best vision possible. With persistence, 80% to 90% of patients requiring reoperation can expect a satisfactory end result.

Indwelling cardiac catheters by producing local mechanical stimulation or trauma can induce electrocardiographic (ECG) patterns which simulate known electrophysiologic phenomena. Catheter-induced ECG patterns were analyzed in 447 consecutive patients undergoing electrophysiologic studies. Iatrogenic nature of these patterns was suggested by 1) absence prior to placement of catheter; 2) sudden appearance with catheter placement and disappearance with catheter repositioning; 3) reoccurrence with remanipulation of catheters; and 4) simulation (in some cases) by programmed electrical stimulation from the catheter. Common catheter-induced patterns were 1) right bundle branch block (RBBB) lasting less than 24 hours occurred in 19 patients; 2) transient third degree atrioventricular block in His-Purkinje system developed in 3/13 patients with pre-existing left BBB; 3) catheter-induced ventricular pre-excitation which simulated ECG patterns of type B Wolff-Parkinson-White syndrome; 4) fortuitous synchronization of right ventricular excitation from the catheter, and left ventricular excitation from sinus beat resulted in normalization of the QRS complexes in 5/68 patients with pre-existing RBBB; 5) premature beats from the atria, right ventricle, and His bundle, which were common, resulted in complex ECG patterns. These iatrogenic ECG patterns must be identified in order to avoid errors in interpretation.

Eight-eight dogs admitted to the intensive care unit of the University of Pennsylvania School of Veterinary Medicine were studied to determine the frequency of intravenous catheter-related infection. Dogs were randomly assigned to 1 of 2 groups. In group 2, the skin was scrubbed with an iodine soap before final rinsing with alcohol and tincture of iodine. After withdrawal of each catheter, its tip was examined by bacteriologic culture, and the limb was examined for signs of phlebitis. Bacteria were isolated from 24 (48.9%) catheter tips in group 1 and from 6 (15.4%) in group 2 (P less than 0.005). Phlebitis was evident in 6 dogs in group 1, and in 1 dog in group 2. One death occurred in group 1, from causes possibly associated with catheter infection. These data suggest that catheter-related infection may be wide-spread in the dog and that it can be reduced by meticulous skin preparation.

Coronary spasm was first demonstrated by Gensini in 1962, and the diagnostic value of spontaneous spasm during coronary angiography is now generally accepted. In its absence, provocation tests with ergonovine or its derivatives form part of routine hemodynamic investigation for confirming the spastic nature of atypical chest pain or pain suggestive of Prinzmetal angina. The coronary spasm so induced gives rise to reduced coronary flow, an increase in coronary resistance and myocardial ischemia as shown by an increased lactate extraction in coronary sinus blood; therefore, once it is documented, it must be treated in order to avoid myocardial necrosis or ventricular arrhythmias. Three groups of drugs of drugs are used to counteract spontaneous or provoked spasm: alpha-blockers, especially phentolamine, nitrate derivatives, trinitroglycerine or isosorbide dinitrate, and calcium inhibitors nifedipine or diltiazem, which have a direct antispastic effect. The hemodynamic and pharmacological actions of these three groups of drugs depend on whether they are given orally, intravenously or by intracoronary injection. Twenty six coronary spasms were observed in 23 patients out of a total of 780 coronary angiographies (3,3 per cent) performed between June 1980 and June 1981: 12 spasms were spontaneous (1,5 per cent), 6 provoked by the catheter (0,8 per cent) and 8 by methylergometrine. There were no complications. Five coronary spasms were also observed during 70 coronary angioplasties (7,1 per cent). The spasm was relieved in all cases by intravenous injection of 1,5 to 3 mg of trinitrin (Lenitral). Calcium inhibitors, especially nifedipine, have been used successfully by Hugenholtz and Bertrand who consider that nifedipine has a slower action and the coronary dilatation obtained is never as great with the nitrate derivatives. Trinitrin remains the treatment of choice for the rapid relief of provoked spasm.

The problems of diagnosis and treatment of iatrogenic injuries to the extrahepatic biliary tract are discussed, reviewing 31 own cases. End-to-end anastomoses should only be performed in immediatly detected lesions. In cases of delayed diagnosis only biliodigestive anastomoses, e.g. hepaticojejunostomy, are indicated to avoid stenosis of the anastomosis. Injuries to the biliary tract can be reduced by early diagnosis of bilary diseases and correct intraoperative diagnostic means.

In six of nine patients with superior vena caval perforation by a central venous catheter, the chest radiograph showed a gentle curve at the tip of the catheter 4 hr to 7 days before clinical or radiographic recognition of perforation. This radiographic sign should prompt catheter repositioning to avoid the morbidity and potential mortality associated with superior vena caval perforation.

Advances in medicine that have led to more sophisticated methods of diagnosing, treating and monitoring patients take an ever increasing toll in iatrogenic complications. It may be argued that the net effect is an improvement in care, but it is self-evident that minimizing iatrogenic complications will increase the benefit to the patients of the ever increasing complex methods of treatment. Iatrogenic complications tend to be sporadic and varied in nature, and are difficult to study as a group. Psychological and medicolegal problems add to this difficulty. However, if the incidence of iatrogenic complications is to be decreased, a concerted effort has to be made to study them. Them report deals with an effort.

Information derived from the relationship of the primary care physician with an older patient provides the best possible way to eliminate or minimize many ethical conflicts that arise in the care of the very old. The conscientious physician can seek information regarding the patient's personal value scheme and his or her expectations and utilize the breadth of available technology to best serve the patient. Many of the issues raised in this article are discussed in much greater detail in subsequent articles. The discussions of the issues they encompass are intended to inform and to stimulate. There is legitimate reason for optimism that, with education and thoughtful review, physicians will be able to improve the manner in which we care for older individuals.

Intensive care unit patients are a group with an increased risk for the development of septicemia. The combination of illness (trauma, burn, surgery, metabolic coma etc.) and iatrogenic factors (foreign bodies, ventilation, drugs etc.) make them more susceptible to severe infections. Rapid diagnosis of septicemia is important, since the prognosis is dependent on rapid treatment. Sedation and ventilation may mask the primary symptoms of septicemia, and in these cases the condition is not diagnosed until signs of complications (shock, disseminated intravascular coagulation, multiple organ failure) appear. Aside from clinical observation and laboratory results, hemodynamic symptoms may be indicative of septicemia. In the presence of septic signs, blood, tracheal secretion, urine etc. must be cultivated without delay, before starting empirical treatment. Surveillance cultures may make for more appropriate initial treatment, though they pose the problem of differentiation between colonization and infection.

During antirejection treatment with antithymocyte globulin (ATG), a 48-year-old male kidney graft recipient was erroneously given 30 mg/kg ATG on day 5 of the treatment course. Clinically, the patient presented with abdominal pain, profuse diarrhea, and fever. Initially, the platelet count dropped to 94 x 10(3)/microliters and showed a further decrease to 65 x 10(3)/microliters 2 days thereafter. Plasmapheresis carried out about 12 h after the end of ATG infusion resulted in a decrease in serum levels of total rabbit immunoglobulin as well as the antibody fraction reactive with human T lymphocytes. Within 10 days after the discontinuation of ATG treatment, the relative and absolute number of the T-cell subpopulations, which had disappeared from the circulation at the time of antirejection therapy, returned to normal values. In addition, at this time both platelet and lymphocyte counts were again found to be in the normal range. Kidney function had recovered from the rejection crisis such that the patient could be discharged 26 days posttransplantation.

A series of patients with esophageal injuries was reviewed to evaluate the role of conservative management of these injuries. Between 1962 and 1978, we treated 108 esophageal injuries. In 74 percent of the cases, the injury was probably iatrogenic. Foreign bodies were the most frequent cause of noniatrogenic esophageal injury. Sixty-eight patients underwent surgery, while the remaining 40 patients received conservative treatment. Of 11 deaths in the series, eight occurred among the surgically treated group. Methods of treatment are discussed, and illustrative cases presented.

In the first part environmental diseases by air pollution, water contamination and dietary factors are discussed. The important role of the combustion of coal and petrol and the increasing confrontation with carcinogenic substances, especially with those originated by smoking of tobacco are stressed and underlined by epidemiologic dates. Other epidemiologic evidences are mentioned concerning the development of cardiovascular diseases, neoplastic diseases of the colon or liver diseases by dietetic factors. In the second part epidemiologic facts of drug induced reactions and iatrogenic cases of death in hospitalized and out-patients are reported. The main responsible pathogenetic factors for such events, prevailing in elder persons, are seen in the reduced hepatic metabolic capacity, the decreasing tubular or glomerular function of the kidneys and above all the different and often unpredictable drug interactions. The most important pathogenetic mechanisms for drug interactions are changes of drug binding to albumin or competitive disturbance of renal excretion and particularly alterations of the biotransformation processes as enzyme induction or enzyme inhibition. The clinical relevance of these theoretical considerations is demonstrated by some practical examples referring to the importance of a solid knowledge of the many possible interactions in drug therapy especially in elder patients.

A survey is given of the most important findings in respect of iatrogenic damage to the nervous system on the basis of published reports and the author's own findings, taking special account of lumbar puncture and suboccipital puncture, myelography, contrast-medium encephalography, ventriculography and cerebral angiography. The possibility of damage such as the danger of embolism in diagnostic and therapeutic vascular puncture is referred to. Among the lesions caused in the course of therapy, the side-effects of treatment with drugs, effects of radiation, effects resulting from anesthesia, sequelae of neural therapy and of manual manipulations, sequelae of operations, and postvaccinal encephalopathies are discussed. The necessity of systematic morphological examinations for exact assessment of ioatrogenic lesions is stressed. Iatrogenic damage due to neglect of diagnostic and therapeutic measures is also considered.

The incidence of iatrogenic cardiovascular foreign bodies is increasing. The most common source is a fragment of an in-dwelling venous catheter. These objects have resulted in severe sequelae and death in many instances. Most should be removed. Percutaneous extraction is the method of choice. Surgery should be reserved for cases with failed percutaneous extraction.