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Szuber N, Toliopoulos P, Busque L, Cerquozzi S, Foltz L, Gupta V, Tefferi A, Vannucchi AM, Hillis C, Leber B, Maze D, Prchal J, Olney HJ, Sirhan S. Perioperative management of myeloproliferative neoplasms: A pan-Canadian physician survey and international expert opinion. Am J Hematol 2022; 97:E466-E469. [PMID: 36151067 DOI: 10.1002/ajh.26739] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/04/2022] [Accepted: 09/13/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Natasha Szuber
- Division of Hematology, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Groupe Québécois de Recherche sur la LMC et NMP (GQR LMC-NMP)/Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group, Montreal, Quebec, Canada
| | - Panagiota Toliopoulos
- Division of General Internal Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Lambert Busque
- Division of Hematology, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Groupe Québécois de Recherche sur la LMC et NMP (GQR LMC-NMP)/Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group, Montreal, Quebec, Canada
| | - Sonia Cerquozzi
- Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Lynda Foltz
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vikas Gupta
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Alessandro Maria Vannucchi
- Center for Innovation and Research in Myeloproliferative Neoplasms, Hematology Unit, Azienda Ospedaliera Universitaria Careggi, University of Florence, Florence, Italy
| | - Christopher Hillis
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Brian Leber
- Juravinski Cancer Centre, McMaster University, Hamilton, Ontario, Canada
| | - Dawn Maze
- Princess Margaret Cancer Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jaroslav Prchal
- Department of Oncology, McGill University, Montreal, Quebec, Canada
| | - Harold J Olney
- Division of Hematology, Department of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Groupe Québécois de Recherche sur la LMC et NMP (GQR LMC-NMP)/Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group, Montreal, Quebec, Canada.,University of Montreal Health Centre, Montreal, Quebec, Canada
| | - Shireen Sirhan
- Groupe Québécois de Recherche sur la LMC et NMP (GQR LMC-NMP)/Chronic Myeloid Leukemia and Myeloproliferative Neoplasms Quebec Research Group, Montreal, Quebec, Canada.,Segal Cancer Center, Jewish General Hospital, Montreal, Quebec, Canada
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Labaran LA, Vatani J, Bell J, Puvanesarajah V, Sequeira S, Raad M, Jain A, Hassanzadeh H. Outcomes Following Posterior Lumbar Fusion in Patients with Polycythemia Vera. World Neurosurg 2019; 134:e372-e378. [PMID: 31639499 DOI: 10.1016/j.wneu.2019.10.071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 10/10/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Polycythemia vera (PV) is a chronic myeloproliferative neoplasm that is associated with increased risk for venous and arterial thromboembolism. The aim of this study was to evaluate outcomes following elective posterior lumbar fusion (PLF) and/or posterior interbody fusion (PLIF) among patients with PV. METHODS Using PearlDiver retrospective national database, Medicare patients <85 years old who underwent elective primary PLF (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code 81.07) and/or PLIF (ICD-9-CM code 81.08) for degenerative lumbar spine pathologies during 2006-2013 were identified. Patients included in the PLF and/or PLIF cohort were separated into patients with a prior diagnosis of PV (ICD-9-CM code 238.4) and a control cohort of patients without PV. Comparisons of postoperative outcomes were made between the PV patient group and matched control group. Significance was set at 0.05. RESULTS Selected study participants included 1491 patients with PV and 29,056 patients in the matched control group. Patients with PV had a significantly increased rate of 90-day acute pulmonary embolism (1.9% vs. 1.2%, odds ratio [OR] 1.65, 95% confidence interval [CI] 1.10-2.38, P = 0.010), 90-day lower extremity deep vein thrombosis (3.4% vs. 1.9%, OR 1.81, 95% CI 1.33-2.40, P < 0.001), and 1-year diagnosis of surgical site infection (5.4% vs. 4.2%, OR 1.30, 95% CI 1.02-1.63, P = 0.027) compared with patients without PV. Nonetheless, PV was not associated with other major medical complications, including stroke, myocardial infarction, and mortality, following PLF and/or PLIF. CONCLUSIONS Patients with PV undergoing elective PLF and/or PLIF have a significantly increased risk for pulmonary embolism, lower extremity deep vein thrombosis, and surgical site infection.
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Affiliation(s)
- Lawal A Labaran
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Jasmine Vatani
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Joshua Bell
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sean Sequeira
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Amit Jain
- Department of Orthopaedic Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, Virginia, USA.
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Riekki TR, Ling E, Cordovani D. Laparoscopic hepatectomy in a patient with uncontrolled polycythaemia vera. Anaesth Rep 2019; 7:92-95. [PMID: 32051960 DOI: 10.1002/anr3.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 11/06/2022] Open
Abstract
This case report describes the peri-operative course of a patient with uncontrolled polycythaemia vera who underwent a laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. Polycythaemia vera is a chronic condition that results in erythrocytosis and puts patients at risk of peri-operative complications including thrombotic events and paradoxical haemorrhage. Little evidence exists on the ideal peri-operative management of uncontrolled polycythaemia vera when the proposed procedure carries a high risk of haemorrhage. Our patient presented with a pre-operative haemoglobin of 197 g.l-1 (haematocrit 65%) and was not phlebotomised pre-operatively. Intra-operatively he lost 2700 ml of blood, reducing his haematocrit to 48%, and then suffered fatal thrombotic complications postoperatively. The patient did not receive any blood product transfusions during his peri-operative course. We review the available evidence to guide the peri-operative management of patients with polycythaemia vera. The inherent risks of thrombosis and haemorrhage associated with polycythaemia vera need to be weighed against the specific surgical and transfusion-related risks. Phlebotomy to achieve a pre-operative haematocrit under 45% is recommended and intra-operative phlebotomy shows promise for reducing blood loss during hepatectomies. Management of postoperative erythrocytosis may be an important and underappreciated aspect of reducing the peri-operative risk of thrombosis in patients with polycythaemia vera.
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Affiliation(s)
| | - E Ling
- McMaster University Hamilton ON Canada
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Kobayashi M, Akatsu M, Fujita Y, Nishikawa K. Successful perioperative management of a patient with erythropoietin-producing uterine myoma. JA Clin Rep 2018; 4:50. [PMID: 32025892 PMCID: PMC6967353 DOI: 10.1186/s40981-018-0185-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Accepted: 06/05/2018] [Indexed: 01/14/2023] Open
Abstract
Background Erythropoietin-producing uterine myoma can cause various complications such as arterial or venous thrombosis and bleeding. Therefore, caution is required in the anesthetic management of affected patients. Case presentation A 57-year-old female was suspected to have an erythropoietin-producing uterine myoma and was scheduled to undergo an abdominal total hysterectomy and bilateral salpingo-oophorectomy. Preoperative levels of hemoglobin and erythropoietin were 21.9 g/dl (normal 11.5–15 g/dl) and 23.2 IU/ml (normal 4.2–23.7 IU/ml), respectively. Preoperative phlebotomy and isovolemic hemodilution were performed to prevent arterial and venous thrombosis, following previous evidence that a hemoglobin level < 16 g/dl reduces the occurrence of polycythemia vera-related complications. Fondaparinux 2.5 mg was subcutaneously injected once daily after the operation, resulting in a good perioperative course without major complications. Conclusion Herein, we have described a successful perioperative management of a patient with erythropoietin-producing uterine myoma. Our findings in this case suggest that this combination of antithrombotic therapies can facilitate anesthetic management of patients with this disease.
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Affiliation(s)
- Masato Kobayashi
- Department of Anesthesiology, Iwaki Kyoritsu General Hospital, 16 Kusehara, Mimaya-machi, Uchigo, Iwaki, Fukushima Prefecture, 9738555, Japan.
| | - Masahiko Akatsu
- Department of Anesthesiology, Iwaki Kyoritsu General Hospital, 16 Kusehara, Mimaya-machi, Uchigo, Iwaki, Fukushima Prefecture, 9738555, Japan.,Department of Disaster and Comprehensive Medicine, Fukushima Medical University, Fukushima, Fukushima Prefecture, 9601295, Japan
| | - Yoshihisa Fujita
- Department of Anesthesiology, Iwaki Kyoritsu General Hospital, 16 Kusehara, Mimaya-machi, Uchigo, Iwaki, Fukushima Prefecture, 9738555, Japan
| | - Koichi Nishikawa
- Department of Disaster and Comprehensive Medicine, Fukushima Medical University, Fukushima, Fukushima Prefecture, 9601295, Japan
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Weingarten TN, Hofer RE, Ahle BJ, Kemp KM, Nkwonta JA, Narr BJ, Pardanani A, Schroeder DR, Sprung J. Perioperative blood product administration and thromboembolic events in patients with treated polycythemia vera: a case-control study. Transfusion 2015; 55:1090-7. [PMID: 25727411 DOI: 10.1111/trf.13006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/13/2014] [Accepted: 10/17/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND Patients with polycythemia vera (PV) have historically been considered to be at high risk for perioperative hemorrhagic and thromboembolic complications. However, no recent studies have compared these outcomes between treated PV patients and patients without PV undergoing similar procedures. STUDY DESIGN AND METHODS Patients with PV who underwent surgery with anesthesia from June 1, 2006, to May 31, 2011, were randomly matched (sex, age, type of surgical procedure, surgical year) at a ratio of 1:4 with control patients without PV. Conditional logistic regression analysis adjusting for surgical duration, preoperative hemoglobin, platelet count, and cardiovascular disease was used to assess the association between PV and blood product transfusions, thromboembolism, and other major cardiovascular and pulmonary complications. RESULTS Fifty-six PV patients who underwent 79 surgeries were matched with 312 controls. During hospitalization, 35 (44.3%) and 82 (25.9%) PV and control patients, respectively, were transfused with blood products. PV patients were at increased risk for transfusion intraoperatively (odds ratio [OR], 4.35; 95% confidence interval [CI], 1.79-10.57; p = 0.001) and during hospitalization (OR, 4.35; 95% CI, 1.84-10.31; p < 0.001). The likelihood of thromboembolic complications and/or other major complications did not differ between the two study groups (thromboembolic-OR 1.53, 95% CI 0.39-6.02, p = 0.540; other major complications-OR 2.15, 95% CI 0.93-4.96, p = 0.073). CONCLUSIONS Medically managed PV patients had an increased likelihood of receiving blood products perioperatively. Given the low number of observed thromboembolic events, we cannot make definitive conclusions regarding the association between PV and thromboembolism.
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Affiliation(s)
| | | | | | | | | | | | | | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics and Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
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Musallam KM, Porter JB, Sfeir PM, Tamim HM, Richards T, Lotta LA, Peyvandi F, Jamali FR. Raised haematocrit concentration and the risk of death and vascular complications after major surgery. Br J Surg 2013; 100:1030-6. [DOI: 10.1002/bjs.9176] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2013] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Preoperative anaemia is associated with adverse postoperative outcomes. Data on raised preoperative haematocrit concentration are limited. This study aimed to evaluate the effect of raised haematocrit on 30-day postoperative mortality and vascular events in patients undergoing major surgery.
Methods
This was a cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Thirty-day mortality and vascular events, demographics and perioperative risk factors were obtained for adults undergoing major surgery. The adjusted effect of raised (over 0·50) compared with normal (0·41–0·50, American Medical Association reference range) preoperative haematocrit concentration on postoperative outcomes was assessed. Separate sex-specific analyses were also conducted, using haematocrit concentration thresholds commonly used in the diagnosis and management of apparent or absolute erythrocytosis.
Results
Some 3961 (2·0 per cent) of 197 469 patients had a raised haematocrit concentration before surgery. After adjustment, the 30-day postoperative mortality rate was higher in patients with raised haematocrit than in those without (odds ratio (OR) 2·23, 95 per cent confidence interval 1·77 to 2·80). Thirty-day rates of deep vein thrombosis (OR 1·95, 1·44 to 2·64) and pulmonary embolism (OR 1·79, 1·17 to 2·73), but not myocardial infarction or stroke, were also higher in patients with a raised haematocrit concentration. The effect on mortality was noted beyond the haematocrit thresholds of 0·48 in women and 0·52 in men; the effect estimates were considerably higher for values exceeding 0·54. Values between 0·41 and 0·45 were not associated with increased mortality risk. Similar observations were noted for venous thrombosis, although with apparent sex differences.
Conclusion
A raised haematocrit concentration was associated with an increased risk of 30-day mortality and venous thrombosis following major surgery.
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Affiliation(s)
- K M Musallam
- Department of Internal Medicine, UK
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - J B Porter
- Department of Haematology, University College London, UK
| | - P M Sfeir
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
| | | | - T Richards
- Division of Surgery and Interventional Science, University College Hospital, London, UK
| | - L A Lotta
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - F Peyvandi
- Angleo Bianchi Bonomi Haemophilia and Thrombosis Centre, Department of Medicine and Medical Specialties, Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Foundation Maggiore Policlinico Hospital, University of Milan, Milan, Italy
| | - F R Jamali
- Department of Surgery, American University of Beirut Medical Centre, Beirut, Lebanon
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McMullin MF, Bareford D, Campbell P, Green AR, Harrison C, Hunt B, Oscier D, Polkey MI, Reilly JT, Rosenthal E, Ryan K, Pearson TC, Wilkins B. Guidelines for the diagnosis, investigation and management of polycythaemia/erythrocytosis. Br J Haematol 2005; 130:174-95. [PMID: 16029446 DOI: 10.1111/j.1365-2141.2005.05535.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Mary F McMullin
- Department of Haematology, Queen's University, Belfast, Belfast City Hospital, Belfast, UK
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Affiliation(s)
- Jerry L Spivak
- Division of Hematology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Schmitt HJ, Becke K, Neidhardt B. Epidural anesthesia for cesarean delivery in a patient with polycythemia rubra vera and preeclampsia. Anesth Analg 2001; 92:1535-7. [PMID: 11375841 DOI: 10.1097/00000539-200106000-00037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- H J Schmitt
- Department of Anesthesiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany.
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Foss JF. Preoperative Evaluation of the Patient for Vascular Surgery in the "Real World". Semin Cardiothorac Vasc Anesth 2000. [DOI: 10.1177/108925320000400403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Patients presenting for vascular surgery frequently have multiple coexisting diseases. To meet the goal of providing a safe anesthetic with optimum resource use, we must ex amine the impact of each of these conditions on the patient and how the data from a particular evaluation or test will impact our anesthetic plan. Existing guidelines may be valu able if adapted to institution-specific circumstances. Con sultants represent a relatively high-cost resource, which can be optimized when used with clear goals in sight. Finally, we may be able to modify our evaluation based on the antici pated procedure, as these patients are exposed to a range of potential hemodynamic stresses.
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Affiliation(s)
- Joseph F. Foss
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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Abyad A, Kligman E. Primary polycythaemia vera in the elderly. J Int Med Res 1994; 22:121-9. [PMID: 8020639 DOI: 10.1177/030006059402200209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
At presentation the history of an 87-year-old woman included progressive memory loss, repeated transient ischaemic attack, increasing fatigue, dizziness, palpitations and frequent falls. Investigations revealed erythrocytosis, leukocytosis, thrombocytosis, normal arterial oxygen concentration and an increased red cell volume. Polycythaemia vera was diagnosed and was successfully managed by phlebotomy with half a unit twice a week and rechecks of her haematocrit, initially; she reported marked improvement after 2 weeks of treatment. The alternative treatments for polycythaemia vera are discussed; in addition to venesection, conventional treatments include bone-marrow depressive agents such as phosphorus-32 and chemotherapy with agents such as hydroxyurea. More recent developments include isovolumic erythrocytophoresis, alpha-interferon and ticlopidine. All of the treatments are associated with complications, or other disadvantages, thrombotic complications in the case of phlebotomy, malignancies in the case of most myelosuppressive treatments, and problems of compliance in others. The optimal treatment for polycythaemia vera is a judicious combination of the alternatives, depending on the phase of the disease, the age of the patient, and other prognostic factors.
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Affiliation(s)
- A Abyad
- Department of Family Medicine, American University of Beirut, Lebanon
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Burkhardt R, Jaeger K, Kettner G, Helmer G. Chronic myeloproliferative disorders: prognostic importance of new working classification. J Clin Pathol 1990; 43:357-64. [PMID: 2370304 PMCID: PMC502425 DOI: 10.1136/jcp.43.5.357] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Variants of chronic myeloproliferative disorders (CMPD) were compared according to their clinical features and classified by bone marrow biopsy appearances. Subsequently, this classification was further evaluated using survival data and histological variables from iliac crest biopsy specimens of an additional 1391 patients, making a total of 2241 patients available for analysis of outcome. The patients were grouped again into three main classes: "typical"; "variant"; and "transformed". "Typical" comprised the "classic" groups. "Variant" included the less uniform myeloproliferative syndromes, distinguished also by more variable clinical features, a different prognosis, and a greater tendency to fibrotic and blastic transformation. "Transformed" defined the end stages of both "typical" and "variant" types. Ten subgroups were distinguished by different histology and prognosis. Particular prognostic importance was assigned to atypia and immaturity of haemopoiesis, predominance of individual haemopoietic cell line, number and anomalies of megakaryocytes and progressive fibrosis. It is suggested that the proposed subclassification would be helpful for studies of epidemiology and therapeutic trials by allowing more homogeneous groups to be recognised.
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Affiliation(s)
- R Burkhardt
- Abteilung für Knochenmarksdiagnostik, Universität, München, West Germany
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Abstract
A number of topics have been reviewed pertaining to hematologic problems in preoperative patients. Most if not all of the problems discussed can be evaluated reasonably well by history, physical examination, and a few simple laboratory tests. Because the morbidity arising from some of these abnormalities can be quite significant, evaluation and treatment should be completed prior to surgery whenever possible. It is also critical to recall that therapy for a number of hematologic problems involves the transfusion of blood or blood products. This therapy should not be taken lightly as both immediate reactions (fever, anaphalaxis, hemolysis) as well as delayed effects (allosensitization and viral infections) occur frequently. The prudent clinician should try to minimize his patients' exposure to these potentially toxic materials by using alternative therapies.
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Snooks SJ, Dharmasena F, Mitchell TJ, Crisp JC. Prostatocutaneous urinary fistula to the thigh after retropubic prostatectomy in a patient with polycythaemia rubra vera. BRITISH JOURNAL OF UROLOGY 1986; 58:558. [PMID: 3779358 DOI: 10.1111/j.1464-410x.1986.tb05469.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Lee CA, Moss S, Fielding J, Lancaster R. Disseminated Intravascular Coagulation Associated with Polycythaemia Rubra Vera. Proc R Soc Med 1976. [DOI: 10.1177/003591577606900721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
| | - S Moss
- St Mary's Hospital, Harrow Road, London W9 3RL
| | - J Fielding
- St Mary's Hospital, Harrow Road, London W9 3RL
| | - R Lancaster
- St Mary's Hospital, Harrow Road, London W9 3RL
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