Pulmonary embolism in children.
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Biomedical subjects
Publications and source records attributed to W W Coon.
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The abdominal hemophilic pseudotumor is a rare but frequently disabling and life-threatening complication in patients with severe hemophilia. Our patients were observed for a considerable period of time to document progressive enlargement of the pseudotumor and increasing disability from severe pain, nerve compression, or leg swelling. The decision to operate was made on the basis of incapacitating symptomatology or fear of impending rupture. Although the complications resulting from operation may be major, with the current availability of large amounts of factor VIII and activated prothrombin complex concentrate, excision of this lesion can be performed without concern for the hazard of uncontrollable hemorrhage. Late recurrence of the pseudotumor may necessitate further operative management.
Secondary operative staging (diagnostic celiotomy after initial lymphoma staging and treatment) is of value in selected patients with Hodgkin's disease if, after appropriate clinical staging, there remains a reasonable doubt concerning the presence of residual or recurrent lymphoma. In our experience, although signs indicating possible recurrence were present in 35 patients, only 20 of these were found to have Hodgkin's disease within the abdomen at operation. These findings allowed us to restrict our intensive therapy to those with documented disease and to withhold potentially harmful treatment from the remaining subjects who on follow-up have shown no evidence to date of subsequent recurrence within the abdomen. The utilization of secondary operative staging in ten patients with non-Hodgkin's lymphoma has been less productive and is not recommended on the basis of our limited current experience.
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Eighty-six patients undergoing elective splenectomy have been investigated preoperatively and postoperatively by serial platelet counts and leg scanning using iodine 125-labeled fibrinogen. The presence of deep leg vein thromboses detected by labeled fibrinogen was confirmed by dye phlebography. In only five patients (6%) did deep venous thrombosis develop. In none of these five patients did an elevation in platelet count to 600,000/cu mm develop before or at the time of development of the thrombosis. None of 21 other patients who did have a rise in platelet count greater than 1,000,000/cu mm had evidenced of venous thrombosis. These data do not substantiate the need for routine prophylactic antithrombotic therapy in patients in whom postsplenectomy thrombocytosis develops.
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Previous investigators have reported significant elevations of serum copper and ceruloplasmin levels in lymphoma patients and subjects using estrogen, but have not taken into account the smoking habits of these populations. In order to determine whether smoking had any effect on these variables, the authors examined five groups for serum and erythrocytic copper and ceruloplasmin levels: 40 healthy subjects, 14 users of oral contraceptives, 25 smokers, 14 nonsmoking pretreatment lymphoma patients, and eight treated lymphoma patients. Significant elevations of serum copper and ceruloplasmin in pretreatment lymphoma patients, treated patients, and estrogen users were found, confirming previous reports. In addition, all groups had elevations of erythrocytic copper compared with the healthy subjects. Also, significant elevations of serum copper (P less than .0053) and ceruloplasmin (P less than .0001) were found in smoking relative to nonsmoking subjects. No correlation between duration of smoking and these elevations was found.
This review of the epidemiology of venous thromboembolism includes estimates of incidence and prevalence of venous thrombosis and its sequelae, a discussion geographical, annual and seasonal variations and data concerning possible risk factors. Selection of patients at increased risk for development of deep venous thrombosis or pulmonary embolism for specific diagnostic screening or for prophylactic therapy with low-dose heparin may be a more effective approach to lowering morbidity and mortality from this disease.
A ten-year analysis of the prevalence of pulmonary embolism found at autopsy examination has been repeated 20 years after a prior study. The frequency of all pulmonary embolism (12.3%) and of "major" pulmonary emboli (7.1%) remains essentially unchanged from that detected 20 years previously (13.6% and 8.6%). Less than 10% of patients had the clinical diagnosis of deep leg vein thrombosis, and only 9.3% had a definitive diagnosis of pulmonary embolism made during life. A sixfold variation in quarterly frequency and a twofold variation in annual prevalence were noted. Since these wide fluctuations in frequency are present, any assumptions regarding a changing disease pattern must be made with great caution. There is no evidence that fatal pulmonary embolism has decreased in frequency in recent years. An effort should be made to increase rate of detection of thromboembolic disease by more widespread use of one or more of the recently developed diagnostic procedures, or a larger segment of the hospital population at risk should receive prophylactic therapy with "low-dose" heparin sodium.
The influence of several diseases and conditions upon the prevalence of pulmonary embolism in autopsies performed during a ten year period at the University of Michigan has been analyzed. The major factors contributing to an increase in risk of development of pulmonary embolism include heart disease, certain types of cancer, obesity, acute paraplegia and accidental and operative trauma. These and several other risk factors defined in other studies should be used in a selective program designed to increase the rate of detection of deep venous thrombosis before pulmonary embolism occurs, or alternatively, patients at increased risk should receive prophylactic low dosage heparin therapy during hospitalization.
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