Predictive model for diagnostic yield of bone marrow examination in patients with HIV infection having fever of unknown origin.

OBJECTIVE: Bone marrow examination is valuable for identifying the cause of fever of unknown origin (FUO) in HIV-infected patients. Based on the outcomes of bone marrow examination of patients with FUO, we aimed to develop a predictive model for identifying the factors that can increase the diagnostic yield of bone marrow examination. DESIGN: For this retrospective cohort study, we enrolled HIV-infected patients, aged more than 15 years and diagnosed with FUO, at Songklanakarind Hospital in Southern Thailand, between January 2009 and December 2019. METHODS: Evaluations were based on bone marrow aspiration, biopsy, and culture; any missing data were imputed with regression imputation. RESULTS: Among the final 108 included patients, 44 (40.74%) showed positive bone marrow results. The diagnoses mainly comprised histoplasmosis, penicilliosis, and tuberculosis. Bone marrow examination led to treatment modifications in approximately 33% patients. Platelet count less than 150 000 cells/µl, alkaline phosphatase (ALP) level at least 200 U/l, and no previous antibiotic treatment were significantly associated with higher diagnostic yields. The HIV bone marrow (HIVBM) model, comprising of spleen size, hematocrit (Hct), platelet count before bone marrow examination, ALP level at admission, and previous antibiotic treatment, was generated as a nomogram to predict the diagnostic yield of bone marrow examination in HIV-infected patients with FUO. CONCLUSION: The results of this study indicate that the HIVBM model can be used to predict the diagnostic yield of bone marrow examination, and therefore assist in clinical decision-making regarding bone marrow procedures, to be performed for identifying the origin of fever in HIV-infected patients.

A New Mobile Application to Reduce Anxiety in Pediatric Patients Before Bone Marrow Aspiration Procedures.

OBJECTIVES: Insufficient preparation for children who are undergoing bone marrow aspiration can cause anxiety and negative outcomes. Nonpharmacological therapies have been proven to reduce fear in children who are undergoing painful procedures. We have therefore developed a mobile application to help reduce these patients' anxiety by providing them with procedural information and coping skills. METHODS: This single-blinded, randomized controlled trial included 60 patients age 5 to 12 years old who were undergoing bone marrow aspiration procedures in Thailand that were conducted between May 2015 and May 2016. Sixty participants were randomly assigned to the intervention group (mobile application added to usual care) or the control group (usual care only). Preprocedural anxiety levels were evaluated by visual analog scales (child anxiety visual analog scale); this was repeated in the intervention group immediately after patients used the mobile application. On the day of the procedure, the patients' cooperation levels were assessed by using the modified Yale Preoperative Anxiety Scale. The total amount of sedative drugs that were used was also recorded. The paired t test and the Wilcoxon signed rank test were used to analyze within-person change, whereas the t test and the Wilcoxon rank sum test were used for group comparisons. RESULTS: The child anxiety visual analog scale score of patients in the intervention group decreased significantly after they used the mobile application (P < .0012). The modified Yale Preoperative Anxiety Scale score of patients in the intervention group was significantly lower than that in the control group (P < .01). There was no difference in sedative use between the 2 groups. CONCLUSIONS: This mobile application possibly had effectiveness in routine use for reducing anxiety and increasing patients' cooperation in bone marrow aspiration procedures.

Penetrating injury of the ascending aorta complicating a sternal biopsy.

Bone marrow aspiration and trephine biopsy are considered safe procedures. Some serious but rare adverse events directly attributable to these procedures have been related in a few reports in the literature. We report a rare case of ascending aortic injury following a sternal trephine biopsy.

Bone marrow solid core biopsy needle: a critical assessment of the utility, benefits and limitations of the instruments employed in current day haematology and oncology.

The optimal clinical evaluation of the bone marrow requires an examination of air-dried and well-stained films of the aspirated tissue along with a histopathological evaluation of adequately processed and properly stained core biopsy specimens. A bone marrow evaluation can be essential in establishing a diagnosis, determining the efficacy of treatment in haematological disorders and to monitor haematological status of patients following bone marrow/stem cell transplantation. It is also an essential component of the staging process for newly diagnosed malignancies. Currently available bone marrow aspiration needles are quite satisfactory and if properly used provide good-quality specimens for morphological evaluation. However, if a bone marrow core biopsy is concerned, several needles are currently in use but not all of them provide good-quality biopsy specimens for histological evaluation or are user friendly. We have compared the recently introduced Moeller Medical single use bone marrow core biopsy needle with the Jamshidi needle with marrow acquisition cradle (CareFusion), J-needle (Cardinal Health) and OnControl device (Vidacare). It is concluded that the Moeller Medical needle system has definite advantages over others and is recommended for routine use.

Management of an Iatrogenic Pseudoaneurysm of the Superior Gluteal Artery by Percutaneous Ultrasound-Guided Thrombin Injection: A Case Report.

We report the unusual case of a pseudoaneurysm of the superior gluteal artery (SGA) as a complication of a bone marrow biopsy. A 75-year-old man presented with pain and swelling of the left buttock 1 month after a bone marrow biopsy of the left iliac crest. The patient was treated by percutaneous ultrasound-guided thrombin injection (UGTI). The procedure was successful without any complication and the patient was discharged at home the same day. Follow-up at 3 months after the procedure confirmed the complete thrombosis of the pseudoaneurysm sac. At the best of our knowledge, UGTI of a pseudoaneurysm of the SGA has never been reported since now in the English literature.

[How to do: Bone marrow biopsy]. / Die Knochenmarkpunktion.

Bone marrow examination plays an important role in the diagnosis of hematological and oncological diseases. Confirmation of a leukemia, clarification of cytopenias and risk stratification of a disease are possible indications for a bone marrow puncture.Here we describe, step by step, the workflow, possible pitfalls and complications of this procedere.

Methods of reducing pain during bone marrow biopsy: a narrative review.

Bone marrow examination plays a crucial role in the diagnosis and management of various hematological and systemic diseases. Even though the procedure has been carried out for decades, it remains an extremely painful and uncomfortable experience for a majority of patients. This paper reviews the different strategies used to provide analgesia and summarizes the advantages and drawbacks of one strategy over the other. A literature review was carried out addressing the different approaches to providing pain relief during bone marrow aspiration and biopsy. Several different methods, procedure modifications and protocols are employed at various centers but pain control and analgesia remain incomplete. Local infiltration with lidocaine or similar local analgesics is the standard at most centers. Although there is limited data, there are several studies in literature demonstrating the pain relieving effects of different methods and drugs when used with local anesthetics. Sedation, usually using benzodiazepines, reduces anticipatory anxiety, provides analgesia and also short term amnesia. Combinations of different agents not only yield potent effects but also reduce the required dose of each individual drug, minimizing adverse effects. Non-pharmacological factors also play key roles. Providing patients with complete and comprehensible information is vital to ensure the least amount of discomfort during the biopsy. Distraction techniques, such as cognitive behavioral therapy, hypnosis and music therapy, may also play a role in minimizing pain.

The Efficacy and Safety of Procedural Sedoanalgesia with Midazolam and Ketamine in Pediatric Hematology.

OBJECTIVE: The aim of this study is to investigate the efficacy and safety of sedoanalgesia performed outside the operating room by pediatricians trained in advanced airway management and life support. MATERIALS AND METHODS: Midazolam and ketamine were administered consecutively by intravenous route under cardiorespiratory monitoring for painful procedures of pediatric hematology. RESULTS: A total of 115 patients had 237 sedoanalgesia sessions. Sedation time was 24.02±23.37 s and sedation success was 92.5% (Ramsay scores of ≥5). Patient satisfaction was high. The recovery time was 28.81±14.4 min. Although statistically significant (p<0.01) increases in systolic and diastolic blood pressure, heart rate, and respiratory rate were observed without clinical importance, they improved without any intervention. No severe adverse events were observed. CONCLUSION: Sedoanalgesia with intravenous midazolam and ketamine for pediatric hematology and oncology patients' painful minor invasive procedures performed in an optimally equipped setting outside the operating room by pediatricians trained and certificated in advanced airway management and life support is effective and safe.

Does transcutaneous electrical nerve stimulation (TENS) alleviate the pain experienced during bone marrow sampling in addition to standard techniques? A randomised, double-blinded, controlled trial.

AIMS: Bone marrow aspiration and trephine (BMAT) biopsies remain important tests in haematology. However, the procedures can be moderately to severely painful despite standard methods of pain relief. To test the efficacy of transcutaneous electrical nerve stimulation (TENS) in alleviating the pain from BMAT in addition to standard analgesia using a numerical pain rating scale (NRS). METHODS: 70 patients requiring BMAT were randomised (1:1) in a double-blind, placebo-controlled trial. -35 patients received TENS impulses at a strong but comfortable amplitude (intervention group) and 35 patients received TENS impulses just above the sensory threshold (control group) (median pulse amplitude 20 and 7 mA, respectively). Patients and operators were blinded to group allocation. Pain assessments were made using a numerical pain scale completed after the procedure. RESULTS: No significant difference in NRS pain recalled after the procedure was detected (median pain score 5.7 (95% CI 4.8 to 6.6) in control vs 5.6 (95% CI 4.8 to 6.4) in the intervention group). However, 100% of patients who had previous experience of BMAT and >94% of participants overall felt they benefited from using TENS and would recommend it to others for this procedure. There were no side effects from the TENS device, and it was well tolerated. CONCLUSIONS: TENS is a safe, non-invasive adjunct to analgesia for reducing pain during bone marrow biopsy and provides a subjective benefit to most users; however, no objective difference in pain scores was detected when using TENS in this randomised controlled study. CLINICAL REGISTRATION NUMBER: NCT02005354.

Effects of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children with cancer.

Cancer and its treatment are stressful and reduce the quality of life in children. The aim of this study was to investigate the effect of massage therapy on pain and anxiety arising from intrathecal therapy or bone marrow aspiration in children with cancer. We conducted a controlled pretest/posttest quasi-experimental study at a paediatric oncology unit in Turkey. Twenty-five children were enrolled in this study. Their pain and anxiety were determined using a visual analogue scale. When the pretest and posttest pain and anxiety levels of the groups were compared, no statistically significant difference was found (P > 0.05). It was determined that pain and anxiety levels in the experimental group decreased significantly. This study provides preliminary evidence for the effectiveness in children of massage in reducing pain and anxiety arising from intrathecal therapy or bone marrow aspiration.

Prospective randomized crossover evaluation of three anesthetic regimens for painful procedures in children with cancer.

OBJECTIVE: To identify the most effective sedation regimen for bone marrow aspiration and lumbar puncture procedures with a prospective trial of 3 combinations of sedation/analgesia. STUDY DESIGN: In this double-blind crossover study, we randomly assigned 162 children with acute lymphoblastic leukemia or lymphoblastic lymphoma to receive fentanyl 1 mcg/kg, fentanyl 0.5 mcg/kg, or placebo, in addition to propofol and topical anesthetic for 355 procedures. RESULTS: We found no significant differences among the 3 regimens in the frequency of pain (pain score > 0) or severe pain (pain score ≥ 5) during recovery, or a >20% increase in hemodynamic/respiratory variables during anesthesia. Treatment with fentanyl 1 mcg/kg was associated with a lower frequency of movement during procedure compared with treatment with fentanyl 0.5 mcg/kg (P = .0476) or treatment with placebo (P = .0545). The placebo group required longer time to recover (median, 18 minutes) compared with the fentanyl 0.5 mcg/kg group (median, 9 minutes) (median difference 2.0, P = .007) and the fentanyl 1 mcg/kg (median 8 minutes), (median difference 2.0, P = .15). The placebo group also required larger total dose of propofol (median 5 mg/kg) compared with that of the fentanyl 1 mcg/kg group (median, 3.5 mg/kg) and the fentanyl 0.5 mcg/kg group (median 3.5 mg/kg) (median differences 1.5, P < .00005, in both comparisons). CONCLUSION: The addition of fentanyl 1 mcg/kg to propofol for brief painful procedures reduces movement, propofol dose, and recovery time.

Procedural care for adult bone marrow aspiration and biopsy: qualitative research findings from Australia.

BACKGROUND: This article presents a subset of findings on the experience of bone marrow aspiration and biopsy (BMAB) from an Australian hematology survivorship study. OBJECTIVE: The aim of the larger research was to document and explore issues associated with the experience of survivorship for hematology patients supported by Leukaemia Foundation of Queensland. The experience with BMABs was one of the issues explored. METHODS: The qualitative study involved in-depth interviews with 50 individuals with a diagnosis of a hematologic malignancy from a range of locations throughout Queensland, Australia. The interviews were transcribed verbatim, coded, and then analyzed thematically. RESULTS: The findings demonstrate that, for many of the hematology patients in the study, BMABs were a painful experience. The findings indicate that a major contributing factor to the pain and discomfort is the lack of effective procedural care. CONCLUSIONS: The findings emphasized the importance of the provision of choice with regard to anesthesia or sedation as part of the procedural care for BMABs. IMPLICATIONS FOR PRACTICE: The insights provide urgency to the call for further research to improve clinical practice and procedural care in relation to BMABs. The strong recommendation from the study is that procedural pain in relation to BMABs for hematology patients be managed from the initial procedure as the consequences of a traumatic experience can be far reaching, particularly in light of the need for repeated BMABs over the treatment trajectory. As specialist nurses are now increasingly taking responsibility for carrying out such procedures, the findings have implications for the nursing profession.

Strategies of pain reduction during the bone marrow biopsy.

Examination of the bone marrow biopsy and aspirate allows diagnosis and assessment of various conditions such as primary hematologic and metastatic neoplasms, as well as nonmalignant disorders. Despite being performed for many years, according to many different protocols, the procedure still remains painful for the majority of patients. This paper summarizes the current knowledge of pain reduction measures in the bone marrow biopsy and aspiration.

A randomized trial of hypnosis for relief of pain and anxiety in adult cancer patients undergoing bone marrow procedures.

Pain and anxiety are closely associated with bone marrow aspirates and biopsies. To determine whether hypnosis administered concurrently with the procedure can ameliorate these morbidities, the authors randomly assigned 80 cancer patients undergoing bone marrow aspirates and biopsies to either hypnosis or standard of care. The hypnosis intervention reduced the anxiety associated with procedure, but the difference in pain scores between the two groups was not statistically significant. The authors conclude that brief hypnosis concurrently administered reduces patient anxiety during bone marrow aspirates and biopsies but may not adequately control pain. The authors explain this latter finding as indicating that the sensory component of a patient's pain experience may be of lesser importance than the affective component. The authors describe future studies to clarify their results and address the limitations of this study.

Pain and anxiety during bone marrow aspiration/biopsy: Comparison of ratings among patients versus health-care professionals.

PURPOSE: To assess pain and anxiety during bone marrow aspiration/biopsy (BMA) among patients versus health-care professionals (HCPs). METHOD: 235 adult hematologic patients undergoing BMA were included. BMA was performed by 16 physicians aided by nine registered nurses (RNs). Questionnaires were used to obtain patients and HCPs ratings of patients' pain and anxiety during BMA. Patterns of ratings for pain and anxiety among patients HCPs were estimated with proportions of agreement P(A), Cohen's kappa coefficient (κ), and single-measure intra-class correlation (ICC). We also explored if associations of ratings were influenced by age, sex, type and duration of BMA. RESULTS: The P(A) for occurrence of rated pain during BMA was 73% between patients and RNs, and 70% between patients and physicians, the corresponding κ was graded as fair (0.37 and 0.33). Agreement between patients and HCPs regarding intensity of pain was moderate (ICC=0.44 and 0.42). Severe pain (VAS>54) was identified by RNs and physicians in 34% and 35% of cases, respectively. Anxiety about BMA outcome and needle insertion was underestimated by HCPs. P(A) between patients and RNs and patients and physicians regarding anxiety ranged from 53% to 59%. The corresponding κ was slight to fair (0.10-0.21). ICC showed poor agreement between patients and HCPs regarding intensity of anxiety (0.13-0.36). CONCLUSIONS: We found a better congruence between patients and HCPs in pain ratings than in anxiety ratings, where the agreement was low. RNs and physicians underestimated severe pain as well as anxiety about BMA outcome and needle insertion.