Bone Marrow Aspiration And Biopsy Research Articles

A Multivariate Analysis of Pain and Distress in Adults Undergoing BMAB.

Clinicians routinely perform bone marrow aspiration and biopsy (BMAB) to diagnose cancer and evaluate disease status; however, few studies address pain and distress with BMAB. A prospective descriptive-correlational design examined patients' (N = 152) ratings of pain intensity (numeric rating scale, 0-10) and distress (distress thermometer) at baseline and 5 min and 1 hr postprocedure. Data were analyzed using descriptive statistics, chi-square, and linear regression models. Mean postprocedure pain intensity at 5 min was moderate, 5.56 (SD = 3.03), and opioid use was associated with decreased pain at 1 hr (p < .001). Preprocedure administration of anxiolytics had no significant effect on distress reduction (p = .88). Being female, first-time biopsy, and increased preprocedure pain were significant predictors of postprocedure distress (p < .001). Treating anxiety alone may not be sufficient to lessen pain and distress. Individualized plans of care should be based on patient risk and response to procedure.

Utility of bone marrow examination for workup of fever of unknown origin in patients with HIV/AIDS

AimsThe utility of bone marrow aspiration and biopsy (BMAB) as a diagnostic tool in patients with HIV/AIDS and fever of unknown origin (FUO) is a subject of debate. Because highly...

Pain management during bone marrow aspiration and biopsy in pediatric cancer patients

The pain associated with bone marrow aspiration and biopsy (BMAB) has an enormous impact on pediatric cancer patients and their families, but no specific reference standards for sedation and analgesia have been developed in Japan. To determine the problems associated with pain management during BMAB, a cross-sectional investigation was conducted. A survey was sent in October 2011 to data managers in institutions belonging to the Tokyo Children's Cancer Study Group, addressing the non-pharmacological and pharmacological pain management for BMAB performed on pediatric cancer inpatients between January 2010 and December 2010. The eligible response rate was 41 of 57 institutions (71.9%). Non-pharmacological pain intervention was provided in 68% of surveyed institutions. All institutions provided pharmacological pain management. In most institutions, sedation/analgesia was performed by pediatric oncologists in a treatment room in the ward. Standards for pain management were developed and utilized in only four institutions. Other means of pain management were provided in various settings. Twelve institutions reported insufficient sedation/analgesia. In total, 80% of institutions reported some adverse events. Two serious adverse events were reported in cases of underlying or complicated conditions. No serious long-term consequences were reported. Significant issues were identified regarding the efficacy and safety of pain management. Adverse events can occur in any institution. Children with underlying or complicated conditions are at high risk for serious adverse events. Therefore, adequate and systematic assessment, patient monitoring, preparation and treatment for adverse events, and cooperation with skilled specialists of pediatric oncology, anesthesiology, and intensive care are essential.

CT-Guided Biopsy Produces High Quality Specimens For Diagnosis: A Retrospective Analysis Of 64 Consecutive Cases Using a Powered Biopsy Device At a Community Based Hospital

IntroductionFor decades, the standard methods of performing bone marrow and bone biopsy procedures in patients with varying bone densities have remained unchanged; despite the fact that the manual method of performing these biopsies has significant limitations; including patient discomfort, needle-related adverse events, and operator physical ability. As a consequence, interventional radiologists are often asked to perform these procedures for patients with difficult-to-reach biopsy targets. In 2010, a new battery/rotary powered biopsy device was introduced, initially for bone marrow sampling; then for examination of focal lesions of bones; procedures often performed by interventional radiologists using image guidance. In a retrospective study sponsored by Vidacare Corporation, an examination of one radiology and one pathology groups' initial experience using the device at a single center was conducted to determine the performance characteristics of the new biopsy device. MethodsMedical records at Holy Family Hospital from March 2010 to July 2012 were examined, and data for patients who had undergone biopsy procedures using the powered device (OnControl, Vidacare Corp, Shavano Park, TX) were compiled. Data included patient demographics, biopsy type, imaging type, analgesia/anesthesia type, anatomical location, number of passes, room time, procedure time, and complications. Pathology data included specimen dimensions, grading for crush and thermal artifact, presence of hemorrhage, overall quality, and ability to provide a definitive or descriptive diagnosis. Results64 patients had biopsy procedures using the powered device by 11 clinicians. Mean patient age was 63.5±15.6; 61% were female. Eleven patients received bone marrow aspiration and biopsy (BMAB) to diagnose/rule out hematological disorders. For the bone marrow biopsy procedures, pathology examination revealed the mean specimen length was 14.8±6.8mm; mean specimen volume was 87.9±64.2mm3 (vs. mean length of 11.0±5.5mm and mean volume of 20.4±9.0mm3 reported for patients receiving manual biopies in a separate study*) Of those specimens, 54.5% were intact, 91.9% were graded excellent or good (compared to 80% rated excellent or good for patients receiving manual biopsies in a separate study*), and the pathologist was able to provide either definitive or descriptive diagnosis for 100% of the cases. For the remaining cases, patients received bone biopsy procedures for focal lesions. Procedures were performed on vertebrae and the ilium in 39% and 38% of the cases, respectively. Other bones included the sacrum, femur, pubis, humerus, rib, and tibia. For all procedures, the mean number of passes was 1.3±0.7, and mean procedure time was 17.8±9.8 minutes. There were no complications. ConclusionsFor random marrow sampling and focal lesions, the powered system yielded outstanding specimens, particularly with respect to volume. Use of the powered device resulted in increased yield rates and higher quality specimens compared to manual devices; as well as easier and faster performance of biopsies, a broader spectrum of potential users (due to the decreased physical requirements for the biopsy), and reduced radiation exposure to patients and operators. The powered devices were especially useful when sampling hard bones and difficult-to-reach bone lesions. Shorter procedure time and diminished physician effort using the new system vastly improved operator ergonomics. The system also transformed previously inaccessible focal lesions into viable biopsy targets.*Berenson JR, Yellin O, Blumenstein B, Bojanower D, Croopnick J, Aboulafia D, et al. Using a powered bone marrow biopsy system results in shorter procedures, causes less residual pain to adult patients, and yields larger specimens. Diagnostic Pathology 2011;6:23 [Display omitted] Disclosures:Symington:Vidacare Corporation: Consultancy, Honoraria, Research Funding. Off Label Use: Not really off-label but could be interpreted as off-label. The study device has a specific indication to be used to biopsy bone marrow, bones of the iliac crest and vertebra and a general indication for bone lesions. Some specific bones other than iliac crest and vertebra were treated, studied and mentioned in this abstract, which could be interpreted as off-label use. Martinez:Vidacare Corporation: Research Funding. Cohen:Vidacare Corporation: Research Funding. Miller:Vidacare Corporation: Co-inventor of study device, Co-inventor of study device Patents & Royalties, Employment. Philbeck:Vidacare Corporation: Employment.

Procedural Care for Adult Bone Marrow Aspiration and Biopsy

This article presents a subset of findings on the experience of bone marrow aspiration and biopsy (BMAB) from an Australian hematology survivorship study. 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. 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. 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. The findings emphasized the importance of the provision of choice with regard to anesthesia or sedation as part of the procedural care for BMABs. 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.

AB1377 Clinical interest of bone marrow examination in rheumatology practice: An observationnal study of 257 patients

BackgroundExamination of the haematopoietic marrow is essential in the diagnosis of many disorders, principally malignant haematological diseases which can be encountered in rheumatology practice. Bone marrow aspiration (BMA) and biopsy...

Perceived Levels of Pain Associated with Bone Marrow Aspirates and Biopsies

Little is known about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB). To evaluate the effectiveness of several strategies aimed at reducing the pain score. We conducted a retrospective analysis of 258 consecutive adult patients who underwent BMAB via 6 different approaches, the first 5 of which were performed by one physician. Group A received local anesthesia with 1% lidocaine hydrochloride (5 mL) and a 5-minute wait time before the procedure; group B received local anesthesia with a double dose (10 mL) of lidocaine; group C received 5 mL of local anesthesia with a 10-minute wait; group D received 5 mL of local anesthesia plus a topical spray with ethyl chloride; group E received oral analgesia and anxiolysis 30 minutes before the procedure in addition to the group A dosage of lidocaine; and group F received the same anesthesia as did group A, but the BMAD was performed by a less experienced practitioner. On a 0 to 10 scale, the mean pain level among the 258 patients was 3.2 (standard deviation = 2.6). Rate of complications was low (<1%). Several strategies failed to improve the pain level, including the administration of a double dose of local anesthesia, waiting longer for the anesthesia effect, and the additional use of a topical anesthetic spray or oral analgesia and anxiolysis. Pain levels were not increased when the procedure was done by a less experienced practitioner. Younger age and female gender were associated with higher pain levels. Given that the average level of perceived pain during BMAB is low to moderate (approximately 3 on a 0-10 scale), the routine use of conscious sedation for this procedure may not be indicated. Several strategies aimed at reducing the pain level, including doubling the dose of anesthesia and using an oral prophylactic regimen of analgesia and anxiolysis, failed to improve pain scores.

Anxiety and pain during bone marrow aspiration and biopsy

BackgroundPreviously we found that pre-procedural nervousness and tension (translated into English as “anxiety”), assessed on a non-validated five-point scale, correlated with pain intensity of the various stages of bone marrow aspiration and biopsy (BMAB). The fewer the previous BMAB procedures the stronger the pain from a repeated procedure. The primary purpose of the present observational study is to evaluate the state of anxiety just before BMAB and to find out whether it affects the pain experiences during the various stages of the BMAB procedure. We also examined whether first-timers differ from patients with previous BMAB experience in the degree of anxiety and intensity of BMAB procedural pain. MethodsA total of 166 adult outpatients undergoing the BMAB from the Helsinki University Hospital were enrolled, 48 of them being first-timers. The level of anxiety was measured with State-Trait Anxiety Inventory (STAI) and the pain experiences associated with the various stages of the procedure were evaluated on the NRS-scale (Numeral Rating Scale 0–10) and using the Finnish pain vocabulary. BMAB was planned to be performed under lidocaine infiltration anaesthesia but, on request, patients were allowed to receive premedication with diazepam orally or alfentanil i.m. If, in spite of supplemental local anaesthetic the patient still felt pain from the sampling needle tip, i.m. alfentanil was administered. ResultsThere was a clear association between anxiety and pain during all stages of the procedure, except during biopsy. The NRS scores varied from 0 to 10 in all the various stages of BMAB. The first-timers did not differ from the more experienced patients with regard to pain experiences; only the pain felt during the local anaesthetic infiltration was milder (P=0.007) in first-timers than in the others. Procedural pain in those who were given analgesic or sedative premedication was similar (P>0.05) to that in the non-pre-medicated patients. The words characterizing the pain of the various stages belonged to a major extent (76–90%) to the sensory class of words. ConclusionPre-procedural anxiety had a major impact on the pain ratings. The first-timers and patients with previous experience of BMAB had a similar degree of pre-procedural anxiety, as well as of the intensity of procedural pain, except that infiltration of local anaesthetic was less painful in the first-timers. ImplicationsIdentification of anxious (fearful) patients prior to BMAB, and premedicating them individually may improve satisfaction in both patient and caregiver.

The Analgesic Effect of Magnetic Acupressure in Cancer Patients Undergoing Bone Marrow Aspiration and Biopsy: A Randomized, Blinded, Controlled Trial

Context Bone marrow aspiration and biopsy (BMAB) is a frequently performed and painful procedure. Objectives To evaluate the efficacy of magnetic acupressure in reducing pain in cancer patients undergoing BMAB. Methods Cancer patients without previous acupuncture or acupressure experience were stratified by the number of prior BMAB and randomized to having magnetic acupressure delivered to either the large intestine 4 (LI4) acupoint or a sham site. The primary study endpoint was the patient’s pain intensity rating during the procedure using a visual analogue scale (VAS). Results Seventy-seven eligible patients received magnetic acupressure: 37 were randomized to treatment at the LI4 site arm and 40 at the designated sham site arm. There was no significant difference between the median pain scores of patients treated at the LI4 site and the sham site ( P = 0.87). However, severe pain (VAS ≥ 7) was reported in only one patient (2.7%) treated at the LI4 site compared with eight patients (20%) at the sham site ( P = 0.03). No patients experienced significant magnetic acupressure-related toxicities. Conclusion Magnetic acupressure at the LI4 acupoint requires minimal training and expense and is well tolerated. Although its use did not significantly reduce median pain scores in patients undergoing BMAB, it does appear to reduce the proportion of patients with severe pain associated with this invasive procedure.

A Randomized Trial of Nature Scenery and Sounds Versus Urban Scenery and Sounds to Reduce Pain in Adults Undergoing Bone Marrow Aspirate and Biopsy

Bone marrow aspiration and biopsy (BMAB) is painful when performed with only local anesthetic. Our objective was to determine whether viewing nature scenes and listening to nature sounds can reduce pain during BMAB. This was a randomized, controlled clinical trial. Adult patients undergoing outpatient BMAB with only local anesthetic were assigned to use either a nature scene with accompanying nature sounds, city scene with city sounds, or standard care. The primary outcome was a visual analog scale (0-10) of pain. Prespecified secondary analyses included categorizing pain as mild and moderate to severe and using multiple logistic regression to adjust for potential confounding variables. One hundred and twenty (120) subjects were enrolled: 44 in the Nature arm, 39 in the City arm, and 37 in the Standard Care arm. The mean pain scores, which were the primary outcome, were not significantly different between the three arms. A higher proportion in the Standard Care arm had moderate-to-severe pain (pain rating ≥4) than in the Nature arm (78.4% versus 60.5%), though this was not statistically significant (p = 0.097). This difference was statistically significant after adjusting for differences in the operators who performed the procedures (odds ratio = 3.71, p = 0.02). We confirmed earlier findings showing that BMAB is poorly tolerated. While mean pain scores were not significantly different between the study arms, secondary analyses suggest that viewing a nature scene while listening to nature sounds is a safe, inexpensive method that may reduce pain during BMAB. This approach should be considered to alleviate pain during invasive procedures.

The Analgesic Effect of Magnetic Acupressure During Bone Marrow Aspiration and Biopsy Procedure in Cancer Patients: A Randomized, Blinded, Placebo Controlled Trial.

Abstract 71 Introduction:Bone marrow aspiration and biopsy (BMAB) is one of the most frequently performed and painful procedures in cancer patients. Magnetic acupressure has been used to reduce pain in patients in China. Our study was designed to study the efficacy of magnetic acupressure in reducing pain in cancer patients undergoing BMAB. Patients and Methods:Patients eligible for this IRB approved study had cancer, had a BMAB planned, and had not previously had acupuncture or acupressure. They were stratified by the number of prior BMAB they had experienced and randomly assigned to receive either magnetic acupressure at large intestine 4 point or at a non-acupuncture point (placebo) located in the proximal fourth interosseus space of the hand. All BMAB procedures were done by one operator (JS) and all acupressure was performed by one experienced operator (TB). All patients as well as the BMAB operator and data collector were blinded to treatment assignment. A visual analog score (VAS) was used to measure the patient's baseline pre-BMAB pain and the pain associated with the BMAB procedure. The acupressure operator was blinded to baseline pain scores and the pain associated with the BMAB by having the patient complete a form which was seen only by an independent data collector. The differences in VAS associated with the BMAB in the real versus placebo acupressure cohorts were compared to determine the analgesic efficacy of magnetic acupressure. Results:From 5/08 to 6/09, 77 cancer patients (47 male, 63 Caucasian, with a median age: 56 yrs, range: 21-80) undergoing BMAB at the Johns Hopkins Kimmel Sidney Comprehensive Cancer Center were enrolled in the study. Thirty-seven patients were randomized to the intervention arm and 40 to the control arm. Thirty-one patients (84%) in the intervention arm and 30 patients (75%) in the control arm had more than 1 BMAB prior to this study (p=0.34). Gender, analgesic or anxiolytic medications intake within 12 hours of BMAB and the pain score before BMAB were well balanced between two arms. The primary outcome was patient rated VAS pain score (0 to 10) during BMAB assessed after the procedure. Only one patient (2.7%) in the intervention arm experienced severe pain (VAS≥7) compared to 8 patients (20%) in the control arm (p=0.03, two- tailed Fisher's exact test). Using a multivariate logistic regression analysis to adjust for the number of BMAB patients had prior to this study, the odds of patients experiencing severe pain during BMAB procedure was 8.4 times (95% CI: 0.98-71.9) higher in the control arm versus the intervention arm. Forty-five percent of patients in each arm requested acupressure for future BMABs. No significant side effects or discomforts related to acupressure were reported by patients in either arm. Conclusions:These results suggest that magnetic acupressure significantly reduces the proportion of patients experiencing severe pain during BMAB. As acupressure requires minimal training and expense and was not associated with adverse events, it could be readily incorporated as a treatment option in this patient population. A larger, multi-centered, randomized, placebo controlled trial is planned to confirm these observations. Disclosures:No relevant conflicts of interest to declare.

Oral administration of analgesia and anxiolysis for pain associated with bone marrow biopsy

Medical literature provides only scarce data about the degree of pain experienced by patients undergoing a bone marrow aspiration and biopsy (BMAB), and little is known about the factors that can modify the perception of pain. In this study, we evaluated the effectiveness of a combination of analgesia and anxiolysis in reducing the pain score of patients undergoing BMAB. Eighty-four consecutive adult patients underwent BMAB after local anesthesia with 5 mL of lidocaine hydrochloride 1% aqueous solution in the left posterior superior iliac crest. Analgesia was obtained with acetaminophen 650 mg and oxycodone 10 mg, and anxiolysis was obtained with lorazepam 2 mg, all drugs given once orally 30 min before the procedure. We assessed the pain level with the Wong-Baker Faces Pain Rating Scale, which distinguishes six levels of pain, from 0 to 5. The 34 patients who received an oral administration of analgesia and anxiolysis reported pain at lower levels, i.e., in the range of 0-2, more frequently than the 50 patients who underwent BMAB without analgesia/anxiolysis (78% vs 64%, respectively). Among several predictors analyzed using a multivariate regression model, three were found to be associated with decreased pain level: the use of analgesia/anxiolysis, male sex, and increase in age (all with p values <0.05). Length of the extracted bone specimen, body mass index, and need of a spinal needle for anesthesia in obese patients did not predict for pain level. An oral administration of prophylactic regimen of analgesia and anxiolysis, at the above-mentioned doses, produced a statistically significant reduction of the perception of pain in patients undergoing BMAB, but its effect did not seem to provide a major and clinically significant reduction of pain level.

Abstract No. 370 EE: An Approach to Routine Bone Marrow Aspiration and Biopsy (BMAB) by the Interventional Radiologist

Bone Marrow aspiration and biopsy is a painful procedure traditionally performed at bedside by hematologist-oncologists. Needle placement is accomplished solely using palpable bony landmarks, and is thus dependent on patient body habitus. Marrow aspiration will typically cause intense pain. Herein we report a step-by-step image guided approach using IR techniques to both reliably obtain adequate specimens and minimize patient pain. For these reasons we have been asked to perform fluoroscopic guided BMAB, with sedation, in over one hundred patients.

Oral analgesia and anxiolysis for pain associated with bone marrow biopsy

20605 Background: Bone Marrow aspiration and biopsy (BMAB) is an invasive procedure commonly performed for the diagnosis of blood disorders and solid tumors. We evaluated the effectiveness of a combination of oral analgesics and minimal sedation (anxiolysis) in reducing the pain score of patients undergoing BMAB. Methods: Our study was retrospective and non-randomized. Seventy-eight consecutive adult patients (pts) underwent BMAB performed by a single physician in the left posterior superior iliac crest, using 5 mL of lidocaine HCl 1% solution (= 50 mg total dose) as local anesthesia in all pts. Thirty-three pts received preemptive analgesia with acetaminophen 650 mg and oxycodone 10 mg, and concomitant anxiolysis with lorazepam 2 mg. Drugs were given orally 30 minutes before the procedure. To assess the degree of pain, we used the Wong-Baker Faces Pain Rating Scale, which distinguishes 11 levels of pain, from 0 to 10. Results: The median pain level of the overall group was 3.5 (± 2.8). Among 45 pts treated with local anesthesia alone, median pain level was 4.0 (range 0–10, SD 2.9), and among 33 pts treated with additional analgesia and anxiolysis, median pain level was 2.9 (range 0–10, SD 2.3) (p>0.05). Statistical analysis did not find a correlation between pain score and several factors, including age, sex, weight, and length of specimen. No hemodynamic or respiratory complications were observed in the group receving analgesia and anxiolysis. Conclusions: The preemptive use of oral lorazepam, acetaminophen, and oxycodone, at the above doses, did not produce a clinically significant reduction of the perception of pain during BMAB. No significant financial relationships to disclose.

A Randomized Double-Blind Placebo-Controlled Study of Low-Dose Intravenous Lorazepam to Reduce Procedural Pain During Bone Marrow Aspiration and Biopsy

To evaluate the efficacy of intravenous lorazepam as premedication for bone marrow aspiration and biopsy (BMAB). Randomized, double-blind, placebo-controlled. One hundred and thirty-eight consenting patients planned to receive BMAB. Patients were randomly assigned to receive either intravenous lorazepam 1 mg or placebo just prior to BMAB. Tertiary referral center, inpatient setting. A questionnaire was used to determine the patient perception about the procedure and pain at baseline, which was completed just after the procedure, and the next day after the BMAB. Pain was rated using a 10-cm linear visual analog scale (VAS). The mean VAS scores measured during the BMAB examination were 6.0 for lorazepam vs 6.2 for placebo. Few adverse events were noted during intravenous lorazepam administration. The patients in the lorazepam group were more likely to accept the next BMAB (P = 0.044). Intravenous lorazepam was safe in patients undergoing BMAB and was more effective than placebo in enhancing cooperation during BMAB and willingness to undergo another procedure. However, use of lorazepam 1 mg provided no reduction in the pain associated with BMAB. Further studies should focus on providing appropriate analgesia for this potentially painful procedure.

Degree of Concordance between Peripheral Blood Leukemic Blast Count and Mid Induction Bone Marrow in Childhood Acute Lymphoblastic Leukemia.

While different Pediatric ALL study groups have used varying definitions of early response (BM vs. PB, prophase vs. day 7 vs. day 14), all agree that it provides critical prognostic information. Bone Marrow aspiration and biopsy (BMA/B) is an invasive procedure requiring sedation or anesthesia, and an early/mid induction specimen may be difficult to interpret even by experienced hematopathologists. In this study we attempted to determine if there was a concordance between peripheral blood blast (PBB) clearance and the findings of the day 14 BMA/B, and whether day 7 PBB count could reliably replace a mid induction BMA/B. Clinical data for newly diagnosed pediatric (<14 years) ALL patients between January 1999 and December 2001 were retrieved from our prospective database. Day 14 BMA/B slides were reviewed independently by two hematopathologist. For the total 165 patients, median age was 4 years, 53.9% were boys. Complete information was available for 151 of these patients and further analysis is based on this number. 124 (82.1%) were treated with 4 agents while the remainder received a 3-drug induction. 23 (18.5%) had positive PBB on D7, and 21 (13.9%) had >5% blasts in the D14 BMA/B. The D7 PBB count could positively and negatively predict the D14 BMA/B 71.9% and 89.4% of the times, respectively. In conclusion, when the D14 BMA/B is used as a measure of early response, an absence of D7 PBB can reliably predict a negative BM, however persistence of PBB does not necessarily predict a sub-optimal BM response to early therapy. Therefore, patients without PBB on D7 may not require BMA/B on D14, therefore avoiding an invasive procedure for this group of patients.