Bone Marrow Aspiration Procedure Research Articles

Hematological Parameters: Comparative Evaluation of Performance between Dxh 500 and XN-10 Equipments

Introduction The development of hematopoietic stem cell transplantation (HSCT) was an extremely important milestone for treating certain malignant and non-malignant hematological diseases. The HSCT process contemplates collecting hematopoietic progenitor cells (HPC) from the donor, conditioning chemotherapy, infusion of HPC, and engraftment. Mobilized peripheral blood is the most commonly used HPC source for HSCT due to its ease of obtaining through an apheresis procedure and high progenitor cell count yields compared to bone marrow source, which requires a bone marrow aspiration procedure, usually performed in a surgical center under general anesthesia, and requires the collection of higher volumes to reach the amount of HPC desired. The total nucleated cell count (TNC) corresponds to the sum of all nucleated cells in the sample and is used as a reference for the target dose for both sources of HPC. The TNC provides essential information on the quality of the sample obtained, since an infusion of insufficient number of cells affects the ability to reconstitute the recipient's hematopoietic system. An insufficient TNC can result in poor engraftment, leading to a slow recovery of blood cell production and increasing the risk of complications such as infections and bleeding. Determination of the number of nucleated cells in bone marrow and peripheral blood samples can be performed automatically by hematological analyzers such as the Beckman Coulter DxH 500 and Sysmex XN-10. This study aims to compare the performance of those equipments in determining hematological parameters in bone marrow and apheresis material. Materials and methods We compared the results of 40 HPC samples (20 bone marrow samples and 20 peripheral blood samples collected by apheresis) analyzed in the Sysmex XN-10 and Beckman Coulter DxH 500 equipments. All these specimens were analyzed without dilution and diluted 1:10. The evaluated parameters were: TNC, hematocrit, platelets, lymphocytes, monocytes, and granulocytes. Results The analysis of the results showed a positive Pearson correlation coefficient (above 0.9) between XN-10 and DxH 500 equipment for the evaluation of TNC in diluted samples obtained by apheresis (figure 1) and by bone marrow (figure 2). In pure samples obtained by apheresis the DxH 500 equipment showed non-linearity for TNC but revealed a positive correlation with the XN-10 when evaluating pure bone marrow samples (figure 2). On the other hand, XN-10 equipment showed linearity when correlating TCN between pure and diluted samples obtained by apheresis (figure 1) and bone marrow aspiration (figure 2). Hematocrit analysis in samples obtained by apheresis showed 90% and 100% of agreement for diluted samples between the equipment and for diluted versus pure samples, respectively, when using the cutoff value of 12%. Hematocrit validation using the Beckman Coulter equipment was impaired due to the sample's viscosity and limited linearity. Also, there was a satisfactory hematocrit correlation for pure bone marrow samples and comparing diluted versus pure bone marrow samples with both equipment. The results also showed a good correlation when analyzing the platelet count in pure and diluted samples (bone marrow and apheresis) with XN-10 or DxH 500, as well as comparing the diluted samples versus the pure samples. The use of differential count of nucleated cells (lymphocytes, monocytes and granulocytes) realized by the two evaluated devices was not approved for bone marrow or apheresis samples. Conclusion The determination of TNC, platelet and hematocrit counts using the Sysmex XN-10 equipment were satisfactory for both pure and diluted samples obtained by apheresis or bone marrow. For pure samples obtained by apheresis analyzed by DxH 500, we could observe absence of linearity for TNC and hematocrit. This situation could be explained by the high number of cells in this sample and the consequent high viscosity.

A comparative study of bone marrow aspiration and trephine biopsy: Experience in a tertiary care center

Abstract Introduction: A bone marrow examination involves the pathological analysis of samples from the bone marrow, which are obtained through bone marrow aspiration (BMA) and biopsy procedures. This examination is employed for the diagnosis of various hematological and nonhematological conditions. Both aspirate and biopsy samples are essential, offering a comprehensive bone marrow assessment. Objectives: In this study, we aim to compare the simultaneous evaluation of bone marrow aspirates and biopsies and to study diagnostic accuracy and concordance rate. Materials and Methods: This research was performed at the Department of Pathology, Shri Aurobindo Medical College, and Postgraduate Institute in Indore, Madhya Pradesh, India. The study was conducted from January 2019 to December 2019 and evaluated 200 patients. In 170 instances, bone marrow biopsy (BMB) and BMA procedures were conducted simultaneously, with 14 cases excluded due to issues like hemodilution or inadequate samples. Microscopic examinations were carried out on both aspirate slides and trephine biopsy sections, with the findings meticulously documented. Results: In the present research, the most prevalent clinical reason for performing a bone marrow examination was anemia (28.2%), closely followed by acute leukemias (21.9%). Among the 156 cases examined, BMA and biopsy led to a definitive diagnosis in 116 patients (74.3%), while biopsy alone diagnosed 27 cases (17.3%). Conclusion: While BMB continues to be the established benchmark for bone marrow analysis due to its heightened reliability and sensitivity, the combined use of both BMA and BMB enhances diagnostic yield significantly.

The Effect of Video Streaming With Virtual Reality on Anxiety and Pain During Bone Marrow Aspiration and Biopsy Procedure

BackgroundPain and anxiety are among the most common symptoms in patients undergoing invasive procedures. Increased pain levels tend to worsen anxiety, and anxiety often leads to more frequent or severe pain. AimsThe study was conducted to determine the efficacy of virtual reality goggles (VRG) on pain and anxiety during bone marrow aspiration and biopsy (BMAB) procedure. DesignA randomized controlled experimental study. SettingsThe outpatient unit of an adult hematology clinic of a tertiary care university hospital. Participants/SubjectsThe study was conducted in patients aged 18 years and older who underwent a BMAB procedure. Thirty-five patients in the experimental (VRG) group and 40 patients in the control group. MethodsPatient identification form, visual analogue scale (VAS), state and trait anxiety inventory (STAI), and VRG were used to collect the data. ResultsPostprocedural state anxiety mean scores were found to be statistically significantly higher in the control group than in the VRG group (p = .022). A statistically significant difference was found between groups in terms of procedure-related pain (p = .002). The postprocedural mean pain scores were found to be statistically significantly higher in the control group than in the VRG group (p < .001). A statistically significant but moderate positive correlation was found between the postprocedural pain and preprocedural state anxiety variable (r = 0.477). A statistically significant and strong positive correlation was found between the postprocedural pain and the postprocedural state anxiety variable (r = 0.657). A statistically significant but moderate positive relationship was found between preprocedural and postprocedural state anxiety variables (r = 0.519). ConclusionsWe determined that video streaming with VRG reduces pain and anxiety felt by adult patients during the BMAB procedure. VRG can be recommended to use in controlling pain and anxiety in patients undergoing a BMAB procedure.

A study of patient-reported pain during bone marrow aspiration and biopsy using local anesthesia alone compared with local anesthesia with intravenous midazolam coadministration at a tertiary academic hospital in South Africa.

During the bone marrow aspiration and biopsy (BMAB) procedure, patients report pain of widely variable intensity. There is limited literature on the factors associated with the pain. The use of local anesthesia (LA) only is still widespread although it does not abolish the pain. Midazolam is the most commonly used benzodiazepine for conscious sedation. Our center introduced universal midazolam sedation unless there is a contraindication to its use, 4 years ago. This study assessed the impact of the universal use of intravenous midazolam for BMAB compared to use of LA only. The factors associated with the pain of BMAB, were analyzed. A retrospective cross-sectional study was performed on adult patients who had a BMAB procedure from July 1, 2018 to March 30, 2019. A questionnaire incorporating a visual analog pain scale, was used for data collection. A total of 182 BMAB procedures were included in the study. Pain was reported in all procedures performed under LA and only in 29.1% of procedures performed with midazolam. Age, sex, race, level of education, body mass index (BMI), indication and diagnosis had no influence on pain. Patients who had previous BMAB experienced less pain. Experience of operator had a significant effect on pain. Midazolam dose showed a negative correlation with pain. LA only is not enough to abolish pain of BMAB. Midazolam conscious sedation used with LA reduces pain to acceptable levels. Patients with previous experience of BMAB under midazolam premedication reported less pain. Furthermore, the experience of operator reduced the pain significantly.

ROLE OF BONE MARROW ASPIRATION AND MARROW BIOPSY IN HAEMATOLOGICAL DISORDERS

Background: Bone marrow aspiration and bone marrow trephine biopsy are the two procedures done for the diagnosis of both hematological and non-hematological disorders and are complimentary to each other. To studyAim and Objective: the essential haematological evaluation of cases where bone marrow aspiration and bone marrow biopsy is indicated and to correlate the ndings of bone marrow aspiration and bone marrow biopsy in diagnosing various haematological disorders. The study wasMaterial and Methods: done on 86 patients in the age group 10-80 years. All had undergone simultaneous bone marrow aspiration and bone marrow biopsy procedures in the department of Clinical Haematology in a tertiary hospital. Standard methods were followed for bone marrow aspiration and biopsy procedure and for staining and evaluation of cellular aspirate. The Male to Female ratio of 1.4:1; 60% of patients belonged to 20-Observation &amp; Results: 60years group. Bone marrow and aspiration yield high diagnostic evaluation in megaloblastic anaemia (89.47%) against aspirates (10.52%) with p value of 0.00086 while in aplastc anaemia the aspirate evaluation shows better diagnostic yield (p value of 0.285). A combinationConclusion: of bone marrow aspiration and bone marrow biopsy give a better morphology of the cells and with good picture of the architecture and pattern of distribution of the cells. There is high diagnostic yield in evaluation of anemia.

PB2341: MIDAZOLAM AND LOCAL ANAESTHESIA CO-ADMINISTRATION GIVES BETTER PAIN CONTROL DURING THE BONE MARROW ASPIRATION AND BIOPSY PROCEDURE

Background: During the bone marrow aspiration and biopsy (BMAB) procedure, patients report pain of varying intensity ranging from complete absence of pain to severe pain. There is limited literature on the patient and procedure related factors associated with the pain. Furthermore, evidence-based guidelines on the best method of pain management during BMAB are lacking. The use of local anaesthesia(LA) only is still widespread although it does not abolish the pain of BMAB. Conscious sedation, other pharmacological agents and non-pharmacological interventions are used to a variable extent. Midazolam is the most commonly used benzodiazepine for conscious sedation and may be used in conjunction with local anaesthesia, other systemic pharmacological agents or as a single agent. Our centre introduced universal midazolam sedation unless there is a contraindication to its use, 4 years ago. Aims: To assess the impact of the universal use of intravenous midazolam premedication for the BMAB procedure compared to the use of local anaesthesia only and to determine the patient- and procedure-related factors associated with the patient-reported pain. Methods: A retrospective cross-sectional study was performed on adult patients who had a BMAB in a day procedure operating theatre over the period from 1st July 2018 to 30th March 2019. Patient demographics, the body mass index (BMI), indications, diagnosis, the number of times the patient had the BMAB procedure and the experience of the operator were documented. A numerical rating scale pain assessment tool and questionnaire were used in interviews conducted by the principal investigator. Further data were extracted from the National Health Laboratory Service laboratory information system, patients’ hospital files and the operating theatre records. Results: A total of 182 BMAB procedures were included in the study; 155 procedures performed with midazolam premedication and 27 performed using local anaesthesia only. Pain was reported in all procedures performed under local anaesthesia and only in 29.1% of procedures performed with midazolam administration. Our study showed no influence of age, sex, race, level of educations, indication, diagnosis, experience of the operator on pain. Patients who had previous BMAB experienced less pain. Midazolam dose showed negative correlation with pain. Summary/Conclusion: Local anaesthesia only is not enough to abolish pain of BMAB. Midazolam conscious sedation used with local anaesthesia consistently reduces the reported pain to acceptable levels. Patients with previous experience of BMAB under midazolam premedication reported less pain. The universal use of midazolam conscious sedation for BMAB under carefully controlled circumstances is strongly recommended.

Bone Marrow Aspiration and Biopsy in Critical Pediatric Patients: A Pathologist's Perspective.

Bone marrow aspiration (BMA) and bone marrow biopsy (BMB), are medical modalities for the detection of non-malignant diseases as well as hematological malignancies in children. BMA attained momentum in the past few years owing to the possibility of achieving hematopoietic stem cells. Liquid bone marrow is aspirated through posterior/anterior iliac crest, tibia, and vertebral spinous process during BMA procedure in children for assessment of morphology at the microscopic level while BMB allows for cytological evaluation of marrow. It is also used for molecular genetics, immune-phenotypic, cytogenetics, and other specialized examinations. Additionally, BMA is also helpful in the reconstruction of tissue. These procedures should be performed by a specialist who has knowledge about the indication, contradictions, and hazards of these procedures due to their invasive nature. Still, there are no transparent guidelines available especially in the case of BMA for children. The purpose of this overview article is to focus on the specific guidelines to carry out the BMA and BMB in children and the techniques as well as complications associated with the BMA and BMB.

Bone Marrow Procedure-Related Pain and Anxiety Improved with Propofol Protocol.

The assessment and management of pain and anxiety related to a bone marrow aspiration and biopsy (BM asp/bx) has received little attention, despite the frequent use of this procedure, and the availability of safe and rapid-acting IV anesthetics. We sought to quantify the severity of pain and anxiety associated with BM asp/bx and to test a protocol using anesthesiologist-administered IV Propofol to prevent procedure-related pain and anxiety. After signing an informed consent, 82 adult patients (pts) participated in the study. The first 45 pts received a BM asp/bx performed in the routine fashion (control cohort). The next 37 pts participated in the Pain-Free Bone Marrow Protocol and received IV Propofol during their procedure (intervention cohort). Each patient completed pre- and post- BM asp/bx surveys. Visual analogue scales (VAS) were used to measure pain and anxiety/concern. Analysis was performed on the total number of patients for whom complete data was available (Table 1 N=65; Table 2 N=70). A multi-departmental study team was necessary to support the Hematology practice change to incorporate the pain-free BM asp/bx option.Bone Marrow Procedure-related Pain and Anxiety: VAS score: Median ( IQ range)QuestionControl n=34Intervention n=31Rate the most severe level of pain40 (23–62)6 (1–17)*Rate your expected level of pain for the BM asp/bx47 (21–76)15 (2–26)*Rate your pre-BM asp/bx level of anxiety37 (11–76)29 (7–46)(VAS: 0=no pain/anxiety 100=most pain/anxiety) *ρ=0.001Concern for Future Bone Marrow Aspirate/BiopsyQuestionControl N=38Intervention N=32How concerned are you about needing a future BM asp/bx? ( VAS: 0= no concern 100=most concern)15; 0–450; 0–6*Given the choice, would you opt for a pain-free BM asp/bx in the future?Yes = 15; 44%Yes = 30; 97%**No = 14; 41%No = 0; 0%Unsure = 5;15%Unsure = 1;0%*ρ =0.008 **ρ =0.000 (Total Control Group v Total Intervention Group)Patients in the intervention cohort expected and experienced significantly less pain during their BM asp/bx. Patients in the intervention cohort had less concern regarding possible future BM asp/bx. A meaningful majority of patients would elect a pain-free BM asp/bx in the future if given the option.Our data demonstrate that BM asp/bx performed in the routine fashion is moderately painful and is associated with moderate pre-procedure anxiety. Our protocol using propofol anesthesia successfully reduced expected and experienced BM asp/bx-related pain for the current procedure and potential future procedures.In our sample, the majority of adult hematology patients would elect a pain-free bone marrow aspiration and biopsy procedure if given the option.

Music Intervention: Nonpharmacologic Method to Reduce Pain and Anxiety in Adult Patients Undergoing Bone Marrow Procedures.

Bone marrow procedures cause anxiety and pain in adult patients with cancer. Music is a safe, inexpensive, noninvasive intervention that is easy to implement and is well received by patients and providers. The purpose of this quality improvement project was to develop, implement, evaluate, and sustain a music protocol during bone marrow biopsy and aspiration procedures for adult patients with hematologic malignancies. In addition, this project sought to decrease pain, anxiety, heart rate, and blood pressure in patients undergoing bone marrow procedures. The project coordinator collected baseline data regarding toleration of bone marrow procedures and then implemented a music protocol during the procedures during a six-month intervention phase. Comparison variables included pain, anxiety, heart rate, blood pressure, and subjective impressions. The music protocol resulted in improved patient anxiety, decreased procedure time, and decreased medication use during bone marrow procedures. All patients who used the music intervention indicated they would use it again.

The Impact of Parental Pain-attending and Non-pain-attending Responses on Child Pain Behavior in the Context of Cancer-related Painful Procedures: The Moderating Role of Parental Self-oriented Distress.

Literature has demonstrated inconsistent findings regarding the impact of parental responses on child pain-related outcomes. Yet, research into factors that may underlie inconsistent findings regarding the variable impact of parental responses is lacking. The current study investigated the moderating role of parental distress in understanding the impact of parental pain-attending (eg, reassuring the child) and non-pain-attending (eg, distracting the child with humor) responses on child pain behavior (eg, crying). Children (18 y and younger) with leukemia, undergoing a lumbar puncture (LP) and/or bone marrow aspiration procedure, and one of their parents, were recruited from the Pediatric Ghent University Hospital. Parent-child interactions were videotaped after the procedure allowing coding of parental responses and child pain behavior. Parents self-reported on experienced personal distress. Participants consisted of 42 children (24 boys, 18 girls) with leukemia and one of their parents. Children were 0.6 to 15 (7.08±4.39) years old. Findings indicated a positive association between parental pain-attending and child pain behavior, but only when parents reported high levels of distress (β=0.56, P=0.001). No association was observed for parents reporting low levels of distress (β=-0.09, ns). Parental non-pain-attending responses contributed to lower child pain behavior (β=-0.24, P=0.045), independently of parental distress (β=-0.07, ns). The current findings point to the moderating role of parental distress in understanding the impact of parental responses on child pain behavior and highlight the importance of interventions targeting parental emotion regulation to promote optimal child pain outcomes.

Comparison of the Analgesic and Sedative Effects of Midazolam-Ketamine and Propofol-Sufentanil Combinations in Painful Procedures of Children with Haematologic Malignancy.

ObjectiveBone marrow aspiration and lumbar puncture play essential roles in the diagnosis and treatment of haematological disorders. These repeated invasive procedures lead to considerable pain and stress in children, which is emotionally stressful for their parents. This study aimed to compare the effectiveness and outcomes of two combinations of midazolam-ketamine (MK) and propofol-sufentanil (PS) in painful procedures of children with haematologic malignancy.MethodsIn this prospective, randomised, double-blind clinical trial, we enrolled 80 eligible patients with haematologic malignancy aged 2–14 years. We randomly allocated them to the MK and PS groups. We recorded and compared the level of sedation, pain severity, hemodynamic indices, the onset of effect, duration of recovery and complications during and after procedure in the two groups. We analysed the data using the SPSS software. We used Mann–Whitney U, independent t-test, chi-square and Fisher’s exact tests to compare continuous and categorical variables.ResultsFrom initially enrolled patients, 68 patients completed the study (38 in PS and 30 in MK group). The levels of sedation and the mean score of pain intensity were significantly lower in the MK group than those in the PS group (p<0.05). Movements and the needs to repeat the dose were significantly lower in the MK group than those in the PS group (p<0.05).ConclusionDuring bone marrow aspiration and lumbar puncture procedures in children with haematologic malignancy, the findings of this trial suggest that MK combination therapy provides better sedation and analgesia than PS.

Hypoxic Preconditioning Effects of Bone Marrow-derived Culture Mesenchymal Stem Cells on CD31+ Expression, Vascular Endothelial Growth Factors-a (VEGF-A) and Stromal-derived Sactors-1 Alpha (SDF-1α)

Increasing the ability of survival stem cells can be determined by assessing the state of hypoxic preconditioning (HPC) in stimulated cells. The assessment is carried out through bone marrow-derived stem (BMSCs) cultures obtained from the femoral bone marrow aspiration procedure (Wismar Rat). This study aimed to prove the hypothesis that there is CD31+ expression on HPC cultures; also, the concentration of VEGF-A and SDF-1α were higher in HPC than control. This research is designed as a laboratory experiment for a period of three months. Male Wistar rat (n = 16) was divided into 2 groups: P0 controls (21% [O2]) and P1 treatments (1% [O2]). Each sample was run into eight repetitions and observed for 48 hours. The stages in this study include isolation and culture of BMSCs, identification of phenotypic BMSCs based on the expression of cell-surface markers (CD105+, CD34−) and hypoxic exposure. After that, it was observed that the potential of angiogenesis in samples was based on CD31+ expression, the paracrine activity of vascular endothelial growth factor-A (VEGF-A) and stromal-derived factor-1 Alpha (SDF-1α). The results showed that there is no CD31+ expression on P1. A of VEGF-A and SDF-1⌑ were higher in P1 than P0.

Localization and characterization of human palatal periosteum stem cells in serum-free, xeno-free medium for clinical use.

Harvesting, expanding, and re-implanting osteogenic mesenchymal stem cells (MSCs) avoids the donor-site morbidity associated with autogenous grafting from bone marrow. Mesenchymal stem cells sourced from the palatal periosteum could be an alternative to isolation of such cells using bone marrow aspiration procedures. For safe use in human therapy, MSCs should be expanded in culture medium that is free from animal or human-derived serum. In this study we localized, quantified, and characterized MSCs from palatal periosteum cultured in serum-free, xeno-free Essential 8 medium. A portion of the palatal periosteum tissues from three patients were dual-immunostained with MSC-specific markers (CD105, CD90, and CD73). The remaining portions were expanded in culture, and the isolated MSCs were analyzed using flow cytometry and tri-lineage differentiation. Palatal periosteum sections were found to contain CD105-, CD90-, and CD73-positive cells. The cultured cells were 73.0±6.7% (mean±SD) positive for all three MSC-specific markers and were without hematopoietic stem cell (HSC) markers 0.5±0.3% (mean±SD). Tri-lineage differentiation analysis confirmed that palatal periosteum cells could become adipoblasts, chondroblasts, and osteoblasts. The results demonstrate that palatal-derived MSCs could be detected insitu within small niches, and when expanded in serum-free, xeno-free medium represent a viable source of MSCs for clinical use.

Task Sharing and Shifting to Provide Pathology Diagnostic Services: The Kenya Fine-Needle Aspiration Biopsy Cytology and Bone Marrow Aspiration and Trephine Biopsy Training Program.

PurposeFine-needle aspiration biopsy (FNAB) cytology is a simple, inexpensive, and accurate diagnostic test for benign, infectious, and malignant lesions of the breast, thyroid, lymph nodes, and other organs. Similarly, bone marrow aspiration and trephine (BMAT) biopsy procedures are relatively simple and inexpensive techniques that are important for diagnosing and monitoring many hematologic diseases including leukemias and lymphomas. However, the scarcity of pathologists in Kenya limits patient access to these simple diagnostic tests. We describe a task sharing and shifting program that sought to improve the provision of FNABs and BMAT biopsies in tertiary public hospitals in Kenya.MethodsBetween January 2016 and February 2017, we trained pathologists, pathology residents, and technologists from the University of Nairobi and Aga Khan University Hospital, Nairobi, in FNAB and BMAT biopsies, who in turn trained pathologists, medical officers (MO), clinical officers (CO), and technologists at five tertiary public hospitals. The program involved curriculum development, training workshops, the establishment of new and strengthening existing FNAB and BMAT biopsy clinics, interim site visits, audits, and stakeholder workshops.ResultsFifty-one medical personnel at the tertiary hospitals were trained. The FNAB numbers increased by 41% to 1,681, with 139 malignant diagnoses (7.1%). BMAT biopsy numbers increased by 268% to 140, with 34 malignant cases. Between 60% and 100% of the FNAB and BMAT biopsy procedures were performed by MO and CO over the project period. One new FNAB and two new BMAT biopsy clinics were established.ConclusionThis project demonstrates a successful model of task sharing and shifting from specialist pathologists to MO and CO that improved access to important FNAB and BMAT biopsy services in a low-resource setting.

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

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. 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. 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. This mobile application possibly had effectiveness in routine use for reducing anxiety and increasing patients' cooperation in bone marrow aspiration procedures.

Safety of Sedation for Patients Undergoing Bone Marrow Biopsy and Aspiration While Febrile.

ObjectiveTo determine the risks and outcomes of providing sedation to febrile patients scheduled for bone marrow aspiration or biopsy procedures.Patients and MethodsDuring the 4-year period from January 1, 2013, through December 31, 2016, data from the periprocedural courses of 12,134 consecutive patients in an outpatient procedure center at a large tertiary medical center were collected retrospectively and analyzed to determine whether febrile patients undergoing bone marrow aspiration and/or biopsy with propofol sedation present a unique patient safety risk.ResultsEighty-four patients (0.7%) had preprocedural temperatures of greater than or equal to 38.3°C. Of these, 6 required unanticipated hospital admission for sustained hypoxemia and symptoms suggesting pneumonia. All 6 of these patients had a productive cough and room air oxygen saturations of less than 92% before their procedures. These 6 patients were diagnosed during their hospitalizations with either confirmed or presumed community-acquired pneumonia. All recovered without pulmonary sequelae. Only 2 of the other 78 febrile patients required unanticipated hospital admission, for both general weakness and dehydration.ConclusionOur findings suggest that patients who are febrile and who also have productive coughs and oxyhemoglobin saturations by pulse oximetry of less than 92% would be best served with outpatient evaluation of their pulmonary symptoms before undergoing their elective bone marrow aspiration procedures. In contrast, febrile patients without pulmonary symptoms fare well.

A Comparison of Resource Utilization, Cost and Mortality in Children Treated for Severe Aplastic Anemia

BACKGROUNDSevere Aplastic Anemia (SAA) in childhood is fatal if untreated and has a reported incidence of 2.34/ million. With the use of treatment guidelines, outcomes have improved over the years. In the United States (US), Hematopoietic Stem Cell Transplantation (HSCT) is preferentially utilized in young patients with an HLA matched sibling donor, whereas Immunosuppressive Therapy (IST) comprised of Horse Antithymocyte Globulin (ATG) and Cyclosporine (CSA) is utilized in those that lack one. Upon failure of IST, the latter typically undergo unrelated donor HSCT. At this time, national trends in resource utilization and the financial impact of this diagnosis and its treatment are unknown. Our objective was to ascertain whether treatment paradigms could be identified within a national database and compare cost and outcomes within Childrens hospitals across the US within the context of SAA. METHODSWe utilized the Pediatric Hospital Information System (PHIS) database to perform a retrospective cohort study of patients admitted to Childrens Hospital Association Hospitals (36 of 48 were free-standing) to compare length of stay (LOS), billed charges and inpatient mortality in patients with SAA who received IST compared to SCT. This database was queried to identify all patients ≤21 years of age who were first admitted between 2010 to 2014 with a diagnosis of SAA, as defined by ICD 9 codes (284. 0, 284.1, 284.9, 284.89, 284.12). Within this data set we identified patients with a Bone Marrow Aspiration (BMA) procedure code (41.3, 41.31) billed within 6 months of the code for SAA and use of transplant procedure codes (41.0, 41.00, 41.02, 41.03, 41.05, 06, and 08) drug codes for agents typically utilized as IST (164130, 164131, and 167115) or conditioning for HSCT (171103, 171125, 164130, and 164131). Patients were excluded for constitutional bone marrow failure, cancer and other diagnoses. Those meeting criteria were summarized using descriptive statistics and comparisons among groups were assessed using non-parametric methods. Cost, number of admissions, LOS, intensive care unit (ICU) utilization, inpatient mortality and comorbidities were analyzed with various charge codes that were adjusted by the CMS wage/price index for the hospital’s location. The data set was validated by internal chart review. RESULTSA total of 446 patients (57% male, 43% female, median age at diagnosis 10 years) met study criteria. 282(63%) patients were treated with IST alone, 98(22.3%) patients who underwent SCT without IST and 66(14.7%) patients received both forms of therapy. The overall mortality rate for the cohort was 8.6%. The likelihood of death correlated with the presence of Graft versus Host Disease (GVHD) and LOS > 100 days in the group that underwent SCT.A total of 1631 admissions were evaluated with a total LOS of 24,369 days. Median LOS for the cohort was 36 days but significantly lower for those that underwent IST only (p<0.0001). Average LOS was highest in the group that had both therapies. ICU utilization was significantly higher in the transplant group that failed IST (P=0.0058). Overall inpatient cost of care across the cohort was $ 389,743,175. However cumulative adjusted charges were significantly different across the groups: a median of $244,513 for patients treated with IST, $793,009 for those who underwent SCT alone and $1,365,051 for those that had both forms of therapy (p <0.0001). The highest costs in each group correlated with pharmacy (37%), nursing and room/operating room (32%) charge codes. 84% of patients included originated from areas with urban zip codes without a significant difference in the payer mix (private or public insurance) for urban or rural patients. CONCLUSIONSThis is the first reported evaluation of inpatient resource utilization, mortality and costs in children treated for SAA in the US. While the overall cost of care for these patients is high, it is >3 fold higher for patients undergoing HSCT and over 6 times higher if HSCT is utilized upon failure of IST. With further comparative analyses, stakeholders can better understand where excess variation in care and cost occurs and define best practices required to further improve outcomes at lower cost. DisclosuresNo relevant conflicts of interest to declare.

Quantification of IGF-1 Receptor May Be Useful in Diagnosing Polycythemia Vera-Suggestion to Be Added to Be One of the Minor Criterion.

Endogenous erythroid colony (EEC) formation is one of the minor criteria for diagnosing polycythemia vera (PV) according to 2008 WHO diagnostic criteria. But EEC requires bone marrow aspiration and sophisticated laboratory procedures; therefore, practically it is rarely used to diagnose PV. Insulin-like growth factor 1 receptor (IGF-1R) was found to be constitutively phosphorylated and was responsible for the EEC formation in PV; therefore, we measured IGF-1R levels in the peripheral blood of 26 PV patients and compared them with those of 33 patients with secondary polycythemia and 29 normal controls. Among the PV patients, 16 were treated with only phlebotomy, 9 received hydroxyurea, and 1 was treated with ruxolinitinib. We found that PV patients treated with only phlebotomy had significantly higher IGF-1R levels than did those PV patients treated with hydroxyurea or ruxolinitinib. None of the secondary PV patients or normal controls had elevated IGR-1R levels, while 14 of 16 (87%) PV patients had significantly elevated IGF-1R levels. The new 2016 WHO has eliminated EEC as a minor criterion for diagnosing PV, but there are still some cases that cannot be definitively diagnosed by the current criteria. Therefore, we suggest that quantifying the IGF-1R level in peripheral blood by flow cytometry to replace EEC as the minor criterion for diagnosing PV.

Vortex-dislodged cells from bone marrow trephine biopsy yield satisfactory results for flow cytometric immunophenotyping.

A good bone marrow (BM) sample is essential in evaluating many hematologic disorders. An unsuccessful BM aspiration (BMA) procedure precludes a successful flow cytometric immunophenotyping (FCI) in most hematologic malignancies. Apart from FCI, most ancillary diagnostic techniques in hematology are less informative. We describe the feasibility of FCI in vortex-dislodged cell preparation obtained from unfixed trephine biopsy (TB) specimens. In pancytopenic patients and dry tap cases, routine diagnostic BMA and TB samples were complemented by additional trephine biopsies. These supplementary cores were immediately transferred into sterile tubes filled with phosphate-buffered saline, vortexed, and centrifuged. The cell pellet obtained was used for flow cytometric immunophenotyping. Of 7955 BMAs performed in 42 months, 34 dry tap cases were eligible for the study. Vortexing rendered a cell pellet in 94% of the cases (32 of 34), and FCI rendered a rapid diagnosis in 100% of the cases (32 of 32) where cell pellets were available. We describe an efficient procedure which could be effectively utilized in resource-limited centers and reduce the frequency of repeat BMA procedures.

Anxiolytic Effect of Citrus aurantium L. on Patients with Chronic Myeloid Leukemia.

The bone marrow aspiration procedure is used in hematological diseases and consists of a painful, invasive procedure causing anxiety-associated symptoms. The present study assessed the effect of Citrus aurantium L. essential oil on the treatment of anxiety, in the moment that precedes the collection of medullary material in patients with chronic myeloid leukemia (CML). Volunteers from both sexes were divided into groups receiving either the C. aurantium essential oil through inhalation, diazepam (10 mg), or the placebo. The evaluation was performed through psychometric scales [State-Trait Anxiety Inventory (STAI)] and physiological measurements (blood pressure and cardiac and respiratory frequency). Inhalation of C. aurantium was associated with a decrease in the STAI-S scores, suggesting an anxiolytic effect. In support of these results, a change in all the physiological measurements was observed in the group exposed to C. aurantium. In the diazepam group, only the diastolic pressure decreased, and no effect was observed in the placebo group. Therefore, the results showed that C. aurantium exhibits an anxiolytic effect and reduces the signs and symptoms associated with anxiety in patients with CML.