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

Measurable residual disease in peripheral blood in myeloma: dream or reality

PURPOSE OF REVIEW

Therapeutic advancements in multiple myeloma have led to increasingly deeper and more durable responses, creating a need for highly sensitive and applicable techniques for measurable residual disease (MRD) assessment. Bone marrow assays can deeply assess for MRD, but it is not conducive to performing frequent and dynamic evaluations, which may be needed for MRD-adapted treatment approaches. Recently, numerous techniques for MRD assessment in peripheral blood have come under investigation, and their integration into routine clinical practice is eagerly anticipated.

RECENT FINDINGS

The identification of circulating tumor cells (CTCs), evaluation of cell-free DNA, and measuring monoclonal protein concentration with mass spectrometry are promising research areas for assessing myeloma in peripheral blood. CTCs assessment and cell-free DNA may carry prognostic significance, but they lack the sensitivity of bone marrow-based techniques. Mass spectrometry has already been implemented in clinical practice in certain centers, but its full potential has yet to be fully realized. This review focuses on recent developments in these fields, emphasizing the potential future roles of these assessments.

SUMMARY

MRD assessment in peripheral blood is still in the development stage but holds promise for not only complementing bone marrow based evaluations but also potential for improving sensitivity.

Serum Erythropoietin level in anemia of elderly with unclear etiology

Anemia is a common condition, but its causes are often unclear, especially in elderly adults. Erythropoietin (EPO) levels are known to be elevated in myelodysplastic syndrome and hematologic malignancies, but decreased in chronic benign anemia. This study aimed to investigate whether EPO levels could be used to identify underlying bone marrow diseases including malignancies, among elderly anemic patients with unclear etiology. This single centered retrospective study included patients presented with isolated anemia and had their EPO levels measured at their first visit. Patients were divided into two groups: bone marrow disease and benign etiologic anemia, based on observation and bone marrow test results. Out of 1180 patients reviewed, 81 patients with anemia of unclear etiology were identified, including 67 with benign anemia and 14 with bone marrow disease. Statistically significant difference in EPO levels between these two groups (P < 0.001) were observed. The receiver operating characteristic curve analysis showed that an EPO cut-off value of 36.4 mU/mL had a sensitivity and specificity of 92.8% and 94.0% for detecting underlying bone marrow disease, respectively. We suggest measuring serum EPO levels can aid in the early detection of benign anemia from bone marrow disease, including malignancies, with high sensitivity and specificity.

Peripheral intravenous cannulation: reducing pain and local complications

Caring for patients with peripheral intravenous cannulas/catheters (PIVCs) is an important part of the nurse's role and insertion of PIVCs has traditionally been a post-registration nursing skill. With the introduction of the Nursing and Midwifery Council Standards of Proficiency for Registered Nurses in 2018, insertion of PIVCs is to be incorporated in pre-registration nursing programmes for all four fields of nursing practice. Although IV cannulation is a commonly performed clinical procedure, it is associated with significant risks and complications, which can cause pain for patients. This article outlines the factors that can cause pain for adult patients requiring a PIVC and recommends that the use of local anaesthetics be more widely considered when inserting a cannula. The identification, prevention and clinical management of commonly occurring painful local complications that can arise post-PIVC insertion are also discussed.

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.

The fear of needles: A systematic review and meta-analysis

AIMS

The aim of this study was to evaluate the prevalence of needle fear and summarize the characteristics of individuals who exhibit this fear.

BACKGROUND

Injections are among the most common medical procedures, yet fear of needles can result in avoidance of preventive measures and treatment.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE (1966-2017), Embase (1947-2017), PsycINFO (1967-2017), and CINAHL (1961-2017) were searched, with no restrictions by age, gender, race, language, or country.

REVIEW METHODS

The prevalence of needle fear was calculated and restricted maximum likelihood random effects models were used for meta-analysis and meta-regression.

RESULTS

The search yielded 119 original research articles which are included in this review, of which 35 contained sufficient information for meta-analysis. The majority of children exhibited needle fear, while prevalence estimates for needle fear ranged from 20-50% in adolescents and 20-30% in young adults. In general, needle fear decreased with increasing age. Both needle fear and needle phobia were more prevalent in females than males. Avoidance of influenza vaccination because of needle fear occurred in 16% of adult patients, 27% of hospital employees, 18% of workers at long-term care facilities, and 8% of healthcare workers at hospitals. Needle fear was common when undergoing venipuncture, blood donation, and in those with chronic conditions requiring injection.

CONCLUSIONS

Fear of needles is common in patients requiring preventive care and in those undergoing treatment. Greater attention should be directed to interventions which alleviate fear in high-risk groups.

Palliative care during and following allogeneic hematopoietic stem cell transplantation

PURPOSE OF REVIEW

The purpose of this review is to synthesize recent literature regarding the provision of palliative care to patients during and following allogeneic hematopoietic stem cell transplantation (HSCT), highlighting factors which mediate impairments in health-related quality of life in this patient population, and the intervention approaches and models of care delivery that clinicians can consider to address unmet needs for palliative care and to strengthen patient and family resiliency.

RECENT FINDINGS

Provision of palliative care simultaneous with the delivery of treatment directed at the underlying malignancy has emerged as a recommended practice for patients with advanced cancer and high-symptom burden, and a recent randomized trial demonstrates the effectiveness of early palliative care in reducing some of the symptom burden and mood disturbances associated with HSCT. Although more research is needed, there is an expanding body of research-tested interventions to ameliorate the physical and psychological morbidity of HSCT across the transplant trajectory.

SUMMARY

Palliative care interventions delivered by an interdisciplinary team that includes transplant clinicians and palliative care across the HSCT trajectory can alleviate physical and psychological morbidity, thereby improving the patient and family experience of HSCT.

Bone marrow aspirations in oncological patients: experience from an in-house standard in paediatrics

BACKGROUND

Nearly all paediatric patients require deep sedation when undergoing bone marrow aspiration (BMA). We analyzed the data from our protocols documented in a standardised procedure for bone marrow puncture over a period of 2 years.

METHODS

Our standard included the documentation of personal data as well as vital parameters. In addition, we documented all medications administered, potential complications and required intervention measures, as necessary.

RESULTS

A total of 107 protocols were available for the evaluation. Our standard covered the usage of midazolam and S‑ketamine and resulted in complications in just 9 patients, which could be remedied using simple measures. For both active substances, the dosage necessary to reach sufficient deep analgosedation was significantly higher for patients under 24 months of age.

CONCLUSIONS

Our standard for BMA provides a practical and feasible procedure. In addition to good examination conditions, our standard also helps ensure the safety of our patients.

The effect of acupressure on pain, anxiety, and the physiological indexes of patients with cancer undergoing bone marrow biopsy

OBJECTIVES

This study aimed to determine the effect of acupressure on pain intensity, anxiety, and physiological indexes of patients with cancer undergoing bone marrow biopsy and aspiration.

METHODS

The study was designed as a randomized, double-blinded, controlled trial. Ninety samples was selected using the convenience sampling method, then for allocation groups random block sampling was used (30 for each group). The three groups were similar by age and gender. LI4 and HT7 (Shen Men) acupressure points were examined for the intervention. Sham pressure was used in the placebo group while no intervention was applied in the control group.

RESULTS

The results showed that the lowest average anxiety score (1.5 ± 0.5; P = 0.01) and the lowest average pain score (4.9 ± 0.8) after the intervention were related to the acupressure method (P = 0.001).

CONCLUSION

Cost effectiveness and short-term simple education make acupressure method useful in clinical settings for different illnesses.

Single- Versus Multiple-Site Harvesting Techniques for Bone Marrow Concentrate: Evaluation of Aspirate Quality and Pain

BACKGROUND

Bone marrow concentrate (BMC) is growing in popularity as an alternative treatment option in orthopaedics. The regenerative capacity of BMC has been linked to the number of mesenchymal stem cells (MSCs) present in the graft at the time of its clinical application. MSC counts in bone marrow aspirate (BMA) are affected by harvest technique, but controversy exists over which aspiration method optimizes cellular yield while taking patient comfort and risk into consideration.

PURPOSE

To compare a single- versus multiple-site bone marrow aspiration technique to determine which would generate a sufficient volume of high-quality BMA for concentration into a BMC graft. The level of pain experienced by the patient was monitored, since patient comfort should be included in the determination of a safe and effective aspiration technique.

STUDY DESIGN

Controlled laboratory study and cohort study; Level of evidence, 2.

METHODS

BMC samples from 6 patients were sent to an outside source for laboratory analysis. All 6 participants underwent bilateral bone marrow aspiration. Each patient received both techniques at the posterior iliac crest: one side underwent a multiple-site aspiration technique, and the contralateral side underwent a single-site technique with needle redirection. BMA and BMC samples were analyzed for concentrations white blood cells, total nucleated cells, red blood cells, neutrophils, and hematopoietic stem cells. One BMC sample was cultured, and MSC analysis was performed via flow cytometry. All patients underwent monitoring of pain scores during and after the procedure through a visual analog pain scale at 24 hours, 72 hours, and 7 days after BMA.

RESULTS

No significant difference was found between the cell ratios of the single- and multiple-site groups. Both aspiration techniques were found to provide ample colony-forming units without a marked difference in appearance. Additionally, no significant difference was found between groups with regard to MSC numbers. Pain during and 24 hours after the procedure was significantly greater with the multiple-site method than the single-insertion method.

CONCLUSION

The single-insertion method produced final cellular concentrations and culture results that were not significantly different from those of a multiple-insertion method. Additionally, the single-insertion site technique was significantly less painful to the patient at the time of the procedure as well as 24 hours after aspiration.

CLINICAL RELEVANCE

The results of this study indicated that a high-quality bone marrow aspirate is possible with a single-stick aspiration method.

Bone Marrow Aspiration: A Randomized Controlled Trial Assessing the Quality of Bone Marrow Specimens Using Slow and Rapid Aspiration Techniques and Evaluating Pain Intensity

BACKGROUND/AIMS

Bone marrow aspiration (BMA) is an essential procedure in the examination of hematological disorders, but there is limited evidence as to whether the aspiration rate affects specimen quality. We aimed to assess the specimen quality and pain intensity using slow (S-technique) or rapid (R-technique) aspiration.

METHODS

This was a single-center, prospective, randomized patient- and assessor-blinded study of 482 patients scheduled for BMA. Specimen quality was evaluated by grading bone marrow (BM) cellularity and counting the number of marrow particles. Pain was assessed using a visual analog scale (VAS).

RESULTS

We found a significant difference between the 2 groups with regard to the quality of specimens. For cellularity, the odds ratio (OR) for having a poor quality aspirate using the S-technique versus the R-technique was 3.05 [confidence interval (CI) 1.79-5.31]. For BM particles, the quality of specimens with the S-technique proved to be poor compared with the R-technique (OR 2.52; CI 1.51-4.28). We found a statistically significant difference of 1 VAS point (p < 0.001) of the median pain intensity in favor of the S-technique.

CONCLUSION

Even though the pain intensity is significantly higher with the R-technique, the median difference is relatively small. We propose that the R-technique is preferable to the S-technique due to better specimen quality.

Trained clinical nurse specialists proficiently obtain bone marrow aspirates and trephine biopsies in a nearly painless procedure--a prospective evaluation study

Patients often experience bone marrow examinations (BMEs) as frightening and painful. Varying operators and uncertainty about who will perform the BME worsen their anxiety. In our study, clinical nurse specialists (CNSs) were trained to perform BMEs to ensure continuity and to test the feasibility, patient satisfaction, and biopsy quality. This exploratory evaluation assessed 574 BMEs at our tertiary center between January 2012 and February 2013, 398 BMEs performed by CNS and 176 by physicians. Our aims were to determine whether BMEs by CNS yield results similar to those of physicians, analyzing (1) patient satisfaction with the BME (a) consent and (b) performance, (2) induced pain, and (3) quality of aspirates and length of trephine biopsies. When performed by CNS, 100 % of the patients were satisfied with the consent procedure and 99 % with the BME performance (physicians 99 and 91 %, respectively). The median pain score was low when both CNS and physicians performed the BME, with no or only mild pain in 92 and 76 % of patients, respectively. Bone marrow (BM) aspirates by CNS and physicians were assessed as technically evaluable in ~70 %; moreover, the median length of trephine biopsies was similar when performed by CNS or physicians with 12 and 13 mm, respectively. In conclusion, BMEs conducted by motivated CNS and within a structured training program are feasible and yield equal outcomes compared to physicians. The use of adequate pain management during BMEs by trained and experienced operators results in an extremely rare use of sedatives, low pain scores, and high patient satisfaction.

Patient perception of pain versus observed pain behavior during a standardized electrodiagnostic test

INTRODUCTION

Clinicians often assume that observations of pain behavior are adequate for assessment of patient pain perception during procedures. This has not been tested during a standardized electrodiagnostic experience.

METHODS

During a prospective trial including extensive, standardized electrodiagnostic testing on persons with lumbar stenosis, vascular claudication, and asymptomatic volunteers, the subjects and an observer rated levels of pain.

RESULTS

In 60 subjects, observers significantly under-rated pain (Visual Analog Scale 3.17 ± 2.23 vs. 4.38 ± 2.01, t = -4.577, df = 59, P < 0.001). Perceived pain during testing related to bodily pain as measured by the visual analog, McGill, Pain Disability, and Quebec scales, but not age, duration of symptoms, Tampa kinesiphobia, Center for Epidemiological Studies Depression scale, or SF-36 health quality of life.

CONCLUSIONS

Persons with worse pain syndromes may perceive more pain during testing than others. Clinicians and researchers should understand that patients may have more pain than they recognize.

How accurate are we at assessing others' well-being? The example of welfare assessment in horses

Healthcare practitioners such as physicians or nurses often underestimate patients’ well-being impairment (e.g., pain, anxiety) which may lead to undesirable consequences on treatment decisions. Lack of recognition/identification of signals and over-exposure are two reasons invoked, but a combination of factors may be involved. Studying human decoding of animals’ expressions of emotions showed that “identification” to the subject was necessary to decode the other’s internal state. In the present study we wanted to compare caretakers’ reports on the prevalence of stereotypic or abnormal repetitive behaviors, to ethological observations performed by an experienced observer on the same horses in order to test the impact of these different factors. On the first hand, a questionnaire was given hand to hand to the caretakers. On the other hand, the experienced observer spent 18 h observing the horses in each stable. Here we show that caretakers strongly underestimate horses’ expressions of well-being impairment. The caretakers who had a strong concern about their horses’ well-being were also those who reported the more accurately SB/ARB’s prevalence, showing that “identification” to the subject is a primary factor of bad-being signal’s detection. Over-exposure also appeared to be involved as no SB/ARB was reported in stables where most of the horses were performing these abnormal behaviors. Being surrounded by a large population of individuals expressing clear signals of bad-being may change professionals’ perceptions of what are behaviors or expressions of well being. These findings are of primary importance as (1) they illustrate the interest of using human-animal relationships to evaluate humans’ abilities to decode others’ states; (2) they put limitations on questionnaire-based studies of welfare.

A powered bone marrow biopsy system versus manual methods: a systematic review and meta-analysis of randomised trials

A significant number of bone marrow biopsies are performed annually. Outcomes of patient pain and sample size of biopsy are important issues as perception of patient pain is underestimated by clinicians and sample size assists in accurate diagnosis. Manual extraction of marrow biopsy is the main method used. Recently a powered system has been introduced. The objectives of this systematic review and meta-analysis were to determine if the powered system reduces patient pain and improves sample capture. A PubMed and Cochrane search for randomised controlled trials was undertaken comparing the powered system with manual methods. Risk of bias assessment and meta-analysis of outcomes using appropriate statistical methods were performed. Five randomised controlled trials were identified. Patient pain (measured via visual analogue scale (VAS)—100 point scale) was significantly reduced using the powered system: mean difference=−6.57; 95% CI −12.93 to −0.22; p=0.04. The relative reduction in pain was 17%–25% with the powered system. Sample biopsy size (length in mm) was also significantly increased with the powered system: mean difference=3.65 mm; 95%; CI 1.61 mm to 5.68 mm; p=0.0005. The relative increase in sample size was 33% with the powered system. Operator ease of use (as measured via VAS) and adverse events were similar. Despite limited operator experience, patients experienced less pain and sample sizes were increased without an increase in adverse events with the powered system. The powered system may offer an option in obtaining samples from patients whose pain is compromised by disease and may reduce redos.

Palliative care and hematologic oncology: the promise of collaboration

Palliative medicine provides active evaluation and treatment of the physical, psychosocial and spiritual needs of patients and families with serious illnesses, regardless of curability or stage of illness. The hematologic malignancies comprise diverse clinical presentations, evolutions, treatment strategies and clinical and quality of life outcomes with dual potential for rapid clinical decline and ultimate improvement. While recent medical advances have led to cure, remission or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses and all are associated with significant symptom and quality of life burden for patients and families. The gravity of a diagnosis of a hematologic malignancy also weighs heavily on the medical team, who typically develop close and long-term relationships with their patients. Palliative care teams provide an additional layer of support to patients, family caregivers, and the primary medical team through close attention to symptoms and emotional, practical, and spiritual needs. Barriers to routine palliative care co-management in hematologic malignancies include persistent health professional confusion about the role of palliative care and its distinction from hospice; inadequate availability of palliative care provider capacity; and widespread lack of physician training in communicating about achievable goals of care with patients, family caregivers, and colleagues. We herein review the evidence of need for palliative care services in hematologic malignancy patients in the context of a growing body of evidence demonstrating the beneficial outcomes of such care when provided simultaneously with curative or life-prolonging treatment.