Contribution to diagnosis and treatment of bone marrow aspirate results in critically ill patients undergoing bone marrow aspiration: a retrospective study of 193 consecutive patients

Optimizing bone marrow harvesting sites for enhanced mesenchymal stem cell yield and efficacy in knee osteoarthritis treatment

Knee osteoarthritis (OA) is a debilitating condition with limited long-term treatment options. The therapeutic potential of mesenchymal stem cells (MSCs), particularly those derived from bone marrow aspirate concentrate, has garnered attention for cartilage repair in OA. While the iliac crest is the traditional site for bone marrow harvesting (BMH), associated morbidity has prompted the exploration of alternative sites such as the proximal tibia, distal femur, and proximal humerus. This paper reviews the impact of different harvesting sites on mesenchymal stem cell (MSC) yield, viability, and regenerative potential, emphasizing their relevance in knee OA treatment. The iliac crest consistently offers the highest MSC yield, but alternative sites within the surgical field of knee procedures offer comparable MSC characteristics with reduced morbidity. The integration of harvesting techniques into existing knee surgeries, such as total knee arthroplasty, provides a less invasive approach while maintaining therapeutic efficacy. However, variability in MSC yield from these alternative sites underscores the need for further research to standardize techniques and optimize clinical outcomes. Future directions include large-scale comparative studies, advanced characterization of MSCs, and the development of personalized harvesting strategies. Ultimately, the findings suggest that optimizing the site of BMH can significantly influence the quality of MSC-based therapies for knee OA, enhancing their clinical utility and patient outcomes.

Value of hemophagocytosis in the diagnosis of hemophagocytic lymphohistiocytosis in critically ill patients

BACKGROUND

Ferritin is an established biomarker in the diagnosis of secondary hemophagocytic lymphohistiocytosis (HLH), which is diagnosed by the HLH-2004 criteria. Among these criteria, detection of hemophagocytosis through invasive procedures may delay early life saving treatment. Our aim was to investigate the value of hemophagocytosis in diagnosing HLH in critically ill patients.

METHODS

In this secondary analysis of a retrospective observational study, we included all patients aged ≥18 years and admitted to any adult ICU at Charité-Universitätsmedizin Berlin between January 2006 and August 2018, who had hyperferritinemia (≥500 μg/L) and underwent bone marrow biopsy during their ICU course.

RESULTS

Two hundred fifty-two patients were included, of whom 31 (12.3%) showed hemophagocytosis. In multivariable logistic regression analysis, maximum ferritin was independently associated with hemophagocytosis. By removing hemophagocytosis from HLH-2004 criteria and HScore, prediction accuracy for HLH diagnosis was only marginally decreased compared to the original scores.

CONCLUSIONS

Our results strengthen the diagnostic value of ferritin and underline the importance of considering HLH diagnosis in patients with high ferritin but only four fulfilled HLH-2004 criteria, when hemophagocytosis was not assessed or not detectable. Proof of hemophagocytosis is not required for a reliable HLH diagnosis.

Diagnostic importance of bone marrow aspiration evaluation: A single-center study

Background & Objective

Early diagnosis can be made based on the morphological examination of bone marrow aspiration (BMA) until the bone marrow biopsy (BMB) result is reported. This allows for treatment to be started immediately, especially in hematological malignancies for which urgent treatment is indicated. This study aimed to determine the sensitivity and importance of bone marrow aspiration in the diagnosis of hematological malignancies.

Methods

In this study, the data of patients who underwent bone marrow aspiration and bone marrow biopsy in Van Yuzuncu Yil University hospital between 2017 and 2019 were retrospectively analyzed. A total of 500 patients who simultaneously underwent BMA and BMB were included in the study. Data were obtained from electronic medical records.

Results

Indication for bone marrow evaluation was abnormalities in complete blood count in 270 (54%) of patients. The diagnosis was made based on the evaluation of BMA in 475 (95%). In 456 (96%) of the 475 patients diagnosed with BMA, the diagnosis was consistent with that of BMB. Agreement of BMB with BMA was 100% in acute and chronic leukemias, while BMA was not sufficient for the diagnosis of lymphoma and solid organ metastasis.

Conclusion

Our study showed that the evaluation of BMA was highly sensitive in the diagnosis of hematological malignancies, such as acute leukemias, chronic leukemias, and multiple myeloma.

Image Guided Bone Marrow Biopsy

Bone marrow biopsy and aspiration are common diagnostic procedures used for the diagnosis and monitoring of multiple conditions including hematologic malignancies, non-hematologic malignancies, infection, and metabolic processes. While these procedures can be done on the inpatient floor or in clinic, imaging guidance has been utilized to improve patient safety. This article will review the patient work-up and considerations, as well as technique for performing both computed tomography and fluoroscopic guided bone marrow biopsies.

High Mortality of HLH in ICU Regardless Etiology or Treatment

Background: Adult hemophagocytic lymphohistiocytosis (HLH) is highly lethal in the ICU. The diagnostic and therapeutic emergency that HLH represents is compounded by its unknown pathophysiological mechanisms. Here, we report on a large cohort of adult HLH in the ICU (ICU-HLH). We analyzed prognostic factors associated with mortality to define the diagnostic and therapeutic challenges in this specific population. Methods: This retrospective study included adult patients diagnosed with HLH in four ICUs in Marseille, France between 2010 and 2020. Patients who fulfilled the HLH-2004 criteria (≥ 4/8) and/or had an HScore ≥ 169 were diagnosed with HLH. HLH was categorized into four groups according to etiology: sepsis-associated HLH, intracellular infection-associated HLH, malignancy-associated HLH, and idiopathic HLH. Results: Two hundred and sixty patients were included: 121 sepsis-associated HLH (47%), 84 intracellular infection-associated HLH (32%), 28 malignancy-associated HLH (11%), and 27 idiopathic HLH (10%). The ICU mortality rate reached 57% (n = 147/260) without a statistical difference between etiological groups. Independent factors associated with mortality in multivariate analysis included age (OR (5 years) = 1.31 [1.16-1.48], p < 0.0001), SOFA score at ICU admission (OR = 1.37 [1.21-1.56], p < 0.0001), degradation of the SOFA score between ICU arrival and HLH diagnosis (Delta SOFA) (OR = 1.47 [1.28-1.70], p < 0.0001), the presence of bone-marrow hemophagocytosis (OR = 5.27 [1.11-24.97], p = 0.04), highly severe anemia (OR = 1.44 [1.09-1.91], p = 0.01), and hypofibrinogenemia (OR = 1.21 [1.04-1.41], p = 0.02). Conclusions: In this large retrospective cohort study of critically ill patients, ICU-HLH in adults was associated with a 57% mortality rate, regardless of HLH etiology or specific treatment. Factors independently associated with prognosis included age, presence of hemophagocytosis in bone-marrow aspirates, organ failure at admission, and worsening organ failure during the ICU stay. Whether a rapid diagnosis and the efficacy of specific therapy improve outcome is yet to be prospectively investigated.

Treatment and Mortality of Hemophagocytic Lymphohistiocytosis in Adult Critically Ill Patients: A Systematic Review With Pooled Analysis

OBJECTIVES

Hemophagocytic lymphohistiocytosis is a cytokine release syndrome caused by uncontrolled immune activation resulting in multiple organ failure and death. In this systematic review, we aimed to analyze triggers, various treatment modalities, and mortality in critically ill adult hemophagocytic lymphohistiocytosis patients.

DATA SOURCES

MEDLINE database (PubMed) at October 20, 2019.

STUDY SELECTION

Studies and case series of patients greater than or equal to 18 years old, of whom at least one had to be diagnosed with hemophagocytic lymphohistiocytosis and admitted to an ICU.

DATA EXTRACTION

Source data of studies and case series were summarized and analyzed on an individual basis. Multivariable logistic regression analysis was performed adjusting for age, sex, and trigger groups. Each single treatment agent was entered as a dichotomous variable to determine treatments associated with survival, regardless if given alone or in combination.

DATA SYNTHESIS

In total, 661 patients from 65 studies and case series were included. Overall mortality was 57.8%. Infections were the most frequent trigger (49.9%), followed by malignancies (28.0%), autoimmune diseases (12.1%), unknown triggers (9.4%), and drugs (0.6%). Treatment with IV immunoglobulins was associated with improved survival (odds ratio, 0.548; 95% CI, 0.337-0.891; p = 0.015), while treatment with cyclosporine was associated with increased risk of death (odds ratio, 7.571; 95% CI, 3.702-15.483; p < 0.001). Considering different trigger groups separately, same results occurred only for infection-triggered hemophagocytic lymphohistiocytosis. No information was available on disease severity and other confounding factors.

CONCLUSIONS

Mortality of hemophagocytic lymphohistiocytosis in the ICU is high. Most common triggers were infections. Results of survival analyses may be biased by treatment indication and disease severity. Future studies prospectively investigating treatment tailored to critically ill hemophagocytic lymphohistiocytosis patients are highly warranted.

A Minimal Parameter Set Facilitating Early Decision-making in the Diagnosis of Hemophagocytic Lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a life-threatening immune dysregulation syndrome characterized by uncontrolled immune cell activation. Timely diagnosis is important, since early treatment can improve survival rates. However, completing all assessments needed to reach ≥5 positive criteria out of the 8 HLH-2004 criteria can be time consuming and may delay timely initiation of treatment. Hence, we applied a data-driven approach to identify a minimal parameter set for early decision-making towards the initiation of HLH-specific treatment. We retrospectively evaluated 165 patients from five Dutch tertiary hospitals with suspected HLH. Sixteen pHLH (median age 0.5 years) and 70 sHLH patients (median age 8.7 years) were identified using the HLH-2004 criteria. Clustering analysis and multi-receiver operator characteristics were used to identify parameters distinctive of HLH. The presence of either increased ferritin, cytopenia in ≥2 lineages, or splenomegaly distinguished HLH from non-HLH cases with a negative predictive value of 100%. A minimal parameter set consisting of 2 major criteria (phagocytosis and splenomegaly) and 3 minor criteria (cytopenia, increased ferritin, and increased triglycerides/low fibrinogen) predicted HLH with 95% (88-99) sensitivity and 94% (86-98) specificity. This finding was replicated in an independent retrospective validation cohort of 109 US patients (n = 109). By dividing a subset of the HLH-2004 criteria into major and minor criteria, this strategy uses the evaluation of less than 5 criteria to quickly identify patients with HLH. When confirmed in a prospective setting, this approach could be of value for timely diagnosis and treatment of HLH.

Primary Immunodeficiency and Thrombocytopenia

Primary immunodeficiency (PID) or Inborn errors of immunity (IEI) refers to a heterogeneous group of disorders characterized by immune system impairment. Although patients with IEI manifest highly variable symptoms, the most common clinical manifestations are recurrent infections, autoimmunity and malignancies. Some patients present hematological abnormality including thrombocytopenia due to different pathogenic mechanisms. This review focuses on primary and secondary thrombocytopenia as a complication, which can occur in IEI. Based on the International Union of Immunological Societies phenotypic classification for IEI, the several innate and adaptive immunodeficiency disorders can lead to thrombocytopenia. This review, for the first time, describes manifestation, mechanism and therapeutic modalities for thrombocytopenia in different classes of IEI.