Hematological profile in pyrexia of unknown origin: role of bone marrow trephine biopsy vis-à-vis aspiration

Abstract

Background: Bone marrow examination, by aspiration and/or trephine biopsy, is an important procedure in arriving at a diagnosis for long-duration febrile illness. The role of trephine biopsy in immunocompromised host, especially HIV-positive patients, has been well studied in the literature. However, its utility in immunocompetent patients is still shrouded by controversy. Thus, the authors attempted to evaluate the utility of marrow aspirate vis-à-vis trephine biopsy in establishing a diagnosis in cases of pyrexia of unknown origin in immunocompetent individuals, along with an analysis of haematological alterations in these patients.

Materials and methods: Over a period of 8 years, 121 patients with pyrexia of unknown origin underwent both bone marrow aspiration and trephine biopsy as a part of diagnostic work-up. These cases were reviewed for their clinical data and hematological findings, including detailed morphological features in aspiration smears and trephine biopsies. Bone marrow aspiration and biopsy were compared for their diagnostic efficacy in these patients.

Results: A wide age range (2–65 years) was noted with a slight male predominance (2 : 1). Anemia was the most common feature in peripheral blood findings, seen in 97·5% of patients. Bone marrow aspiration was diagnostic in only 16·5% of cases, which revealed leishmaniasis or pure red cell aplasia. Granulomas were infrequent in marrow aspiration smears, as only two cases (1·6%) showed ill defined epithelioid cell collections. Compared to this, trephine biopsy offered a diagnosis in 76% of the cases. Granulomas were a frequent finding in the trephine biopsy, being present in 70% of the cases included. Additional cases diagnosed on biopsy (over those diagnosed with aspiration smears) included lymphoma, tuberculosis, fungal infection, sarcoidosis and hypocellular marrow.

Conclusion: Bone marrow trephine biopsy is an important adjunct to aspiration in arriving at an aetiological diagnosis of patient with long-duration febrile illness, and should be routinely performed in such cases. The presence of granulomas in trephine biopsy increases the likelihood of an etiologic diagnosis in these patients.     

Megaloblastic pancytopenia vis-à-vis non-megaloblastic pancytopenia: is mean platelet volume useful discriminating indicator

Introduction: Megaloblastic anaemia may present with pancytopenia and clinically mimic other causes of pancytopenia including myelodysplastic syndrome or aplastic anaemia. Bone marrow examination may be required for precise differentiation. The study was conducted to evaluate the role of mean platelet volume (MPV) to discriminate between pancytopenia due to megaloblastic anaemia or non‐megaloblastic causes. Methods: A total of 268 cases of pancytopenia were divided into megaloblastic and non‐ megaloblastic group depending on clinical, laboratory and bone marrow examination. Mean MPV was statistically analyzed in both the groups along with comparison with healthy controls. Results: The mean MPV in 88 cases of megaloblastic group (7.97 fl) was although statistically significantly higher than mean MPV in 180 cases of non‐megaloblastic group (7.04 fl) with P value <0.05 but had limited sensitivity and specificity to discriminate megaloblastic and non‐megaloblastic pancytopenia (cut off of 7.45 fl was 63.6% sensitive and 67.3% specific as observed by receptor operating characteristic curve analysis).The mean MPV in aplastic/hypocellular marrow and acute leukaemia category of non‐megaloblastic group was significantly lower than megaloblastic group of pancytopenia (P value <0.05). MPV was also significantly lower in non‐megaloblastic pancytopenia as compared to controls (P < 0.001) while there was no statistical difference in MPV between megaloblastic pancytopenia and controls (P < 0.057). Conclusion: MPV has limited sensitivity and specificity to discriminate between megaloblastic and non‐megaloblastic pancytopenia. Pancytopenia due to aplastic/hypocellular marrow and acute leukaemia has significantly lower MPV than megaloblastic group while other pancytopenic cases do not show any statistical difference in MPV from megaloblastic pancytopenia.     

Attitude et croyances du personnel soignant en Médecine Interne vis-à-vis de la vaccination antigrippale saisonnière : étude transversale descriptive

IntroductionThe rate of vaccination in HCWs in France remains low. We aimed to analyze the attitude and beliefs of HCWs toward influenza vaccination in Internal Medicine wards.MethodsWe conducted a cross-sectional survey of HCWs in the departments of Internal Medicine of two tertiary hospitals in France. An anonymous questionnaire designed for this study was used to collect demographic, health beliefs and attitudes, and medical knowledge related to the influenza and influenza vaccine. The survey started shortly prior the 2019 influenza season.ResultsThe surveys were completed by 158 (29[18–62] years-old ; 75.9% female ; 69.6% non-medical workers) of 187 (84.5%) HCWs. Overall, influenza vaccination coverage rate was 50.6% (n = 80/158). Higher vaccination coverage was found in physician and in HCWs who had a better knowledge about the virus transmission. The reason to fulfill vaccination recommendations was to protect the patients, their relatives and themselves for more than 80% of HCWs compliant to vaccination recommendation. More than a third of HCWs (n = 59/158; 37.3%) refused to be vaccinated or hesitated. Among them, 12 (12/59, 20.3%) believed that influenza vaccine could cause flu. The main reasons for reluctant HCWs to eventually accept to be vaccinated were a mandatory vaccination program and the demonstration of a better vaccine efficacy to prevent the disease.ConclusionInfluenza vaccination coverage among HCWs in Internal Medicine remains low. Education campaigns targeting in priority nurses and nurse assistants is mandatory to improve the compliance of HCWs to vaccination recommendation.     

Is multidisciplinary care of heart failure cost‐beneficial when combined with optimal medical care?

BACKGROUND: Multidisciplinary care (MDC) of heart failure (HF) can significantly reduce rates of unplanned hospitalisation, the major cost component of HF care. AIMS: This prospective, randomised, controlled study examines the cost-benefits of MDC of HF in the setting of optimal medical care. METHODS: 98 NYHA class IV HF patients (mean age 70.8+/-10.5 years) were randomised to MDC (n=51) or routine care (RC; n=47) of HF. A direct intervention cost was calculated from contact time (scheduled and unscheduled) spent by the MDC team. Unplanned hospitalisation costs for HF were calculated at a daily rate of 242. Outcomes were determined in monetary terms, i.e. the cost of the service per hospitalisation prevented and net costs/savings at 3 months. RESULTS: The direct intervention cost of the MDC team was 5860, with an average cost per patient of 113 (95% Cl: 97-128). At 3 months, there were a total of 12 unplanned HF readmissions in the RC group (25.5% rate, 195 days) compared to 2 in the MDC group (3.9% rate, 17 days). The number needed to treat to prevent one hospitalisation for HF was 6 over 3 months. The cost of the service per hospitalisation prevented was 586. The intervention produced a net cost saving of 37,216 for 51 patients treated over 3 months. Sensitivity analyses using 50% variation in costs and lower relative risk reductions confirmed the cost-benefits of the intervention. CONCLUSION: MDC of HF remains cost-beneficial when combined with optimal, medical care. The significant clinical and cost-benefits suggest that this intensive approach to MDC and medical management should become the standard of care for HF.     

Impact of cultural competence on medical care: where are we today?

The Institute of Medicine's 2002 Report on Unequal Treatment calls attention to disparities in health care and proposes corrective steps. Proposed actions included improvement in cross-cultural skills among providers. This article highlights evidence for unequal treatment, and delineates current medical educational efforts aimed at improving cultural competence. Improvement is needed in the uniform adoption of cultural competence curricula and focus needs to be placed on its impact through outcomes research.     

Heart failure management programs: can we afford to ignore the inpatient phase of care?

Disease management programs have become an integral component of the overall care strategy of patients with heart failure. The standard approach with such programs is to enroll patients following discharge from hospital, and in general play little role in the in-patient phase of care. By ignoring the in-hospital phase an opportunity to significantly influence the quality of care is lost, likely contributing to persistently high readmission rates. At present, the major concerns with in-hospital care are the lack of consistent speciality involvement, incomplete investigation, lack of patient and family education, and failure to adequately prescribe proven medical therapies. This review underlines the need to complement the proven advantages of out-patient disease management programs by focusing more completely on in-hospital care. The likely advantages of a structured in-patient service and the practical difficulties in applying such a service are discussed.     

Continuity of HIV-related medical care, New York City, 2005-2009: Do patients who initiate care stay in care?

In this era of effective antiretroviral therapy, early diagnosis of HIV and timely linkage to and retention in care are vital to survival and quality of life. Federal guidelines recommend regular monitoring of HIV-related laboratory parameters and initiation of antiretroviral treatment at specified thresholds. We used routinely reported laboratory data to measure intervals between visits by New York City residents newly diagnosed with HIV July 1 to September 30, 2005, and initiating care within 3 months of diagnosis. We measured regular care (≥1 visit every 6 months) and retention in care (last visit ≤6 months before close of analysis) through June 30, 2009. Patients were followed for 45-48 months. Seventy-seven percent (650/842) of patients initiated care within 3 months of diagnosis; 609 (93.7%) made at least one subsequent visit; 45.4% had regular care. Risk factors for not receiving regular care included age 13-24 versus 50+ (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.5, 6.0), black race (AOR 2.0, 95% CI 1.4,2.8), eligibility for antiretroviral treatment (AOR 1.5, 95% CI 1.1, 2.2), and injection drug use (IDU; AOR?=?2.7. 95% CI 1.0, 7.1). In a time-to-event analysis, risk factors for loss to care were age 13-24 versus 50+ at diagnosis (adjusted hazard ratio [AHR] 1.9, 95% CI 1.1, 3.4), non-hospital site of care (AHR 1.4, 95% CI 1.0, 2.0) and early stage (non-AIDS) disease (AHR 1.4, 95% CI 1.0, 2.0). The analysis demonstrates how mandated reporting of HIV-related laboratory tests provides surveillance systems with the capacity to monitor utilization of care, identify deficits, and evaluate progress in programs designed to facilitate retention in care.     

The clinical significance of histopathologic subgroups in idiopathic interstitial pneumonia: is surgical lung biopsy essential?

For many years, the clinical entity of idiopathic interstitial pneumonia (IIP) has been a source of confusion for physicians. There has been much debate over the utility of subclassifying this condition histopathologically. It now appears that such classification is useful, and the most important distinction is the presence or absence of usual interstitial pneumonia (UIP). Unlike the other histopathologic subgroups, UIP has a grave prognosis and responds poorly to traditional therapies. To emphasize this clinical difference, the diagnosis of idiopathic pulmonary fibrosis (IPF), once used synonymously with IIP, is now reserved for only those patients with the histopathologic pattern of UIP. Although the gold standard for the diagnosis of IPF/UIP remains surgical lung biopsy, recent studies suggest that careful clinical and radiographic evaluation can identify IPF/UIP with a specificity of 90% or more. In the absence of a clear clinical diagnosis, we recommend pursuing surgical lung biopsy. Knowledge of the underlying histopathology will allow for more accurate prognosis, help guide therapy, and make possible the clinical investigation of novel therapeutic agents for patients with IIP.     

Overview of recent clinical trials in heart failure: what is the current standard of care?

Heart failure develops as a consequence of cardiac injury. As the heart begins to fail to meet the body's metabolic demands, the renin angiotensin aldosterone system (RAAS) and the sympathetic nervous system are activated. These interrelated systems act in concert to facilitate cardiac output and tissue perfusion. Though these neurohormonal systems are initially compensatory, evidence suggests that they promote deleterious cardiac remodeling and myocyte destruction. Recent studies in patients with heart failure have targeted the RAAS and sympathetic nervous system for therapeutic intervention. This article reviews major recent multicenter, randomized, double-blind, and placebo-controlled trials in heart failure that have resulted in a new standard of care for patients with this devastating disease.