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1.
Environ Sci Pollut Res Int ; 31(13): 19047-19070, 2024 Mar.
Article in English | MEDLINE | ID: mdl-38372917

ABSTRACT

As the urgency to address climate change intensifies, the exploration of sustainable negative emission technologies becomes imperative. Enhanced weathering (EW) represents an approach by leveraging the natural process of rock weathering to sequester atmospheric carbon dioxide (CO2) in agricultural lands. This review synthesizes current research on EW, focusing on its mechanisms, influencing factors, and pathways for successful integration into agricultural practices. It evaluates key factors such as material suitability, particle size, application rates, soil properties, and climate, which are crucial for optimizing EW's efficacy. The study highlights the multifaceted benefits of EW, including soil fertility improvement, pH regulation, and enhanced water retention, which collectively contribute to increased agricultural productivity and climate change mitigation. Furthermore, the review introduces Monitoring, Reporting, and Verification (MRV) and Carbon Dioxide Removal (CDR) verification frameworks as essential components for assessing and enhancing EW's effectiveness and credibility. By examining the current state of research and proposing avenues for future investigation, this review aims to deepen the understanding of EW's role in sustainable agriculture and climate change mitigation strategies.


Subject(s)
Carbon Sequestration , Soil , Carbon Dioxide , Agriculture , Weather , Climate Change
2.
World Neurosurg ; 183: 204-205, 2024 03.
Article in English | MEDLINE | ID: mdl-38143030

ABSTRACT

Idiopathic intracranial hypertension (IIH) is usually caused by sinus stenosis, which manifests in magnetic resonance venography (MRV) as occlusion or intraluminal webbing. We present the case of a 27-year-old patient with IIH, and time-of-flight (TOF) MRV only exhibited a rare "wrinkle sign," which was eventually proved to indicate sinus obstruction. The patient received venting and recovered. The TOF MRV provides a nonradioactive approach to identify IIH patients who potentially need intervention.


Subject(s)
Intracranial Hypertension , Pseudotumor Cerebri , Humans , Adult , Pseudotumor Cerebri/diagnostic imaging , Pseudotumor Cerebri/surgery , Phlebography , Magnetic Resonance Angiography , Magnetic Resonance Imaging , Magnetic Resonance Spectroscopy , Intracranial Hypertension/diagnostic imaging , Intracranial Hypertension/etiology
3.
J Vasc Surg Venous Lymphat Disord ; 12(2): 101724, 2024 Mar.
Article in English | MEDLINE | ID: mdl-38135217

ABSTRACT

OBJECTIVE: The primary etiology of pelvic venous disorder is multifactorial and challengeable in vascular surgery as it mandates multidisciplinary team cooperation for its evaluation and management. METHODS: All patients investigated for pelvic venous disorder in a high-volume, tertiary referral university hospital were identified and analyzed retrospectively during the period (March 2021 through September 2022). Demographic and medical data were scored. Agreement between the noninvasive modalities (computed tomographic venography [CTV] or magnetic resonance venography [MRV]) and diagnostic venography in detecting the refluxing pelvic veins was analyzed. Sensitivity, specificity, and diagnostic accuracy are also measured. No patients' treatments were reported in this study as the treatment is scheduled in other sessions in some cases and is out of the scope of this article. All patients had a diagnostic venogram regardless of the axial imaging modality. The main goal was to compare cross-sectional imaging with diagnostic venography. RESULTS: The total number of patients was 120 with a mean age of 34.4 ± 7.1 years; 86.7% were multiparous. All patients presented chronic pelvic pain with vulvoperineal and/or atypical lower limb varicosities. Then patients were divided into two groups: those with CTV and those with MRV. Sensitivity, specificity, and diagnostic accuracy of CTV were 50%, 33%, and 47% for the detection of incompetent ovarian veins, 83%, 33%, and 53% for the detection of incompetent internal iliac veins, and 50%, 40%, and 47% for the detection of incompetent pelvic plexus veins, respectively, whereas time-resolved MRV achieved sensitivity, specificity, and diagnostic accuracy of 73%, 25%, and 60% for the detection of incompetent ovarian veins, 75%, 46%, and 53% for the detection of incompetent internal iliac veins, and 67%, 33% and 60% for detection of incompetent pelvic plexus veins, respectively. CONCLUSIONS: The desire to avoid the drawbacks of diagnostic venography led to an increase in the use of noninvasive imaging modalities. Our results achieved acceptable sensitivity, specificity, and diagnostic accuracy outcomes for cross-sectional imaging with the superiority of MRV over CTV in diagnosing PCS.


Subject(s)
Magnetic Resonance Imaging , Vascular Diseases , Humans , Adult , Phlebography/methods , Retrospective Studies , Magnetic Resonance Imaging/methods , Pelvis/diagnostic imaging , Iliac Vein/diagnostic imaging
4.
Virol Sin ; 38(6): 877-888, 2023 Dec.
Article in English | MEDLINE | ID: mdl-37931840

ABSTRACT

Emerging and re-emerging viruses from wild animals have seriously threatened the health of humans and domesticated animals in recent years. Herein, we isolated a new mammalian orthoreovirus (MRV), Pika/MRV/GCCDC7/2019 (PMRV-GCCDC7), in the Qinghai-Tibet Plateau wild pika (Ochotona curzoniae). Though the PMRV-GCCDC7 shows features of a typical reovirus with ten gene segments arranged in 3:3:4 in length, the virus belongs to an independent evolutionary branch compared to other MRVs based on phylogenetic tree analysis. The results of cellular susceptibility, species tropism, and replication kinetics of PMRV-GCCDC7 indicated the virus could infect four human cell lines (A549, Huh7, HCT, and LoVo) and six non-human cell lines, including Vero-E6, LLC-MK2, BHK-21, N2a, MDCK, and RfKT cell, derived from diverse mammals, i.e. monkey, mice, canine and bat, which revealed the potential of PMRV-GCCDC7 to infect a variety of hosts. Infection of BALB/c mice with PMRV-GCCDC7 via intranasal inoculation led to relative weight loss, lung tissue damage and inflammation with the increase of virus titer, but no serious respiratory symptoms and death occurred. The characterization of the new reovirus from a plateau-based wild animal has expanded our knowledge of the host range of MRV and provided insight into its risk of trans-species transmission and zoonotic diseases.


Subject(s)
Lagomorpha , Orthoreovirus, Mammalian , Animals , Dogs , Mice , Lagomorpha/metabolism , Orthoreovirus, Mammalian/genetics , Phylogeny , Virulence , Animals, Wild , Genomics
5.
Radiol Case Rep ; 18(10): 3592-3597, 2023 Oct.
Article in English | MEDLINE | ID: mdl-37577080

ABSTRACT

Coronavirus disease 2019 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); it has recently been associated with several hematologic disorders. A 4-year-old boy who had SARS-CoV-2 10 months prior was admitted to the emergency department of our hospital with seizures. His SARS-CoV-2 IgG II level was 885.7 AU/mL. Neuroimaging with cranial computed tomography after admission showed abnormal images of the venous sinus, but this was not sufficient to diagnose cerebral venous sinus thrombosis. Therefore, magnetic resonance imaging and digital subtraction angiography were conducted, which confirmed the diagnosis. He was treated with thrombectomy and anticoagulation drugs, and the clinical outcomes were satisfactory. Because our patient had a medical history of SARS-CoV-2 and exhibited no other risk factors, we present this case as evidence of a potential association between cerebral venous sinus thrombosis and SARS-CoV-2.

6.
Emerg Radiol ; 30(4): 443-451, 2023 Aug.
Article in English | MEDLINE | ID: mdl-37341879

ABSTRACT

PURPOSE: Accurate assessment of dural sinus, deep and cortical venous thrombosis on MR imaging is challenging. The aim of this study is to evaluate the accuracy of 3D-T1 turbo spin echo (T1S), sequences in detecting venous thrombosis and comparing it with susceptibility-weighted imaging (SWI), magnetic resonance venography (MRV) and post contrast T1 magnetization-prepared rapid acquisition gradient echo (T1C). METHODS: A blinded retrospective observational analysis of 71 consecutive patients evaluated for cerebral venous thrombosis (CVT) and 30 control patients was performed. Multimodality reference standard adopted included T1C, SWI with MRV. Sub-analyses in superficial, deep and cortical venous segments were performed in addition to correlation of signal intensity of thrombus with the clinical stage. RESULTS: A total of 2222 segments in 101 complete MRI examinations were evaluated. Sensitivity/specificity/positive predictive value/negative predictive value/accuracy and precision of T1S for detection of cortical vein thrombosis was 0.994/1/1/0.967/0.995/1, 1/0.874/0.949/1/0.963/0.950 for detection of superficial venous sinus thrombosis and 1/1/1/1/1/1 for deep venous thrombosis. The AUC yield for T1S was 0.997 for cortical, 1 for deep and 0.988 for superficial venous segments. CONCLUSION: T1S paralleled the accuracy of conventional sequences in the overall detection of CVT but showed superior accuracy in the detection of cortical venous thrombosis. It makes a fitting addition to the CVT MRI protocol in scenarios demanding negation of gadolinium administration.


Subject(s)
Intracranial Thrombosis , Sinus Thrombosis, Intracranial , Venous Thrombosis , Humans , Intracranial Thrombosis/diagnostic imaging , Magnetic Resonance Imaging/methods , Retrospective Studies , Sinus Thrombosis, Intracranial/diagnosis , Venous Thrombosis/diagnostic imaging
7.
Clin Case Rep ; 11(5): e07329, 2023 May.
Article in English | MEDLINE | ID: mdl-37151935

ABSTRACT

Key clinical message: Cerebral venous sinus thrombosis (CVST) should be on the differential for intracranial hypertension, and the preferred diagnostic tests are CT venogram or MR venography. Abstract: Cerebral venous sinus thrombosis (CVST) is a rare cause of stroke and is on the differential for intracranial hypertension. Non-contrast head CT is often normal. CT venogram or MR venography are the preferred diagnostic tests, as was required in our patient. We review the presentation, diagnosis, and management of CVST.

8.
Radiol Clin North Am ; 61(3): 501-519, 2023 May.
Article in English | MEDLINE | ID: mdl-36931766

ABSTRACT

Cerebral venous thrombosis (CVT) is a rare cerebrovascular disease caused by an occlusion of the cerebral venous sinuses or cortical veins. It has a favorable prognosis if diagnosed and treated early. CVT can be difficult to diagnose on clinical grounds, and imaging plays a key role. We discuss clinical features and provide an overview of current neuroimaging methods and findings in CTV.


Subject(s)
Magnetic Resonance Angiography , Sinus Thrombosis, Intracranial , Humans , Prognosis , Sinus Thrombosis, Intracranial/diagnostic imaging
9.
Clin Neuroradiol ; 33(3): 695-700, 2023 Sep.
Article in English | MEDLINE | ID: mdl-36799990

ABSTRACT

BACKGROUND: Based on increased understanding of the idiopathic intracranial hypertension (IIH) pathophysiology, venous sinus stenting (VSS) has emerged as an effective treatment for patients with transverse sinus stenosis (TSS). The presence of a reliable TSS screening tool is warranted. The combined conduit score (CCS) is the most widely used score for evaluation of the cerebral sinovenous stenosis in contrast-enhanced magnetic resonance venography (CE-MRV). PURPOSE OF THE STUDY: To evaluate the interobserver agreement between neuro-interventionalists and radiologists with respect to the CCS in evaluation of transverse sinus stenosis in patients with idiopathic intracranial hypertension using CE-MRV. METHODS: A retrospective study was conducted on 26 consecutive patients diagnosed with IIH and underwent CE-MRV. The 2 neuro-interventionalists and 2 radiologists separately evaluated the cerebral venous sinuses using the CCS. RESULTS: The mean CCS was significantly different between the neuro-interventionalists and radiologists (p < 0.001), higher for the radiologists. The inter-rater reliability was excellent (ICC = 0.954, 95% CI: 0.898-0.979) between the 2 neuro-interventionalists, good between the 2 radiologists (ICC = 0.805, 95% CI: 0.418-0.921), but was not acceptable between the neuro-interventionalists and the radiologists (ICC 0.47 95% CI:-2.2-0.782). CONCLUSION: Despite the excellent agreement between the neuro-interventionists and the good agreement between the radiologists, there was no agreement between the neuro-interventionists and the radiologists. Our finding suggests that there is a gap between the 2 specialties but does not favor any of them. Factors related to the observers, the venous sinus system, the MRV or the CCS score may have resulted in this discrepancy. Automatic or semi-automatic feature extractions to produce quantifiable biomarkers for IIH are warranted. The clinical decisions should not depend only on strongly observer-dependent scores with training and/or experience-dependent influences.


Subject(s)
Pseudotumor Cerebri , Humans , Pseudotumor Cerebri/diagnostic imaging , Retrospective Studies , Phlebography/methods , Constriction, Pathologic/diagnostic imaging , Reproducibility of Results , Cranial Sinuses/diagnostic imaging , Magnetic Resonance Spectroscopy
10.
J Med Virol ; 95(2): e28492, 2023 02.
Article in English | MEDLINE | ID: mdl-36633204

ABSTRACT

Mammalian orthoreovirus (MRV) infects many mammalian species including humans, bats, and domestic animals. To determine the prevalence of MRV in bats in the United States, we screened more than 900 bats of different species collected during 2015-2019 by a real-time reverse-transcription polymerase chain reaction assay; 4.4% bats tested MRV-positive and 13 MRVs were isolated. Sequence and phylogenetic analysis revealed that these isolates belonged to four different strains/genotypes of viruses in Serotypes 1 or 2, which contain genes similar to those of MRVs detected in humans, bats, bovine, and deer. Further characterization showed that these four MRV strains replicated efficiently on human, canine, monkey, ferret, and swine cell lines. The 40/Bat/USA/2018 strain belonging to the Serotype 1 demonstrated the ability to infect and transmit in pigs without prior adaptation. Taken together, this is evidence for different genotypes and serotypes of MRVs circulating in US bats, which can be a mixing vessel of MRVs that may spread to other species, including humans, resulting in cross-species infections.


Subject(s)
Chiroptera , Deer , Orthoreovirus, Mammalian , Orthoreovirus , Animals , Dogs , Humans , Cattle , United States , Swine , Orthoreovirus, Mammalian/genetics , Phylogeny , Ferrets
11.
Radiol Case Rep ; 18(3): 1201-1204, 2023 Mar.
Article in English | MEDLINE | ID: mdl-36660571

ABSTRACT

Ulcerative colitis is an idiopathic inflammatory bowel condition that may be worsened by thromboembolic events such deep vein thrombosis, cerebral venous thrombosis, and pulmonary embolism. Cerebral venous thrombosis is a rare but critical consequence of ulcerative colitis characterized by high mortality and morbidity rate. It is thought to be caused by the hypercoagulable state that occurs during ulcerative colitis relapse. Cerebral venous thrombosis is a reversible condition with good outcomes when detected early and treated properly. In this study, we describe the case of a young woman who presented with cerebral venous thrombosis secondary to ulcerative colitis complicated by venous infarction with petechial cerebral hemorrhage.

12.
Cells ; 13(1)2023 12 20.
Article in English | MEDLINE | ID: mdl-38201223

ABSTRACT

Mandarin fish ranavirus (MRV) infection poses a substantial challenge to the mandarin fish culture industry as no effective preventive or therapeutic measures currently exist. The creation of a highly permissive cell line from a natural host is crucial for developing a vaccine for MRV and understanding its pathogenic mechanisms. In this research, the mandarin fish (Siniperca chuatsi) kidney cell line (SCK) was isolated from mandarin fish kidneys. Subsequently, SCK-a to SCK-g monoclonal cell lines were derived from the SCK cell population, distinguished by morphological variations. Notably, MRV infection induced an advanced cytopathic effect (CPE) in almost all cells of the SCK-f clone. Further tests showed that MRV achieved a peak viral titer of 1010.7 50% tissue culture infectious dose (TCID50)/mL and consistently exceeded 1010 TCID50/mL across nine passages in SCK-f cells. Electron microscopy verified the MRV virion integrity within SCK-f. In vivo experiments revealed that MRV infections led to cumulative mortality rates of 86.9% in mandarin fish and 88.9% in largemouth bass (Micropterus salmoides). Such results suggest that SCK-f is highly permissive to MRV. This study underscores the importance of cellular diversity in developing viral permissive cell lines. The SCK monoclonal cell line pool may offer potential for generating highly permissive cell lines for other mandarin fish viruses.


Subject(s)
Ranavirus , Animals , Fishes , Cell Line , Kidney , Cloning, Molecular
14.
JACC Case Rep ; 4(19): 1231-1241, 2022 Oct 05.
Article in English | MEDLINE | ID: mdl-36406912

ABSTRACT

Echocardiography is the first-line modality for assessing mitral regurgitation (MR). In addition to evaluation of the MR jet characteristics, echocardiography can provide quantitative parameters of MR severity. This case series illustrates the importance of integrating multiple parameters in the evaluation of MR and the role of multimodality imaging. (Level of Difficulty: Advanced.).

15.
Environ Sci Technol ; 56(20): 14743-14752, 2022 10 18.
Article in English | MEDLINE | ID: mdl-36201663

ABSTRACT

Methane mitigation from the oil and gas (O&G) sector represents a key near-term global climate action opportunity. Recent legislation in the United States requires updating current methane reporting programs for oil and gas facilities with empirical data. While technological advances have led to improvements in methane emissions measurements and monitoring, the overall effectiveness of mitigation strategies rests on quantifying spatially and temporally varying methane emissions more accurately than the current approaches. In this work, we demonstrate a quantification, monitoring, reporting, and verification framework that pairs snapshot measurements with continuous emissions monitoring systems (CEMS) to reconcile measurements with inventory estimates and account for intermittent emission events. We find that site-level emissions exhibit significant intraday and daily emission variations. Snapshot measurements of methane can span over 3 orders of magnitude and may have limited application in developing annualized inventory estimates at the site level. Consequently, while official inventories underestimate methane emissions on average, emissions at individual facilities can be higher or lower than inventory estimates. Using CEMS, we characterize distributions of frequency and duration of intermittent emission events. Technologies that allow high sampling frequency such as CEMS, paired with a mechanistic understanding of facility-level events, are key to an accurate accounting of short-duration, episodic, and high-volume events that are often missed in snapshot surveys and to scale snapshot measurements to annualized emissions estimates.


Subject(s)
Air Pollutants , Natural Gas , Air Pollutants/analysis , Methane/analysis , Natural Gas/analysis , Sulfides , United States , United States Environmental Protection Agency
16.
Radiol Case Rep ; 17(10): 3713-3717, 2022 Oct.
Article in English | MEDLINE | ID: mdl-35957661

ABSTRACT

Cerebral venous sinus thrombosis (CVST) is a rather uncommon disorder. CVST is potentially lethal, therefore early detection and treatment is critical. CVST has been linked to pregnancy and puerperium, while COVID-19 infection has been linked to a hypercoagulable state. CVST can be difficult to detect and treat due to the wide range of neurological manifestations, especially in patients with hypercoagulability. The goal of this study is to conduct a literature review and present a unique case of a pregnant woman with CVST who had left hemiplegia and headache. After 6 months of treatment in the hospital, the patient's hemiplegia was fully resolved. Here, we discuss the treatment of CVST in pregnant women who have a suspected past COVID-19 infection.

17.
Cureus ; 14(7): e27251, 2022 Jul.
Article in English | MEDLINE | ID: mdl-36039220

ABSTRACT

Cerebral venous sinus thrombosis (CVST) is the occlusion of cerebral veins of the brain secondary to blood clot formation. These can result in increased intracranial pressure, cerebral edema, and may even have fatal consequences such as a stroke. Despite CVSTs being considered a rare pathology, these are said to have an increased incidence in the pediatric population. These individuals with CVST are often asymptomatic causing physicians to often overlook and delay possibly life-saving interventions. The current literature is lacking on CVST examples in the "older" range of the pediatric population, specifically teenagers. Here we present the case of a 13-year-old female with trauma secondary to a fall from a golf cart, who was found to have intraparenchymal and subarachnoid hemorrhages with transverse sinus thrombosis.

18.
J Neurosci Rural Pract ; 13(3): 529-536, 2022 Jul.
Article in English | MEDLINE | ID: mdl-35946000

ABSTRACT

Purpose The purpose of this study is to evaluate magnetic resonance (MR) angiography (MRA) and venography (MRV) findings in tuberculous meningitis (TBM). Methods Thirty consecutive patients of clinically diagnosed TBM were enrolled. Apart from T2-weighted imaging, T1-weighted imaging (T1WI), diffusion-weighted imaging, susceptibility-weighted imaging, fluid-attenuated inversion recovery, and postcontrast T1WI, time-of-flight (TOF) MRA and postcontrast MRV were done in all the patients. MRV was done after intravenous administration of gadolinium-based contrast agent followed by postcontrast T1WI. MRA and MRV findings were analyzed. Results Mean age of the patients was 33.13 ± 14.93 years. Duration of symptom was 34.90 ± 33.82 (range: 10-150) days. Out of 30 patients, 11 were categorized as definite TBM and 19 probable TBM. Eighteen (60%) were grade I, 7 (23%) grade II, and 5 (16%) grade III TBM based on severity. MR abnormalities were in varying combinations of leptomeningeal enhancement in 24 (80%), pachymeningeal in 2, both in 3, tuberculomas in 13 (43.3%), ventriculitis in 1, hydrocephalus in 16 (53.3%), and infarcts in 10 (33.3%) patients out of which the tubercular zone infarct in 9 patients. TOF MRA showed arterial abnormality in 13 patients. Anterior cerebral artery and middle cerebral artery have commonly involved vessels. Dural sinus thrombosis was noted in two patients. Both were female. One patient had subacute thrombus in the posterior part of superior sagittal sinus, left transverse sinus, and proximal right transverse sinus. The second patient had a filling defect in the transverse sinus. Conclusion In TBM, there is predominant arterial involvement causing infarcts which are usually seen in the tubercular zone. However, occasionally, there may be venous involvement causing cerebral venous sinus thrombosis.

19.
J Neurosurg Case Lessons ; 3(26): CASE22175, 2022 Jun 27.
Article in English | MEDLINE | ID: mdl-35855207

ABSTRACT

BACKGROUND: Cerebral venous sinus thrombosis (VST) is a complication of head injury and can be secondary to sinus compression by depressed skull fractures. Fracture elevation is a treatment option for VST secondary to extrinsic compression, but conservative management may also be effective. Venous sinuses can also be lacerated from skull fractures, resulting in epidural or subdural hematomas. The authors presented a case of sagittal sinus injury and thrombosis from a depressed skull fracture that caused a subgaleal hematoma. The injury was successfully managed conservatively. OBSERVATIONS: A 14-year-old boy presented after a head injury with a diastatic, depressed parietal bone fracture. Computed tomography venogram showed disruption and occlusion of the superior sagittal sinus with a subgaleal hematoma in continuity with the injured sagittal sinus. Because of concern for hemorrhage if tamponade on the sinus was removed, the patient was treated nonsurgically. At follow-up, the sinus had recanalized and the fracture had healed. LESSONS: Skull fractures with underlying sinus thrombosis can be managed conservatively with good outcome. Careful assessment for venous sinus injury should be made before undertaking fracture elevation to relieve sinus compression.

20.
J Family Med Prim Care ; 11(4): 1335-1340, 2022 Apr.
Article in English | MEDLINE | ID: mdl-35516681

ABSTRACT

Introduction: Pancytopenia is a hematological condition in which there is a reduction in all three cell lines of blood. This study aims to evaluate the utility of reticulocyte indices such as reticulocyte % (retic %), immature reticulocyte fraction (IRF), and mean reticulocyte volume (MRV) in identifying the cause of pancytopenia. Materials and Methods: Reticulocyte indices were measured by an automated coulter. These values were then correlated with relevant biochemical and bone marrow results and cases were stratified into different etiological groups. Receiver operator curve (ROC) analysis was performed and various cut-off values were derived based on the reticulocyte indices. ROC was repeated to further classify cut-off values at every level to help formulate a diagnostic algorithm. Results: A total of 154 cases of pancytopenia were obtained. Ages ranged from 7 months to 87 years with a mean of 42, the male:female ratio was 1.08:1. The majority of the cases were megaloblastic anemias in which the cut-off values for retic % was <0.91 with a sensitivity of 78.1% and specificity of 70%, IRF was 0.45 with a sensitivity of 76.7% and specificity of 64%, and MRV was >121.8 fl with a sensitivity of 83.6% and specificity of 80%. The values on ROC could segregate nutritional from nonnutritional causes. The IRF and MRV also helped to differentiate megaloblastic anemia from dual deficiency anemia. Conclusion: Reticulocyte indices help identify the cause of pancytopenia. They can segregate nutritional anemia from other causes of pancytopenia allowing presumptive treatment to be initiated and may obviate invasive procedures such as bone marrow examination.

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