Hemophagocytic Lymphohistiocytosis.

Hemophagocytic lymphohistiocytosis is a life-threatening condition associated with hyperinflammation and multiple organ dysfunction. It has many causes, symptoms, and outcomes. Early recognition is critical for treatment. Fever, cytopenias, coagulopathy, and hepatosplenomegaly are hallmark findings. Identifying the trigger event is crucial but challenging because of the varied presentations and infrequent provider experience. Diagnostic features include anemia, thrombocytopenia, neutropenia, elevated ferritin, hypertriglyceridemia, hypofibrinogenemia, hemophagocytosis (in bone marrow, spleen, or lymph nodes), low or absent natural killer cells, and elevated soluble interleukin 2 receptor assay. Primary treatment goals are eliminating the underlying trigger and suppressing hyperinflammation with steroids, immunoglobulins, or immunomodulators. Specific treatment includes corticosteroids, etoposide, and antithymocyte globulin followed by hematopoietic stem cell transplantation in patients with refractory or relapsing disease. Prompt immunochemical therapy is essential but often complicated by a high risk of treatment-related morbidity and disease recurrence. Despite these challenges, improvements in diagnostic technology and treatment have enhanced survival.

The analgesic effect of magnetic acupressure in cancer patients undergoing bone marrow aspiration and biopsy: a randomized, blinded, controlled trial.

CONTEXT: Bone marrow aspiration and biopsy (BMAB) is a frequently performed and painful procedure. OBJECTIVES: To evaluate the efficacy of magnetic acupressure in reducing pain in cancer patients undergoing BMAB. METHODS: Cancer patients without previous acupuncture or acupressure experience were stratified by the number of prior BMAB and randomized to having magnetic acupressure delivered to either the large intestine 4 (LI4) acupoint or a sham site. The primary study endpoint was the patient's pain intensity rating during the procedure using a visual analogue scale (VAS). RESULTS: Seventy-seven eligible patients received magnetic acupressure: 37 were randomized to treatment at the LI4 site arm and 40 at the designated sham site arm. There was no significant difference between the median pain scores of patients treated at the LI4 site and the sham site (P=0.87). However, severe pain (VAS ≥ 7) was reported in only one patient (2.7%) treated at the LI4 site compared with eight patients (20%) at the sham site (P=0.03). No patients experienced significant magnetic acupressure-related toxicities. CONCLUSION: Magnetic acupressure at the LI4 acupoint requires minimal training and expense and is well tolerated. Although its use did not significantly reduce median pain scores in patients undergoing BMAB, it does appear to reduce the proportion of patients with severe pain associated with this invasive procedure.

Short- vs long-axis approach to ultrasound-guided peripheral intravenous access: a prospective randomized study.

OBJECTIVE: The objective of the study was to determine if the short-axis approach and long-axis approach to ultrasound-guided peripheral intravenous access (USGPIV) differ in success rate, catheter insertion time, and number of needle sticks. METHODS: A convenience sample of emergency department patients aged 18 to 65 years with difficult IV access (2 or more failed landmark attempts) was prospectively randomized to short-axis or long-axis USGPIV. Time from skin puncture to catheter insertion (insertion time) and number of needle sticks were recorded. Number of needle sticks and insertion time were compared using Mann-Whitney U tests. RESULTS: Forty subjects were enrolled; 20 were randomized to the short-axis and 20 to the long-axis approach. Success rate was 95% (19/20; 95% confidence interval, 85%-100%) in the short-axis group compared with 85% (17/20; 95% confidence interval, 69%-100%) in the long-axis group. All 3 subjects with failed IV placement in the long-axis group had successful rescue USGPIV placement in short axis. Median insertion time was 34 seconds (interquartile range, 35 seconds) for the short-axis group compared with 91 seconds (interquartile range, 59 seconds) for the long-axis group (P = .02). Mean number of needle sticks was 1.5 (±SD 0.7) in the short-axis group compared with 1.4 (±SD 0.7) in the long-axis group (P = .82). CONCLUSIONS: Short-axis USGPIV technique required less insertion time than the long-axis technique. Success rate was higher in the short-axis group, but this difference was not statistically significant. However, all of the failed IVs in the long axis were rescued successfully in short axis.