Hemorrhage from Adrenal Vein Rupture during Adrenal Vein Sampling

We describe a case of right adrenal hemorrhage from adrenal vein sampling treated conservatively with overnight admission and pain control. We review the existing literature on rates of this complication, typical clinical outcomes, and practical tips to avoid its occurrence.

ACR Appropriateness Criteria® Central Venous Access Device and Site Selection

The use of central venous access devices is ubiquitous in both inpatient and outpatient settings, whether for critical care, oncology, hemodialysis, parenteral nutrition, or diagnostic purposes. Radiology has a well-established role in the placement of these devices due to demonstrated benefits of radiologic placement in multiple clinical settings. A wide variety of devices are available for central venous access and optimal device selection is a common clinical challenge. Central venous access devices may be nontunneled, tunneled, or implantable. They may be centrally or peripherally inserted by way of veins in the neck, extremities, or elsewhere. Each device and access site presents specific risks that should be considered in each clinical scenario to minimize the risk of harm. The risk of infection and mechanical injury should be minimized in all patients. In hemodialysis patients, preservation of future access is an additional important consideration. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Asking questions can help: development and preliminary evaluation of a question prompt list for patients living with Heart Failure

Funding Acknowledgements

Type of funding sources: None.

Background

Discussing disease trajectories with patients living with chronic illnesses is recommended in guidelines worldwide and Heart Failure [HF] is no different. Discussions are centered around day-to-day disease management and less on illness trajectory including prognosis, symptoms, treatment options, preferences, and advanced care planning. Lack of open communication is common leading to prolonged suffering and unnecessary admissions [1] and can be improved when patients are able to initiate discussions, ask questions that are of concern to them, and engage in healthcare decision making [2,3].

A range of approaches have been employed to promote patient participation and empowerment. One such approach is the use of Question Prompt Lists [QPL]. Studies show that QPLs are linked to more questions asked, increased satisfaction, and reduced unmet information needs [3,4]. Despite this, they are less commonly used in non-oncology contexts and not available in Lebanon. Health system differences and cultural factors may influence content and impact of QPLs and as such cross-cultural adaptation is essential [5]. As the need for disclosure can vary among cultures, examining QPLs through an anthropological lens is imperative.

Purpose

To develop a culturally sensitive QPL designed to improve communication about HF illness trajectory.

Methods

A review of literature on HF QPLs was done. To address cultural and country specific needs, studies on HF from Lebanon and the Middle East were reviewed. This comprised the initial draft of a QPL that included context specific challenges and concerns. A Delphi survey inviting an interdisciplinary team of healthcare providers caring for HF patients was used to seek expert consensus regarding the draft. Sixteen experts rated each question for relevance, using a Likert scale from 0 to 4, clarity, and need to rephrase and suggested additional questions. Ratings were analyzed to determine the level of consensus. Questions that received less than 80% favorable answers [Very Relevant/Relevant and/or more than 20% indicated lack of clarity or the need to rephrase] were discussed in the second round of Delphi. Experts met and reviewed the comments provided on some questions and questions that were rated unfavorably, suggested for deletion, as well as those added by the panelists. Clarity of questions and suggestions for wording improvements was ensured.

Results

During the second round of Delphi, 12 questions were rephrased, one was dropped, and one was added. A final QPL of 42 questions and 6 categories was reached.

Conclusion

This is the first step of more research work that will aim at developing Arabic QPLs in the Middle East. The immediate next step would be repeating the Survey with patients, caregivers, and HF providers. Data will be analyzed using central tendency and levels of dispersion to assess consensus. The final QPLs will be translated to Arabic, culturally validated, and pilot tested in Lebanon.

Dyadic lived experiences of ventricular assist device in a crisis torn country

Funding Acknowledgements

Type of funding sources: None.

Dyadic lived experiences of ventricular assist device in a crisis torn country

Background

 Patients with Heart Failure benefit from advanced treatment modalities like the Left Ventricular Assist Device [VAD]. Literature has addressed the complexity of the VAD experience in terms of lifestyle changes and adaptive processes affecting dyads, patients and their caregivers 1,2. In Lebanon, a knowledge gap on the experiences of dyads after VAD implantation is identified. Dyads in Lebanon are challenged by the country’s political and economic instability. It is thus imperative to explore VAD dyadic lived experiences in a country with limited resources and aggravated crises. 

Purpose

 This study aims to explore the lived experiences of VAD dyads and gain insight on how they adapt to their new life with the VAD.

Methods

 Following a qualitative phenomenological design, we interviewed 5 patients [3:2, Male: Female] along with their identified caregivers [1:4, Male: Female]. Transcription was completed verbatim in Arabic. Back translation to English was completed independently by the researchers. Colaizzi’s descriptive phenomenological method guided the thematic analysis.

Results

 4 out of 5 dyads reported a complementary care approach where both members of the dyad counterpart each other in caring for the VAD patient. One dyad had a caregiver oriented approach. Two themes emerged capturing determinants that impact adaptation to a life with a VAD. 

Theme I

Challenges to the VAD experience, personal and contextual. Patients perceived body image alterations as a barrier for intimacy. Spousal caregiver role was problematic. With patients’ heightened sensitivity, spouses dwelled on the need for vigilance with every act. Initially, the presence of the VAD was coupled with dyadic anticipated concern on adaptation and caregiving. Patients complained about the weight of the VAD. Contextual challenges centered around the economic crisis resulting in supply cutoffs and inflated prices for daily VAD care supplies. Along with the medical bills’ steep rise, dyads had to endure electrical supply shortage. 

Theme II

Facilitators to the VAD experience, personal and cultural. Dyads considered the need for VAD placement to be determined by God’s will. Faith assisted them to cope and accept their lifestyle changes. Mental wellbeing promoted high spirits and positively impacted their recovery. In line with the collectivistic culture, support from the family and social circle elevated morale. One of the patients who was unmarried described the lack of responsibilities as a facilitator for acceptance of the VAD. 

Conclusion

This is one of the first studies to address the paucity of knowledge on how dyads experience their new life following VAD implantation. The unstable living conditions add to the complexity of the VAD experience. The identified challenges and facilitators inform healthcare professionals on means to support VAD patient caregiver dyads.