Addressing the needs of terminally-ill patients in Bosnia-Herzegovina: patients' perceptions and expectations

BACKGROUND

Many terminally ill patients in Bosnia-Herzegovina (BiH) fail to receive needed medical attention and social support. In 2016 a primary healthcare centreer (PHCC) in Doboj (BiH) requested the methodological and technical support of a local partner (Fondacija fami) and the Geneva University Hospitals to address the needs of terminally ill patients living at home. In order to design acceptable, affordable and sustainable solutions, we involved patients and their families in exploring needs, barriers and available resources.

METHODS

We conducted interviews with 62 purposely selected patients using a semi-structured interview guide designed to elicit patients' experiences, needs and expectations. Both qualitative and quantitative analyses were conducted, using an inductive thematic approach.

RESULTS

While patients were aware that their illnesses were incurable, they were poorly informed about medical and social support resources available to them. Family members appeared to be patients' main source of support, and often suffered from exhaustion and financial strain. Patients expressed feelings of helplessness and lack of control over their health. They wanted more support from health professionals for pain and other symptom management, as well as for anxiety and depression. Patients who were bedridden or with reduced mobility expressed strong feelings of loneliness, social exclusion, and stigma from community members and - occasionally - from health workers.

CONCLUSIONS

Our findings suggest a wide gap between patients' end-of-life care needs and existing services. In order to address the medical, psychological and social needs of terminally ill patients, a multi-pronged approach is called for, including not only better symptom management through training of health professionals and improved access to medication and equipment, but also a coordinated inter-professional, inter-institutional and multi-stakeholder effort aimed at offering comprehensive medical, psycho-social, educational and spiritual support.

Differential and opposed transcriptional effects of protein fusions containing the VP16 activation domain

Overexpression of strong transcriptional activators like herpes simplex virion protein 16 (VP16) may lead to non-specific inhibition of gene expression as a result of the titration of transcription factors. Here we report that a fusion between the homeoprotein Hoxa2 and the VP16 activation domain inhibits transcription from the strong promoter/enhancers of cytomegalovirus (CMV) and Rous sarcoma virus (RSV). A similar fusion involving a Hoxa2 mutant protein that is defective in DNA binding has no effect on the CMV promoter but increases, rather than inhibits, the RSV promoter activity. This suggests that depending on its ability to bind DNA, the VP16 activator can interact with different sets of cofactors, giving rise to distinct transcriptional effects.

Is ultrasonography useful in the assessment of diffuse parenchymal liver disease?

One hundred twenty-five patients investigated at the Royal Brisbane Hospital, who underwent both hepatic ultrasonography and liver biopsy between 1980 and 1983, were scored quantitatively for ultrasound features of loss of detail, echogenicity, and attenuation, as well as for histologic features of fat, fibrosis, and inflammation. Strong correlations were found between the score for fat content and each of the three ultrasound features, and between the score for hepatic fibrosis and loss of detail and echogenicity, but there was no strong correlation with attenuation. Hepatic inflammation did not correlate with any of the ultrasound features. The correlations for fat were strongest when the interval between ultrasonography and liver biopsy was less than or equal to 7 days. Although ultrasonography had a positive predictive value of 98% in the diagnosis of diffuse parenchymal abnormality, it did not distinguish fat from fibrosis nor reliably diagnose cirrhosis. Ultrasonography gave false-positive results in only 2 patients, but in 17 patients, false-negative ultrasound examinations were encountered. These findings indicate that ultrasound is not a useful screening investigation for parenchymal liver disease, nor is it useful in gauging hepatic pathology. However, abnormal hepatic ultrasonography in patients with suspected liver disease strongly suggests the presence of diffuse liver disease.