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.

[Fournier's gangrene and reconstruction of its defects].

Fournier's gangrene is remarkebly rare but severe, life threatening condition. Thanks to better earlz recongnition of disease in past few years, the percentage of patients which survive this condition is considerable, but consequence of this fact is large number of patients with defects of cutis and subcutis in perineal and scrotal reigions. Reconstruction of this defects is cimplicate and require helathy, well vascularised tissue from another anatomical region which is not involved in gangreneous process. Authors present two cases of reconstruciton of defects in perineal and scrotal regions. First case is large defect which is covered by transposition of musculus gracilis musculo-cutaneous flap. Second case is lesser defect which is enclosed by mobilisation of local skin flaps.

Multilayer vs. monolayer amniotic membrane transplantation for deep corneal ulcer treatment.

The purpose of the study was to evaluate the efficacy of multilayer amniotic transplantation (AMT) for reconstruction of corneal stroma and epithelium. Corneal ulcer (28) was a consequence of a previous infectious or neurotrophic keratitis. In the first group (17) ulcer was covered with monolayer AM, while in the other group (11) there were two or more layers of AM situated in the ulcer and the whole cornea was covered with AM sheet. Monolayer AMT was successful in 64% while the multilayer AMT success rate was 72%. AM gradually dissolved within 3-6 postoperative weeks. AM transplantation facilitates rapid healing of corneal epithelium, reduces inflammation and stimulates epithelial cell regrowth. In eyes with deep corneal ulcer multilayer technique proved to be better then monolayer procedure.

[Results of kidney transplantation at the Institute of Urology and Nephrology of the Serbian Clinical Center in Belgrade]. / Rezultati transplantacije bubrega u Institutu za urologiju i nefrologiju klinickog centra Srbije u Beogradu. Rezultati Rezultati Rezultati transplantacije bubrega u Institutu za urologiju i nefrologiju Klinickog centra Srbije u Beogradu.

UNLABELLED: Over the period 1980-1992 256 kidney transplantations were carried out in the Institute of Urology and Nephrology, Clinical Centre, Belgrade: 105 (41%) from cadaveric and 151 (59%) from alive related donors. The first kidney transplantation was performed in our Institution in 1974; however, in the first decade only 27 kidney transplantations were performed. Since 1987, thanks to an increasing number of living kidney donors, the number of transplantations continually increased, and after that period an average of 30 kidney transplantations are performed annually (Figure 1). The aim of the study was to establish the survival of patients and grafts, and factors influencing this survival, as well as to determine the causes of patients' death and graft loss. All the patients were followed-up in our outpatient department within at least 5 years to maximum 17 years. Drug combination therapies were changed in the observation period. From 1983 cyclosporin A (CyA) was added to azathioprine (Aza) and prednisolone (Pr). An increasing number of patients with high immunological risks necessitated the strongest initial immunosuppressive treatment with ALG in addition to Aza and Pr. CyA in a dose of 8 mg/kg b.w. was introduced when serum creatinine concentration fell below 300 mumol/L. The triple treatment including CyA, Aza and Pr was the most common maintenance immunosuppressive therapy in our patients. RESULTS: One and five years survived 95% and 75% of patients, and 84% and 52% of grafts. In assessing the impact of donor source, the year of transplantation, and age of donors we obtained the following results: Living related grafts survived better than cadaver grafts, especially during the first posttransplantation year (Figure 2). Furthermore, graft survival rates from 1987 to 1992 were significantly better than those from early period i.e. 1980 to 1986 (Figure 3). The significantly worse survival rate for grafts from donors older than 60 was noted than for grafts from younger donors. Searching for factors influencing the survival, non immunological and immunological differences between donors and recipients were analyzed. Our analysis showed that 50 living related donors were older than 60. In addition, the majority of them were 20 years older than their graft recipients. Two and more HLA mismatches were observed in 46% of our transplant patients, and 20 patients were highly sensitized. However, the immunological risks were higher in living related transplantations: different ABO blood groups, historical positive cross match reaction between donors and recipients (Table 1). A multivariate analysis using Cox proportional hazards model was performed to determine the important independent predictors of graft survival, and it revealed the following factors (Table 2): number of acute rejections, graft function at the end of the first month and until the end of the first posttransplant year, donors' age, and age and sex differences between donors and recipients. The occurrence of acute rejection at any time had a significant negative effect on graft survival. Since better HLA matching is likely to mean less early rejection it could be concluded that HLA matching influenced graft function and survival in our patients. Absence of acute rejection and delayed graft function or acute tubular necrosis were associated with an improvement of the graft function based on serum creatinine concentration, indicating that delayed graft function also influenced graft survival. The relative risk of graft loss was 2 times higher for patients receiving graft from donors older than 60. Until December 1997, when our analysis was done, of 256 kidney transplant patients 156 lost their grafts. The major causes of graft loss (Table 3) in the early period from 1980 to 1986 were non immunological such as acute tubular necrosis, vascular thrombosis and patients death with functioning graft. (ABSTRACT TRUNCATED)

[Quality of life after kidney transplantation]. / Kvalitet zivota nakon transplantacije bubrega.

316 kidney graft recipients responded to the questionnaire. The questionnaire concerned general, physical and mental life quality as well as sexual capacity, the attitude towards graft and donor and immunosuppressive side effects. The questionnaire had a rating scale from 0 to 4. The ratings were correlated with clinical data (creatinine, hemoglobins levels, duration after transplantation) by simple bivariate correlation coefficient (r) was estimated. Statistical significance (P < 0.05) was defined as r > 0.11 for n = 316. A general improvement of life quality after renal transplantation was noted by 87.5% of patients. This statement did not correlated to time after transplantation, serum creatinine levels or hemoglobin levels. 40.8% of patients evaluated their physical conditions as good, these data again did not correlate to hemoglobin levels or kidney function (expressed as serum creatinine). 73.1% regarded their mental condition as excellent and only 4% as poor. Again, mental condition did not correlate to hemoglobin levels or renal function. Sexual function was assessed to be good or excellent by 48% of patients. In contrast to these positive results, a minority of 14.5% of patients participated in sporting activities on a regular full basis and only 37.5% of all patients believed them selves to be capable of performing a full time job. Only 12.9% suffered from drug-related side effects. Transplantation itself posed no emotional problem for the recipients. Only 2.2% felt unpleasant about carrying a foreign organ and only 17.4% reflected on their donor.

[Quantitative indicators of renal function in scintigraphy with mercaptoacetyl-triglycine in patients with transplanted kidneys (99m TC MAG3 in the quantitative evaluation of the transplanted kidney)]. / Ispitivanje kvantitativnih pokazatelja funkcije bubrega tokom scintigrafije merkaptoacetil-triglicinom kod bolesnika s transplantisanim bubregom (99m TC MAG3 u kvantitativnoj proceni funkcije presacenog bubrega).

99mTc MAG3 is the radiopharmaceutical agent that provides simultaneous investigation of renal perfusion, functional parenchyma and collecting system. Clearance of MAG3 which is equal to its tubular extraction rate (TER) and other quantitative parameters of renal function can be determined at the same time. The aim of the study was to analyze importance of TER, clearance index (CI) and renal accumulation rate (RA) of MAG3 in the assessment of the functional status of renal transplants. 31 kidney transplant recipients and 14 healthy donors were investigated. Dynamic renal scintigraphy was carried out 20 min. after i.v. injection of 150-220 MBq MAG3. Clearance was determined by single sample volume distribution method. For the calculation of CI and RA counts from transplant region acquired during the second minute of study were used. Results of TER, CI and RA were correlated with blood urea (Pu), serum creatinine (Pcr) and creatinine clearance (Ccr). The sensitivity of TER, CI and RA in well functioning kidney graft as well as in chronic rejection were analyzed. We concluded that: TER, CI and RA are more sensitive in comparison with Pu, Pcr and Ccr in quantitative assessment of renal transplant function; sensitivity of TER is greater than the sensitivity of CI and RA.

Living related kidney donors over 60 years old.

The lack of available cadaveric organs for transplantation has resulted in an increased number of kidney transplants from living donors. During a period of 6 years, 149 kidney transplantations were performed from living related donors in our institute, 33.5% of whom were older than 60 years of age. In this study we examined the survival of patients and grafts as well as the graft function in 50 patients with transplants from donors over 60 years (mean age 65 years) as compared with those of 99 patients with transplants from donors younger than 60 years (mean age 47 years). There were no significant differences in the course of donor nephrectomy, postoperative complications, or remnant kidney function. However, delayed graft function occurred more frequently in recipients of transplants from older donors. Improvement in graft function was also slower in recipients of kidneys from older donors, with significant differences in serum creatinine levels observed during the first 12 months after transplantation. More frequent acute complications and more progressive chronic graft failure, irrespective of the causes, occurred during the 1st post-transplant year in recipients with grafts from older donors. Five-year patient survival (77% vs 92%) and kidney graft survival differed significantly for the same period with worse results for patients receiving grafts from older donors. It may be concluded that kidney grafts from donors older than 60 years -- and especially those older than 70 years -- may be used for living related kidney transplantation, but with precautions.

[Case report of pheochromocytoma with an atypical localization]. / Slucaj feohromocitoma s atipicnom lokalizacijom.

One of the endocrine causes of arterial hypertension is pheochromocytoma, usually located in the adrenal gland medulla. Extra-adrenal tumor locations are seldom encountered, and this can considerably complicate the diagnostic procedure. If a distinct clinical manifestation exists, supported by the finding of elevated catecholamine values, it is essential to persistently and carefully search for the place of their increased production. Such an attitude is completely justified in regard to the knowledge that this endocrinologically conditioned hypertension can be permanently and successfully solved with a surgical procedure. A case of pheochromocytoma has been presented with an atypical mediastinal location, prolonged and complicated diagnostic procedure, which has been successfully solved by surgery.

Intensity of thrombin activity and surgical trauma.

Increased level of in vivo thrombin activity represents the essential mark of prethrombotic state. In order to assess the influence of surgical trauma on the constitution of prethrombotic state immediately after the surgical intervention, dynamic estimations of fibrinopeptide A (FPA) have been done in a group of 18 patients who had undergone abdominal surgery and in the group of 25 patients who underwent the replacement of artificial hip, and who were on preventive treatment with subcutaneous heparin. At the same time the presence of soluble fibrinmonomer complex and, in the group of patients on heparin treatment, the concentration of plasma heparin were examined. The investigations were done before the surgical intervention and on the first, third and seventh postoperative day. Our dynamic study showed the existence of certain relation between the surgical trauma and values of FPA which were the expression of intensity of in vivo thrombin activity. The mean values of FPA increased markedly on the first postoperative day in comparison with the preoperative levels. On the third postoperative day significant reduction of FPA was observed and on the seventh day marked increase was found only in patients who were not on heparin prevention. Although preventive application of subcutaneous heparin did not affect the whole blood coagulability it showed a suppressive impact on the thrombin activity level in examined surgical patients.(ABSTRACT TRUNCATED AT 250 WORDS)