scholarly journals Report on the Treatment of Hodgkin Lymphoma With ABVD Chemotherapy at Two Rural District Hospitals in Rwanda

2016 ◽  
Vol 2 (3_suppl) ◽  
pp. 67s-67s ◽  
Author(s):  
Rebecca J. DeBoer ◽  
Caitlin D. Driscoll ◽  
Yvan Butera ◽  
Jean Bosco Bigirimana ◽  
Clemence Muhayimana ◽  
...  
Keyword(s):  
Hodgkin Lymphoma ◽  
Conflicts Of Interest ◽  
Treatment Protocol ◽  
Rural District ◽  
Standard Chemotherapy ◽  
International Partnership ◽  
Low Resource ◽  
High Resource ◽  
District Hospitals ◽  
Abvd Chemotherapy

Abstract 34 Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high resource settings, there are few reports of HL treatment in low resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and preliminary outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy confirmed HL seen at Butaro and Rwinkwavu hospitals between June 2012 and August 2015. Data was extracted from clinical charts and analyzed using descriptive statistics. Results: 43 HL patients were seen at Butaro (n=38) and Rwinkwavu (n=5); 58% male, median age 17 (range 4-54). Five (12%) were HIV positive. Of 22 patients with biopsy specimens evaluated for EBV, 12 (55%) were positive, 9 (41%) negative, and one indeterminate. Most patients were staged with chest x-ray (79%); fewer had liver ultrasound (33%) or CT (9%). With that, Ann Arbor stages were I (28%), II (23%), III (21%), IV (21%), and undetermined (7%). Of 39 patients who started ABVD, 25 (64%) completed all 6 cycles. Median time to completion of the 24 week ABVD regimen was 26.1 weeks (IQR 25-27); 26 patients (67%) experienced at least one treatment delay. Dose reductions were rare. At the time of data extraction, 5 (12%) were still on treatment, 18 (43%) in remission, 2 (5%) alive with relapse, 15 (35%) deceased, and 2 (5%) lost to follow up. Conclusions: Here we demonstrate the feasibility of treating HL with standard chemotherapy in a low resource setting through international partnership. Our preliminary results suggest that a majority of patients who complete treatment may experience a clinically significant remission with this approach. Further data analysis will identify areas for improvement with the hope of increasing sustained remissions. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

scholarly journals Report on the Treatment of Hodgkin Lymphoma with ABVD Chemotherapy at Two Rural District Hospitals in Rwanda

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 4053-4053
Author(s):  
Cyprien Shyirambere ◽  
Rebecca Deboer ◽  
Yvan Butera ◽  
Caitlin Driscoll ◽  
Jean Bosco Bigirimana ◽  
...  
Keyword(s):  
Hodgkin Lymphoma ◽  
Median Time ◽  
High Income ◽  
Rural District ◽  
Standard Chemotherapy ◽  
Loss To Follow Up ◽  
Low Resource ◽  
District Hospitals ◽  
Abvd Chemotherapy

Background: While Hodgkin lymphoma (HL) is highly curable with standard chemotherapy in high-resource settings, there are few reports of HL treatment in low-resource settings. In Rwanda, a treatment protocol using six cycles of ABVD chemotherapy (doxorubicin, bleomycin, vinblastine, dacarbazine) without radiotherapy has been implemented at two rural district hospitals. Here we report on the feasibility of this approach, our patient characteristics, and outcomes. Methods: We conducted a retrospective cohort study of all patients with biopsy-confirmed HL seen at Butaro and Rwinkwavu hospitals between October 2009 and June 2018. Data were extracted from clinical charts and analyzed using descriptive statistics and Kaplan-Meier logrank testing. Results: Ninety HL patients were seen at Butaro (n=85) and Rwinkwavu (n=5); 58% male, median age 16 (IQR 10.6-30.5) with 54% under age 18. Eleven (12%) were HIV positive. Mean duration of presenting symptoms at the time of intake was 54 weeks; 70% had B symptoms. Nodular sclerosis was the predominant histological subtype (47%) followed by mixed cellularity (28%). Of 24 biopsy specimens evaluated for EBV, 14 (58%) were positive, 10 (42%) negative. Most patients were staged with chest x-ray (81%); fewer had abdominal ultrasound (34%), CT (21%), or bone marrow biopsy (20%). Resulting Ann Arbor stages were I (17%), II (28%), III (32%), IV (20%), and undetermined (3%). Median time from initial biopsy to first dose of ABVD was 6.1 weeks (IQR 3.6-11.9). Of 76 patients who started ABVD, 56 (74%) completed all 6 cycles; the leading reasons for discontinuation were loss to follow up (n=9) and death (n=7). Median time to completion of the 24-week ABVD regimen was 26.1 weeks; 51 patients (67%) experienced at least one treatment delay. Neutropenia, social factors, and infection were the most common reasons for delays. Dose reductions were rare. Mean dose intensity over 6 cycles was 87.2% calculated per Owadally, et al. 2010; <86% in 40% of patients, 86-97% in 32%, and >97% in 28%. Of the 76 patients started on ABVD, 34 (45%) are in clinical remission, 21 (28%) are deceased, 2 (3%) referred to palliative care, and 19 (25%) are lost to follow up at a median interval of 48 months from intake. Univariate analysis demonstrates that stage III-IV (p=0.0000), ECOG performance status 2-4 (p=0.0004), hemoglobin <10.5 g/dL (p=0.01), WBC > 15,000 mm3 (p=0.05), B symptoms (p=0.004), and extranodal disease (0.0004) were associated with worse survival. Conclusions: We observed a strikingly younger age distribution in our cohort compared to the classic bimodal distribution reported in high income countries, suggesting biologic differences that warrant further investigation. Treating HL with standard chemotherapy in a low-resource setting through international partnership is feasible, and nearly half of patients who complete treatment may experience a clinically significant remission with this approach. Late presentation, treatment delays, and loss to follow up are among major reasons to explain the discrepancy in survival compared to high income countries. Further efforts should tackle these identified barriers to achieve better survival outcomes. Figure Disclosures No relevant conflicts of interest to declare.

Pediatric Hodgkin Lymphoma-Treatment Outcome with COPDac/ABVD Combination Chemotherapy – Single Institution Experience

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 5449-5449
Author(s):  
Mehboob Ahmed ◽  
Shazia Riaz ◽  
Syed Nasir Abbas ◽  
Fahim Rehman
Keyword(s):  
Hodgkin Lymphoma ◽  
Conflicts Of Interest ◽  
Single Agent ◽  
Treatment Protocol ◽  
Comparable Efficacy ◽  
Single Center ◽  
Multiple Treatment ◽  
Single Center Experience ◽  
First Line Therapy

Abstract Background: We describe single center experience of using ABVD/COPDac . This regimen was adapted due to perceived excessive toxicity with OEPA/COPDac by treating physicians. Hodgkin lymphoma is being treated with multiple treatment regimens single agent or in combination. MOPP (mechlorethamine, vincristine, procarbazine and prednisolone) has been standard treatment for almost two decads. But it had significant toxic effects including infertility in both genders, myelosuppression and second malignancies . ChlvPP( chlorambucil, vincristine, procarbazine and prednisolone ) has comparable efficacy and toxicities to MOPP . ABVD( Adriamycin, bleomycin, vincristine and doxorubicin ) was mostly used as second line with high activity without permanent male sterility, myelodysplasia or risk of leukemia. Objective : We describe single center experience of using ABVD/COPDac . This regimen was adapted due to perceived excessive toxicity with OEPA/COPDac by treating physicians. Results 62 patients out of 301( 20.6%) with age range of 2-18 years were treated with COPDac/ABVD alternating courses depending on the treatment group from 2012 to date. Out of this 62, 49 (79%) are on follow up and are free from disease relapse or recurrence. Mean duration of follow up is 12 months with a range of 8-16 months. No patient lost to follow up. No death reported due to any cause during or after completion of treatment till last follow up. 9 out of 62 has had progression of disease while on this treatment protocol (15%) and 4 out of 62(6%) has had relapse after completion of the therapy. Conclusion In our single center experience of ABVD/COPDac as first line therapy seems effective and safe when compared with historical published literature. Disclosures No relevant conflicts of interest to declare.

Treatment of Hodgkin Lymphoma without G-CSF Does Not Increase the Risk of Febrile Neutropenia.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 2502-2502
Author(s):  
Leonard A. Minuk ◽  
Ian Chin-Yee ◽  
Kang Howson-Jan ◽  
Reinhard Lohmann ◽  
Alejandro Lazo-Langner ◽  
...  
Keyword(s):  
Febrile Neutropenia ◽  
Hodgkin Lymphoma ◽  
Neutrophil Count ◽  
Conflicts Of Interest ◽  
Bone Marrow Involvement ◽  
Practice Change ◽  
Hematologic Toxicity ◽  
Chemotherapy Administration ◽  
Dose Delay ◽  
Abvd Chemotherapy

Abstract Abstract 2502 Poster Board II-479 Background: Patients with Hodgkin Lymphoma (HL) being treated with ABVD chemotherapy frequently develop neutropenia, though the complication of febrile neutropenia is relatively uncommon. In most cancer centres, including our own until recently, the presence of neutropenia on the planned day of chemotherapy administration (absolute neutrophil count (ANC) <1.5×109/L) often resulted in delays in chemotherapy administration and/or dose attenuation, plus the addition of G-CSF prophylaxis through all subsequent cycles of chemotherapy. G-CSF is costly and it can cause side effects such as bone pain. There is also some suggestion in the literature that G-CSF may increase the risk of bleomycin lung toxicity (BLT). Several retrospective studies have reported that full dose ABVD can be safely administered to patients without routine G-CSF support, regardless of the neutrophil count on the day of treatment. Based on this data, our centre decided to change the practice of routinely delaying chemotherapy and starting G-CSF prophylaxis in neutropenic patients, and to prospectively monitor the safety of this practice change. We present the results of our planned interim safety analysis. Methods: Newly diagnosed patients with HL with no bone marrow involvement and no significant co-morbidities were enrolled and followed prospectively throughout their treatment. ABVD chemotherapy was administered every two weeks without dose delay or attenuation and without the addition of G-CSF, regardless of the neutrophil count on the day of treatment. Dose reductions were permitted for non-hematological toxicities. G-CSF was added as secondary prophylaxis to all subsequent cycles in patients who developed febrile neutropenia. We also retrospectively reviewed the charts of patients with HL treated with ABVD at our centre from 2004-2007 (prior to practice change) and collected data on the incidence of neutropenia, febrile neutropenia, G-CSF use and BLT. Continuous variables were analysed using the Mann Whitney U test and dichotomous variables using Chi squared analysis. Results: Since September 2008, 17 patients have been enrolled in the study. No patients met criteria for exclusion. A total of 149 ‘doses' (half cycles) of ABVD have been administered so far. Table 1 shows demographic information on the prospective and retrospective patient populations, as well as rates of neutropenia, febrile neutropenia, and BLT. Almost all study patients (15/17, 88%) had documented neutropenia at some point during treatment, the majority (13 patients) as early as cycle 1B. Excluding cycle 1A, the median neutrophil count on day of treatment was 1.3×109/L. Half of the chemotherapy doses (74/149) were administered with an ANC <1.5×109/L; one third (52 doses) with grade 3/4 neutropenia. None of the chemotherapy was dose reduced (except for non-hematologic toxicity) and most of the treatments were given on time, with a median dose interval of 14 days. One patient developed BLT after cycle 4B. There was 1 episode of low risk febrile neutropenia occurring after cycle 3B in which no causative organism was identified. This patient received all subsequent chemotherapy with G-CSF prophylaxis with no further episodes of neutropenic fever. Conclusion: This interim analysis shows that ABVD chemotherapy can be safely administered to patients with HL without dose attenuation, delays or the routine use of G-CSF prophylaxis in the setting of neutropenia. This practice change resulted in a similar very low rate of febrile neutropenia (<1%), but significant reductions in cost and dose delay secondary to neutropenia. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Investigating competencies needed by European-trained doctors in rural South African hospitals

2020 ◽  
Vol 12 (1) ◽  
Author(s):  
James R. Barnacle ◽  
Oliver Johnson ◽  
Ian Couper
Keyword(s):  
South Africa ◽  
South African ◽  
Online Survey ◽  
Rural District ◽  
Eastern Cape ◽  
Rural Medicine ◽  
Rural South ◽  
District Hospitals ◽  
Kwazulu Natal ◽  
Postgraduate Diploma

Background: Many European-trained doctors (ETDs) recruited to work in rural district hospitals in South Africa have insufficient generalist competencies for the range of practice required. Africa Health Placements recruits ETDs to work in rural hospitals in Africa. Many of these doctors feel inadequately prepared. The Stellenbosch University Ukwanda Centre for Rural Health is launching a Postgraduate Diploma in Rural Medicine to help prepare doctors for such work.Aim: To determine the competencies gap for ETDs working in rural district hospitals in South Africa to inform the curriculum of the PG Dip (Rural Medicine).Setting: Rural district hospitals in South Africa.Methods: Nine hospitals in the Eastern Cape, KwaZulu-Natal and Mpumalanga were purposefully selected by Africa Health Placements as receiving ETDs. An online survey was developed asking about the most important competencies and weaknesses for ETDs when working rurally. The clinical manager and any ETDs currently working in each hospital were invited to complete the survey.Results: Surveys were completed by 19 ETDs and five clinical managers. The top clinical competencies in relation to 10 specific domains were identified. The results also indicate broader competencies required, specific skills gaps, the strengths that ETDs bring to South Africa and how ETDs prepare themselves for working in this context.Conclusion: This study identifies the important competency gaps among ETDs and provides useful direction for the diploma and other future training initiatives. The diploma faculty must reflect on these findings and ensure the curriculum is aligned with these gaps.

scholarly journals A framework for designing medical devices resilient to low-resource settings

2021 ◽  
Vol 17 (1) ◽  
Author(s):  
Davide Piaggio ◽  
Rossana Castaldo ◽  
Marco Cinelli ◽  
Sara Cinelli ◽  
Alessia Maccaro ◽  
...  
Keyword(s):  
Delphi Study ◽  
Middle Income ◽  
Low Resource Settings ◽  
Health Technologies ◽  
Low Resource ◽  
Middle Income Countries ◽  
High Resource ◽  
International Experts ◽  
Global Population ◽  
Different Parts

Abstract Background To date (April 2021), medical device (MD) design approaches have failed to consider the contexts where MDs can be operationalised. Although most of the global population lives and is treated in Low- and Middle-Income Countries (LMCIs), over 80% of the MD market share is in high-resource settings, which set de facto standards that cannot be taken for granted in lower resource settings. Using a MD designed for high-resource settings in LMICs may hinder its safe and efficient operationalisation. In the literature, many criteria for frameworks to support resilient MD design were presented. However, since the available criteria (as of 2021) are far from being consensual and comprehensive, the aim of this study is to raise awareness about such challenges and to scope experts’ consensus regarding the essentiality of MD design criteria. Results This paper presents a novel application of Delphi study and Multiple Criteria Decision Analysis (MCDA) to develop a framework comprising 26 essential criteria, which were evaluated and chosen by international experts coming from different parts of the world. This framework was validated by analysing some MDs presented in the WHO Compendium of innovative health technologies for low-resource settings. Conclusions This novel holistic framework takes into account some domains that are usually underestimated by MDs designers. For this reason, it can be used by experts designing MDs resilient to low-resource settings and it can also assist policymakers and non-governmental organisations in shaping the future of global healthcare.

Low Resource ASR: The Surprising Effectiveness of High Resource Transliteration

2021 ◽  
Author(s):  
Shreya Khare ◽  
Ashish Mittal ◽  
Anuj Diwan ◽  
Sunita Sarawagi ◽  
Preethi Jyothi ◽  
...  
Keyword(s):  
Low Resource ◽  
High Resource

Psychological Determinants of Personaliti Bullying in the Sociometric Dimension

2020 ◽  
Keyword(s):  
Conflicts Of Interest ◽  
Mental States ◽  
Negative Consequences ◽  
International Partnership ◽  
Psychological Determinants ◽  
Exchange Program ◽  
Self Confidence ◽  
Depth Study ◽  
The Individual ◽  
High Degree

The article considers the main problems that arise when conflicts of interest between people in the sociometric dimension. The need for their comprehensive study will help to eliminate the negative consequences and use positive solutions to these conflicts for the development of the individual, his integration into society. The urgency of the work lies in the search for rational approaches to the origin and prevention of psychological bullying in the sociometric dimension as a consequence of the conflict of personality in agreement with its characterological education, psychological attitudes and beliefs. that is why the problem of bullying deserves in-depth study. The aim of the article is to study the influence of bullying on the uncertainty of adolescents in the sociometric dimension. The work is based on the provisions of prevention and reduction of external discrimination, isolation, humiliation and harassment, which will serve as factors to prevent personal uncertainty in the future. Bullying undermines the victim's self-confidence, destroys health, self-esteem and human dignity. There is a bullying structure, which is a social system that includes the offender, the victim and observers. Methods of measuring the manifestations of psychological bullying are determined, the corresponding set of methods of psychodiagnostics is presented and tested. Empirical data show that with insufficient and excessive mobilization of the individual there are with a high degree of probability such mental states that disturb the adaptive balance. Thus, with insufficient mobilization in a difficult life situation, it is likely to appear apathy and reduce energy expenditure. On the other hand, in a situation of excessive mobilization there is a state of high voltage against the background of excessive energy consumption. The results of this study are important in establishing international cooperation in the study of programs and projects in the context of transforming the human health system in accordance with international partnership standards and implementing a cultural exchange program for education and culture between countries.

scholarly journals Patient, clinician and logistic barriers to blood pressure control among adult hypertensives in rural district hospitals in Rwanda: a cross-sectional study

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
J. P. Sibomana ◽  
R. L. McNamara ◽  
T. D. Walker
Keyword(s):  
Blood Pressure ◽  
Blood Pressure Control ◽  
Pressure Control ◽  
Rural District ◽  
World Health ◽  
Medication Cost ◽  
Hypertension Management ◽  
Cross Sectional ◽  
Major Barrier ◽  
District Hospitals

Abstract Background Hypertension management in rural, resource-poor settings is difficult. Detailed understanding of patient, clinician and logistic factors which pose barriers to effective blood pressure control could enable strategies to improve control to be implemented. Methods This cross-sectional, multifactorial, observational study was conducted at four rural Rwandan district hospitals, examining patient, clinician and logistic factors. Questionnaires were administered to consenting adult outpatient hypertensive patients, obtaining information on sociodemographic factors, past management for hypertension, and adherence (by Morisky Medication Adherence 8-item Scale (MMAS-8). Treating clinicians identified local difficulties in providing hypertension management from a standard World Health Organisation list and nominated their preferred treatment regimens. Blood pressure measurements and other clinical data were collected during the study visit and used to determine blood pressure control, according to goals from JNC-8 guidelines. Medication availability and cost at each hospital’s pharmacy were reviewed as logistic barriers to treatment. Results The 112 participating patients were 80% female, with only 41% having completed primary education. Self-reported adherence by the MMAS-8 was high in 77% (86/112) and significantly associated) with literacy, lack of medication side effects and the particular hospital and pharmacy attended (all p < 0.05). However, of 89 patients with blood pressure data, only 26 (29%) had achieved goal blood pressure. No patient factor were statistically associated with poor blood pressure control. Among 30 participating clinicians, deficiencies in knowledge were evident; 43% (13/30) and 37% (11/30) chose a loop diuretic as their prescribed medication and as an ideal medication, respectively, for a newly diagnosed hypertensive patient without comorbidities, counter to JNC 8 recommendations, and 50% (15/30) identified clinician non-adherence to hypertension guidelines as a barrier. In the pharmacies, common anti-hypertensive medications were affordably available (> 6 out of 8 examined medications available in all pharmacies, cost <US$0.50 per month); however, clinicians perceived medication cost and availability to be barriers to care. Conclusions Clinician-based factors are a major barrier to blood pressure control in rural district hospitals in Rwanda, and blood pressure control overall was poor. Patient and logistic barriers to blood pressure were not evident in this study.

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