Corticosteroids therapy is the mainstay of treatment for GVHD, however, it heavily impacts on post transplant morbidity and new modalities are continually needed. Alemtuzumab a humanized monoclonal antibody to CD52 has been used mainly as GVHD prophylaxis. Only a few patients have been treated with this antibody. From December 2004 to May 2006, we recruited 13 steroid refractory acute GvHD patients in a prospective trial evaluating the efficacy of alemtuzumab (Campath 1H) after exclusion of other severe HST-related complications. Primary endpoints were response to treatment after 14 and 28 days. Secondary endpoints were side effects and incidence of infectious complications. Treatment consisted of Campath 1H 10mg given s.c. on days 1–5. Median age was 33 years old (range:1–59) years, a fludarabine-based reduce intensive conditioning (RIC) regimen was used and the hematopoietic cells were obtained from HLA-identical siblings in 12 cases and one patient received stem cell from umbilical cord blood. All but one received CSA and MTX for GvHD prophylaxis. GvHD affected gut in 6 cases, skin in 3 liver in 4, and combination of gut and skin in 6 patients. In 6 of the 13 patients the clinical manifestations of GVHD were noticed after the first 100 days of HSCT. Complete resolution of GvHD, partial response and no response were seen respectively in 23%, 62% and 15%. Six over the 13 patients were able to decrease steroid use. Five patients developed CMV (pp65) reactivation and 3 of them were successfully treated with valganciclovir. All patients maintained complete chimerism during and after alemtuzumab therapy, and after a median follow-up of 4 months (range, 1– 17months), 8 remain alive, 3 without evidence of GVHD. Five patients died, 3 due to GvHD and the others due to infectious complications. This preliminary study suggests that alemtuzumab is a well-tolerated agent and has a beneficial effect in the treatment of refractory GvHD. It is only a pilot study and more studies are needed, but we suggest that this modality could be used early in the management of these patients in order to improve quality of life and reduce the long-term side effects of corticosteroids.
In 2013, scientists implemented a binational exchange for emergency planners and responders in communities near Nevado del Ruiz in Colombia and volcanoes of the Cascade Range of the United States (US). This program was designed to promote understanding of volcanic disasters and effective mitigation options, motivate participants to strengthen emergency planning efforts, and promote trust-building among participants. The 2013 Binational Exchange was funded by the Volcano Disaster Assistance Program (VDAP), a joint U.S. Geological Survey (USGS)-U.S. Agency for International Development (USAID) program. During a week-long visit to Colombian emergency response agencies, Nevado del Ruiz, and lahar-destroyed ruins of the city of Armero and the region of Viejo Rio Claro, US participants became familiar with Colombian counterparts who have had recent and frequent experiences addressing volcanic crises. Aging survivors and authorities of the Nevado del Ruiz catastrophe of 1985 gave participants first-hand accounts, and ideas for improved preparedness and response. While in the US, Colombian participants observed emergency response capabilities and facilities, and received training in systems of incident command. Colombians made presentations to the US public and officials about the similarities of lahar risks in both nations. This article describes the 2013 Binational Exchange as an experiential learning event and uses results of post-exchange discussions and interviews as evidence of steps achieved within the learning process. Six years hence, this article provides examples of progress with volcano hazards mitigation in both nations. The article offers the binational exchange model as an effective tool that employs both experiential learning and socialization of participants to create a highly motivating and effective learning environment.
The UTRGV DHR Internal Medicine Program conducted a study addressing end of life (EOL) care focused on our Hispanic community in regards to communication and trust between patients, caregivers, and healthcare providers. Our residents train at a community hospital which cares for an 89% Hispanic population of 1.2 million, spanning over 4 counties of the Rio Grande Valley. Trainees are often involved in family meetings while treating hospitalized, terminally ill patients. Although family meetings are a standard approach in palliative care, Hispanic family meetings tend to occur more often and with a larger, extended family unit. Our intent was to educate our residents to initiate conversations about EOL care choices promoting delivery of patient-centered, family oriented care utilizing culturally appropriate information regarding EOL issues. Baseline surveys were provided to all 39 trainees which assessed anxiety, incompetence, and communication skills in delivering bad news during family meetings. An advanced care planning process was implemented over 3 months with a goal to engage patients in EOL conversations, initiation, and completion of advanced directives. Residents received weekly training on interactive methods and ethical concepts including group discussions, role-playing, and demonstrations which were culturally and linguistically appropriate. We found that physician competence in conducting Hispanic family meetings is vital. Residents completed a post-training survey resulting in 100% improved attitudes and behaviors such as confidence, satisfaction, caring and empathy. They felt more comfortable and prepared to speak to a larger family unit who was likely to ask a lot of questions and request multiple meetings.
Hispanic minorities have a higher incidence of chronic disease which may result in increased hospitalizations and life-threatening illness. Our growing geriatric population led our community hospital to create a dedicated Palliative Care department, an interprofessional team of physicians, nursing, pharmacy, social work, counselors, and chaplains whose collaborative practice has improved outcomes thus strengthening healthcare delivery. When our new medical school established graduate programs, including Internal Medicine residency and Hospice/Palliative Medicine fellowship, our team embraced the opportunity to optimize our palliative service through enhanced interprofessional care. We created a geriatric rotation on July 1, 2018 in which 60% of residents worked with palliative care professionals as a consult team bringing together the inpatient resident service and palliative interdisciplinary team. This collaborative model allowed the palliative team to interface with our trainees and teach them to identify the range of needs of older adults early on in their care. Residents reported 100% satisfaction on evaluations, specifically on clinical training, goal fulfillment, and team support. Our learners valued the opportunity to learn with and from other healthcare professionals. Supervising providers also felt that working with residents was beneficial to their practice habits (i.e., providing evidence-based practices, application of guidelines), which offered them a more holistic approach in caring for patients and families. The interprofessional collaboration between a community hospital and medical school to educate and train clinicians who care for individuals with advanced illness has fostered confidence, trust, mutual respect, open communication and effective sharing of critical information for both clinicians and patients.
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