University EBP Report: Factors Predicting Hodgkin's Lymphoma Relapse

This report employs an evidence-based practice approach to investigate the factors associated with the relapse of Hodgkin's lymphoma (HL). It begins with a detailed search strategy utilizing databases like Medline, PsycINFO, CINAHL, and BNI, employing specific keywords, Boolean operators, and inclusion/exclusion criteria to identify relevant peer-reviewed articles published within the last ten years. The report focuses on articles emphasizing relapse factors in adult patients, excluding case studies and non-English publications. The methodological quality of the selected articles is assessed. A specific paper by Shah et al. (2016) is critically appraised using the CASP tool, examining risk factors predicting outcomes for primary refractory HL patients treated with salvage chemotherapy and autologous stem cell transplantation. The report aims to provide insights into predicting factors, which include anaemia, age, presence of B symptoms, low-performance status (PS), extranodal relapse, bulky disease or relapse in the previous radiation field, and their impact on patient outcomes, contributing to improved patient care strategies.

Running head: HODGKIN’S LYMPHOMA
Relapse of Hodgkin’s lymphoma
Name of the Student:
Name of the University:
Author Note:

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Table of Contents
Introduction................................................................................................................................2
Search strategy...........................................................................................................................3
Inclusion criteria.....................................................................................................................5
Exclusion criteria...................................................................................................................5
Assessment of methodological quality...................................................................................6
Critical appraisal........................................................................................................................7
Paper selected.........................................................................................................................7
Overview................................................................................................................................8
Reasons for selecting the stated paper...................................................................................8
A brief overview of the paper................................................................................................8
Critical Appraisal of the Paper using the CASP tool.................................................................9
Summary..............................................................................................................................13
References................................................................................................................................14
Appendix..................................................................................................................................17
Search strategy for CINHL..................................................................................................17
Search strategy for Medline.................................................................................................17
Search strategy for BNI........................................................................................................18
Search strategy for PsycINFO..............................................................................................18

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Introduction
Evidence-based practice is a diligent approach of problem-solving to clinical practice
that integrates the most suitable evidence from the available literature of well-organised
studies, patient preferences and values, and the expertise and opinions of the patient in the
decision-making of their treatment. It implies the incorporation of individual clinical
expertise of the nursing professionals with the most relevant clinical evidence available from
systematic research (LoBiondo-Wood, Haber & Titler, 2018). The evidence-based practice
serves as a vital tool in providing adequate care to the patient to improve the overall patient
outcome. Evidence-based practice is useful in promoting a habit of self-inquiry among the
nursing professionals while developing a plan for the care of the patient which guides them to
search for more effective ways of improving patient outcome by integrating their experiences
with the most suitable research study available on the issue. It also enables the judicious use
of finite health care resources (Ellis, 2019).
Hodgkin’s lymphoma is observed as a curable disease with the latest and advanced
technologies for its treatment for about two-thirds of the patient population. However, a
minor section of the patients has demonstrated instances of relapses, specifically in patients
with advanced HL (Nikolaenko, Chen & Herrera, 2017). This paper focuses on developing a
search strategy to extract the best available evidence on the factors predicted to be associated
with a relapse of the Hodgkin’s lymphoma disease. It focuses on the factors estimated for the
second diagnosis of Hodgkin’s lymphoma (HL) after a first-line cure. It does not include
methods of diagnosis or management strategies of Hodgkin’s lymphoma. Evaluating the
factors associated with the relapse of HL is essential as it is observed that about 20% of the
patients experience relapse despite highly efficient first-line techniques of cure of HL at

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present (von Tresckow & Moskowitz, 2016). Moreover, estimates suggest that the relapse
occurs above the age of 60 years, though most patients were diagnoses with it in the early
stages. Increasing incidences of relapses of the disease are indicative of inefficiency of the
existing technology in the curability of the disease. Thus, it is essential to identify the
probable causes for relapses of HL to analyse the efficiency of the treatment options used in
first-line cure. The current government policy on the relapse of HL focuses on reviewing the
effect of post-autologous stem cell transplantation (ASCT) treatment and the use of
Brentuximab Vedotin (BV) (Australian Government Department of Health, 2016;
Kaloyannidis et al., 2020). This topic requires critically predicting the factors, which include
anaemia, age, presence of B symptoms, low-performance status (PS), extranodal relapse,
bulky disease or relapse in the previous radiation field. This critical estimation of the factors
is essential because despite the advanced treatment options for the treatment of HL, which
includes ASCT, responders have been diagnosed with a relapse of the disease. The
percentage of relapse among responders in 20% and is vital to study the factors associated
with the relapse. The association of the prognostic factors with HL helps in developing
strategies to reduce the chance of a relapse and prepare the patients which demonstrate the
factors and are at high risks.
The question under focus is as follows:
In patients previously cured with HL, what are the predicted factors associated with its
relapse?
Search strategy
The medical databases used to select the most suitable literary article include
Medline, PsycINFO, CINHAL and BNI. The NICE Healthcare Database Advanced search
was used to access these medical databases. These databases were preferred for the search for

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highly relevant research articles as they consist of a multitude of decent and appropriate study
articles on nursing practices. These databases have a collection of papers that provide
appropriate direction to the professional practices of various health care professionals such as
mental health therapists, nursing professionals, social and health care workers (Aagaard,
Lund & Juhl, 2016). Thus, the selection of these databases was justified as the question under
the review of this paper is primarily on the professional practices of nurses. The databases
were searched with the help of search terms and keywords. The first set of keywords used to
search included “relapse”, “Hodgkin’s lymphoma”, “predicted factors” along with other
search terms such as “relapse factors”, “lymphoma recurrence”, “recurrence factors”, “HL
relapse” and “relapse causes”. The primary keywords were accompanied with additional
terms for the search to broaden the search area and increase the total count of search results
obtained. The high count of search results obtained was further narrowed down to limit the
search to the most relevant articles. The search was narrowed with the help of Boolean
operators. The Boolean operator ‘OR’ helped in refining the search results by elaborating on
the underlying interpretation of the keywords. ‘NOT’ was another Boolean operator used in
the searching for relevant articles by specifying the type of articles to are unacceptable in the
search and obtain only specific, related articles. The use of the Boolean operator ‘AND’
between the keywords as mentioned above filtered the research articles meeting the criteria
for both the keywords and provide articles of high suitability to the question under review
(Bramer et al., 2016). Besides, the strategy of using truncation of words was also used to
manipulate the variations of the keywords in the search results.
The search for relevant articles can be enhanced further by using inclusion and exclusion
criteria, as described in the following sections.

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Inclusion criteria
The fundamental criterion of inclusion was restricting the search of articles to peer-
reviewed articles only. The time frame of the articles chosen was restricted to the past ten
years. This time-frame ensured that the studies selected were recent and updated for further
evaluation. Another inclusion criterion was to select articles published in the English
language or translatable to the English language. This criteria of language allowed an
understanding of the papers. No specific geographical boundary was set on the search and
selection of articles (Tsang, 2014). Eliminating geographical boundary helped in increasing
the generalizability of the research outcomes and obtain a global outlook of the factors
associated with the relapse of Hodgkin’s lymphoma. Another essential criterion applied was
to include full-text articles only. Many of the articles obtained in the search results contain
the abstract only, which cannot be used to conclude findings. Another inclusion criterion used
to filter search results was to select articles based on the hierarchy of evidence. Systematic
reviews and randomised controlled trials were given more preference as they provide
authentic and reliable information for further evaluation (Leung, Trevena & Waters, 2014).
After randomised controlled trials, cohort studies are given preference for obtaining
information. Besides, research articles focusing on adult patient populations were only
selected for further evaluation. Also, articles emphasising on the relapse incidences of the
adult patient population was chosen, mainly focusing on the probable factors associated with
the relapse for concise results.
Exclusion criteria
Exclusion criteria are equally important as the inclusion criteria to eliminate less
valuable articles and select only the articles that are highly suitable and relevant to the
question under focus. The primary exclusion criterion was to exclude editorial papers,
unpublished articles, case studies and opinion letters. It helps to exclude unreliable sources of

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information and use only authentic data for evaluation. Secondly, articles published before
2011 were eliminated as the information and results illustrated might have been contradicted
and updated with more advanced techniques. Besides, articles published in languages other
than English or non-translatable to English have also filtered out the search results. Research
articles containing only the abstract were also readily excluded from the results. Also, articles
focusing on non-adult populations were eliminated to maintain reliability. Also, research
articles not focusing on relapse cases of Hodgkin’s lymphoma were excluded from the
search. It is useful for the maintenance of the legitimacy of the study.
The inclusion and exclusion criteria can be better understood in table 1 as follows:
Inclusion criteria Exclusion criteria
Peer-reviewed articles Unpublished articles
Time frame: 2011 to 2020 Time frame: Older than 2011
English or translatable to English articles
only
Non-English or non-translatable to English
Full-text articles Abstract-only articles
A systematic review, RCTs and cohort
studies
Editorials, opinion letters and case studies
Table 1
Assessment of methodological quality
After filtering the search results successfully, a quality check of the articles was
conducted to assess the reliability and validity of the research results. It is an essential step in
the review of literature articles to analyse the reliability of the evidence obtained. On
searching using the keywords only, the count of articles obtained was 13142. The use of
Boolean operators narrowed the search to 6514 articles. Further, the specification of the

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patient population to adults resulted in 5812 articles. This initial search was further narrowed
down by additional limitations. The inclusion criteria for English limited the search results to
3166. Additionally, the time gap from 2011 to 2020 presented a count of 956 articles. Finally,
the filter of full-text articles resulted in 143 articles only. These 143 articles were further
filtered by refocusing the question to ‘predictive factors for the relapse of Hodgkin’s
lymphoma after an efficient first-line cure’. This reduced the articles discussing the factors
associated with the relapse before the completion of the full course of the treatment. This is
because the initial search strategy including only the factors associated with the relapse of HL
presented with many results where the patients had not completed the course of the treatment
and were observed with a relapse of the disease. To eliminate the bias, the question under
review was refocused to the patient population that has completed their first-line cure.
However, the use of Boolean operators is useful to narrow the search down to highly specific
and relevant articles, which was further refined with the help of inclusion and exclusion
criteria.
Critical appraisal
Paper selected
Shah, G. L., Yahalom, J., Matasar, M. J., Verwys, S. L., Goldman, D. A., Bantilan, K. S., ...
& Moskowitz, C. H. (2016). Risk factors predicting outcomes for primary refractory
Hodgkin lymphoma patients treated with salvage chemotherapy and autologous stem
cell transplantation. British journal of haematology, 175(3), 440-447. doi:
10.1111/bjh.14245

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Overview
Hodgkin's lymphoma — previously named Hodgkin's disease — is a lymph cell
cancer that becomes part of the immune system. It can impact individuals of any generation
but is more prevalent in people between the ages of 20 and 40 and those over 55. Cells in
Hodgkin's lymphoma develop alarmingly inside the lymphatic system and extends far beyond
that. Hodgkin's lymphoma has been one of two popular forms of lymph system cancers.
Much more severe is the other form, non-Hodgkin's lymphoma. Developments of Hodgkin's
lymphoma detection and care have managed to give patients with this condition a chance to
heal completely. The prognosis for patients diagnosed with HL tends to increase. The paper
(Shah et al., 2016) selected to be critically appraised is mentioned above.
Reasons for selecting the stated paper
There is little research about the correct method for managing primary relapse
Hodgkin lymphoma (HL). For the last two decades, patients have been diagnosed with
ifosfamide, carboplatin and etoposide (ICE)-based treatment in concurrent phase II clinical
trials with the goal of combination with high-dose (HDT) treatment and autologous stem cell
transplantation (ASCT) (Omuro, 2015). The paper (Shah et al., 2016) offers a summary of
10-year event-free survival (EFS), and overall survival (OS) was 45 per cent and 48 per cent
respectively on a sample of 75 patients between 1985 and 1989. Chemo sensitive pre-ASCT
disorder was the only element correlated with improved OS since the understanding of the
clinical symptoms of primary refractory HL is restricted because the medical literature still
does not separate such patients from relapsing HL.
A brief overview of the paper
The paper (Shah et al., 2016) focuses on the primary refractory HL patients to
determine variables affecting full reaction (CR) to salvage chemotherapy (Kumar, 2015) as

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well as assess HDT and ASCT outcomes. The primary outcome for patients who had HDT
with ASCT was EFS calculated from transplant day to HL deterioration, mortality due to
either cause of no progression, or last follow-up. Although the first-line diagnosis was
relatively standardised, everyone provided doxorubicin, bleomycin, vinblastine, and
dacarbazine (ABVD), pre-ASCT recovery and conditioning varied greatly, and radiation
therapy was often introduced. The recorded 5-year EFS was observed over a range of 40% to
63% and 5-year OS from 52% to 87% overall. In each of these trials, as well as
the previously conducted researches, pre-transplantation recurrent functional imaging (FI)
avidity was correlated with an even worse EFS and OS. Step IV disorder was also strongly
associated with recovery in several trials, with the development of B-symptoms before rescue
therapy. The study conducted in the paper (Shah et al., 2016) focused on the patients with
primary HL refractory and to determine variables forecasting complete reaction (CR) to
rescue chemotherapy, and assessing HDT and ASCT outcomes.
Critical Appraisal of the Paper using the CASP tool
The paper aimed to define risk factors (Epperla et al., 2017) that predict the reaction of
functional imaging (FI) to salvaging chemotherapy and to analyzing findings in primary
relapse of Hodgkin lymphoma (HL) subsequent to autologous stem cell transplantation
(ASCT) (Omuro, 2015). Between 1 October 1994 and 10 July 2015, about 192 central
refractory HL individuals were handled utilising second line sequential protocols. Event-free
survival (EFS) and overall survival (OS) were measured from the day the refractory disease
was verified histologically. The study was performed in 192 prospectively diagnosed primary
refractory patients who were diagnosed with salvage therapy focused on ICE supplemented
by HDT and ASCT. Moreover, the Event-free survival and OS were measured using the
Kaplan– Meier approach with mean, 1-, 3-, 5- and 10-year survival figures and 95 per cent

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confidence intervals and contrasted with the ITT and transplanted population log-rank check.
Thereby, the paper (Shah et al., 2016) answers all the aspects of PICOT analysis, leading to
the answer of the question being yes.
The research performed consists of successive patients with predominant refractory HL
diagnosed from 1 October 1994–10 July 2015 on prospective retrospective studies at the
Memorial Sloan Kettering Cancer Centre (MSKCC). The primary refractory disease was
described as an improvement on front-line therapy or inability to produce a FI CR conducted
one month after initial chemotherapy was completed. Since several of these were
fludeoxyglucose positron emission tomography (FDG-PET) scans, most of them were
referred to as PET scans in the remainder of the article, with the remaining gallium scans.
Answering the question, yes the paper (Shah et al., 2016) conducts a randomised controlled
trial as it deals with research analysing follow-up visualisation following initial treatment
indicated that these assessments only detected a quarter of all relapses (Schaapveld et al.,
2015), but paid for half of the follow-up expenses.
Consecutive HL patients diagnosed on prospective longitudinal studies at the Memorial
Sloan Kettering Cancer Centre (MSKCC) from 1 October 1994–10 July 2015 have been
reported. The primary refractory disease was described as frontline therapy progression or
inability to maintain a FI CR conducted one month after the initial chemotherapy was
completed. Since many of these were fludeoxyglucose positron emission tomography
(FDG-PET) scans, it is more likely referred to as PET scans in the majority of the paper
(Shah et al., 2016) for the remaining gallium scans. The data for the gallium and PET scan
can be merged based on a sensitivity study recorded in the segment of findings. In order to be
placed on procedures, patients were expected to undergo a regular biopsy demonstrating
successful HL and were treated via the Cotswolds adaptation of the Ann Arbor staging
method. During this time, most patients obtained standard salvage accompanied by HDT and

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ASCT with ICE-based chemotherapy. Patients underwent a radiation-based treatment
program annually because both nodal disease locations could be found in a radiation area and
patients did not undergo previous radiation therapy (RT). Socioeconomic and clinical
influences were collected from the time the refractory condition was verified histologically.
Our institutional oversight board has issued a waiver of the authorisation to carry out this
study. The primary outcome for patients who witnessed HDT with ASCT was EFS calculated
from the date of transplantation to HL development, mortality due to either cause if no
improvement, or last follow-up. OS has been calculated from the donation day to death or the
last follow-up period. Explanatory variables of concern included age, ethnicity, the
prevalence of B symptoms, extranodal locations, bulk up to 5 cm, along with the phases of
refractory disease verification, chronic pre-ASCT PET abnormality.
The Kaplan– Meier procedure of mean, 1-, 3-, 5- and 10-year survival projections and 95
per cent confidence intervals was calculated for event-free survival and OS, and measured by
the log-rank check for both ITT and transplanted populations. Non-relapse mortality (NRM)
of one hundred days after measurement of ASCT utilising composite occurrence functions
under which relapse was viewed as a competitive case. For the ITT group, univariate and
multivariate analyses were conducted using logistic regression to investigate the association
between covariates and chronic PET abnormality. In multivariate analyses, relevant variables
at P < 0 have been found. Collinearity was tested and in case of a close association between
two relevant predictors, one variable was chosen dependent on clinical judgment. Covariates
for interaction with EFS for the ITT and transplanted populations were evaluated using Cox
proportional hazards regression. In multivariate analyses, relevant variables at P < 0 have
been found. As a sensitivity examination, the report utilised Kaplan – Meier approaches to
analyse the discrepancy in result dependent on PET positivity divided by scan form (Gallium
vs FDG-PET). A risk score for EFS was developed in the transplanted population using

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significant predictors through multivariate analyses. One point was allocated for every
element, and the cumulative score was determined. Additionally, Kaplan – Meier approaches
were used to determine annual and mean survival rates. The log-rank test was used to
measure the discrepancy between increasing the risk score values of survival. Lastly, the
study was observed to be performed using SAS 9.4.
The first result for the intention-to-treat (ITT) community was a negative PET scan after
salvage treatment was done. A survival free of event was then estimated starting from the
first date of the histological diagnosis of the relapse of the disease to HL development,
mortality attributable to either cause whether there was no improvement or last follow-up.
From the date of histological diagnosis of the relapse of the disease to the final follow-up or
death, OS was determined. The conducted trials provide data for 192 prospective diagnosis of
primary refractory patients provided with salvage treatment dependent on ICE supplemented
by HDT and ASCT. We found an 89-year mean EFS through ITT study. The 5-year EFS was
63 per cent for transplanted patients. Our findings favourably correlate with other refractory
HL sequences, possibly attributed to the usage of pre-ASCT radiation for qualifying patients,
which is not standard procedure at other institutions. Moreover, following regular and
intensive usage of RT, the findings reported low incidences of fatalities related to treatment
or second primary malignancies. However, neither of these studies, therefore, recognises CR-
related causes. In our ITT study, we observed that for lack of a full answer to PET pre-ASCT,
the occurrence of tumour bulk ~5 cm and B symptoms before salvage therapy was expected.
Additionally, the study observed that stage IV disease was expected for shorter EFS at the
time of confirmation of refractory disease. In a combination of the two HL- relapsed and
refractory HL with non-response to salvage treatment, a new study obtained from the German
Hodgkin Study Group likewise focused on the effect of the characteristics of patients on PFS.

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Summary
The paper (Shah et al., 2016) aims to define threat factors influencing the reaction of
functional imaging (FI) to the treatment option of salvage-based chemotherapy and to analyse
findings in primary refractory Hodgkin lymphoma (HL) preceding autologous stem cell
transplant (ASCT) (Omuro, 2015). Between 1 October 1994 and 10 July 2015, 192 central
refractory HL patients were handled using second-line sequential protocols. Overall survival
(OS) and event-free survival (EFS) were measured from the day the refractory disease was
histologically verified. Covariates for the relationship to FI response and EFS were analysed.
The median EFS was 8.9 years by intent-to-treat, and the OS 10.4 years, with 41 per cent
optimistic post-salvage FI. After the study was completed, it was extracted from the
multivariate review, the prevalence of B symptoms and the bulk average of 5 cm expected for
optimistic FI, with odds ratios of 2.15 and 2.03 respectively. 60 per cent had a negative pre-
ASCT FI among the 167 (87 per cent) patients transplanted. Mean EFS and OS of the
remaining cases were not met despite a mean follow-up of 3.6 years. Worse results were
correlated with both stage IV refractory disease and chronic FI abnormality pre- ASCT. The
paper (Shah et al., 2016) ends with the observation that more research is required to verify
our prognostic model for patients (Satwani et al., 2015) with multiple risk factors and to
evaluate the appropriate therapy. The paper is useful as it further explains the creation of a
model of risk with chemosensitive conditions and point, individuals without either risk factor
had EFS of 84 per cent for five years. Therefore, provided the promising outcomes for this
community, the need for autologous transplantation could be abrogated by future studies
utilising novel agents. On the other side, following an ASCT, individuals presenting the two
risk factors had a mean EFS of under one year. In order to avoid or postpone relapse, these
patients can benefit from stabilization therapy.

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References
Aagaard, T., Lund, H., & Juhl, C. (2016). Optimizing literature search in systematic
reviews–are MEDLINE, EMBASE and CENTRAL enough for identifying effect
studies within the area of musculoskeletal disorders?. BMC medical research
methodology, 16(1), 161.
Australian Government Department of Health (2016) Guidelines for preparing a
submission to the Pharmaceutical Benefits Advisory. Committee Available,
https://pbac.pbs.gov.au/content/information/files/pbac-guidelines-version-5.pdf.
Bramer, W. M., Giustini, D., & Kramer, B. M. (2016). Comparing the coverage, recall,
and precision of searches for 120 systematic reviews in Embase, MEDLINE, and
Google Scholar: a prospective study. Systematic reviews, 5(1), 39.
Ellis, P. (2019). Evidence-based practice in nursing. Learning Matters.
Epperla, N., Hamadani, M., Cashen, A. F., Ahn, K. W., Oak, E., Kanate, A. S., ... &
Tallarico, M. (2017). Predictive factors and outcomes for ibrutinib therapy in
relapsed/refractory mantle cell lymphoma—a “real world” study. Hematological
oncology, 35(4), 528-535.
Illés, Á., Jóna, Á., & Miltényi, Z. (2015). Brentuximab vedotin for treating Hodgkin’s
lymphoma: an analysis of pharmacology and clinical efficacy. Expert opinion on drug
metabolism & toxicology, 11(3), 451-459.
Kaloyannidis, P., Hertzberg, M., Webb, K., Zomas, A., Schrover, R., Hurst, M., ... &
Connors, J. M. (2020). Brentuximab vedotin for the treatment of patients with

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relapsed or refractory Hodgkin lymphoma after autologous stem cell
transplantation. British journal of haematology, 188(4), 540-549.
Leung, K., Trevena, L., & Waters, D. (2014). Systematic review of instruments for
measuring nurses' knowledge, skills and attitudes for evidence‐based practice. Journal
of Advanced Nursing, 70(10), 2181-2195.
LoBiondo-Wood, G., Haber, J., & Titler, M. G. (2018). Evidence-Based Practice for
Nursing and Healthcare Quality Improvement-E-Book. Elsevier Health Sciences.
Moskowitz, A. J., Schöder, H., Yahalom, J., McCall, S. J., Fox, S. Y., Gerecitano, J., ... &
Kumar, A. (2015). PET-adapted sequential salvage therapy with brentuximab vedotin
followed by augmented ifosamide, carboplatin, and etoposide for patients with
relapsed and refractory Hodgkin's lymphoma: a non-randomised, open-label, single-
centre, phase 2 study. The Lancet Oncology, 16(3), 284-292
Nikolaenko, L., Chen, R., & Herrera, A. F. (2017). Current strategies for salvage
treatment for relapsed classical Hodgkin lymphoma. Therapeutic advances in
hematology, 8(10), 293-302.
Satwani, P., Ahn, K. W., Carreras, J., Abdel-Azim, H., Cairo, M. S., Cashen, A., ... &
Fenske, T. S. (2015). A prognostic model predicting autologous transplantation
outcomes in children, adolescents and young adults with Hodgkin lymphoma. Bone
marrow transplantation, 50(11), 1416-1423.
Schaapveld, M., Aleman, B. M., van Eggermond, A. M., Janus, C. P., Krol, A. D., van
der Maazen, R. W., ... & Van Imhoff, G. W. (2015). Second cancer risk up to 40 years
after treatment for Hodgkin’s lymphoma. New England Journal of Medicine, 373(26),
2499-2511.

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Shah, G. L., Yahalom, J., Matasar, M. J., Verwys, S. L., Goldman, D. A., Bantilan, K.
S., ... & Moskowitz, C. H. (2016). Risk factors predicting outcomes for primary
refractory hodgkin lymphoma patients treated with salvage chemotherapy and
autologous stem cell transplantation. British journal of haematology, 175(3), 440-447.
Tsang, E. W. (2014). Generalizing from research findings: The merits of case
studies. International Journal of Management Reviews, 16(4), 369-383.
von Tresckow, B., & Moskowitz, C. H. (2016). Treatment of relapsed and refractory
Hodgkin lymphoma. In Seminars in hematology (Vol. 53, No. 3, pp. 180-185). WB
Saunders.
Welch, M. R., Sauter, C. S., Matasar, M. J., Faivre, G., Weaver, S. A., Moskowitz, C. H.,
& Omuro, A. M. (2015). Autologous stem cell transplant in recurrent or refractory
primary or secondary central nervous system lymphoma using thiotepa, busulfan and
cyclophosphamide. Leukemia & lymphoma, 56(2), 361-367.
Younes, A., Santoro, A., Shipp, M., Zinzani, P. L., Timmerman, J. M., Ansell, S., ... &
Cohen, J. B. (2016). Nivolumab for classical Hodgkin's lymphoma after failure of
both autologous stem-cell transplantation and brentuximab vedotin: a multicentre,
multicohort, single-arm phase 2 trial. The lancet oncology, 17(9), 1283-1294.
Zhou, P., Liu, P., Zhou, S. Y., He, X. H., Han, X. H., Qin, Y., ... & Zhao, L. Y. (2015).
Ifosfamide, cisplatin or carboplatin, and etoposide (ICE)-based chemotherapy for
mobilization of autologous peripheral blood stem cells in patients with
lymphomas. Chinese medical journal, 128(18), 2498.

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Appendix
Search strategy for CINHL
In the search of the database CINHL, ‘Nursing’ was chosen as the subject in the option of
choosing a subject. After successfully logging in to the database, the keywords and search
terms were provided in the search boxes asking to enter the keywords for a broader search of
the database. In the next search box, the keywords were entered with Boolean operators to
narrow down the search. The keywords were entered in quotations to search the database for
the phrases and not as individual search terms. Then, after the search terms were set up, the
search was further limited to systematic reviews, randomized controlled trials and cohort
studies from the options provided in publication type. Other limiters such as clinical trials,
meta-analysis and evidence-based practices were also applied to obtain legitimate articles
relevant to the research question.
Search strategy for Medline
Medline is known as one of the largest medical databases and contained a large collection of
reliable research articles. Thus, it is important to apply appropriate search methodology to
extract the most relevant articles. The keywords were entered in the search box to obtain the
results. Further, the Boolean operators were included in between the keywords to make the
search results specific to the question under review. The database maps the term entered to
two other terms closely linked to the keyword searched. This helps in accessing articles
related to the review question. Then, the time frame for the study articles was set to further
filter the search results. The attribute of ‘Focus’ should be avoided as it restricts the search
by closely narrowing it down. Then the search was further limited by adding additional

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limitations. The additional limitations added were to include full-text articles, specific patient
population and publication type. The limits were added very carefully.
Search strategy for BNI
The search strategy for British Nursing Index is a valuable database to review and extract
research articles highly relevant to nursing practices. The primary step includes entering the
keywords in the search box. The terms related to the entered were obtained which could be
selected to broaden the literature and search for more suitable evidence. After successfully
selecting all the search terms, they were accompanied with Boolean operators to limit the
results to the articles specific to the question under focus. Further, additional filters such as
the publication time-frame was added from 2011 to 2020 for the recent studies related to the
review question. The filters of English language and preferred study design of the articles
helped in narrowing the results to the most suitable articles for a detailed study and analysis.
Search strategy for PsycINFO
The database of PsycINFO was searched by adding the keywords in the search boxes. After
adding the keywords in the search boxes, the search terms were truncated to increase the
count of results obtained and gain a broader perspective of the literature available. The
subsequent search boxes were input with Boolean operators such as ‘AND’, ‘OR’ and ‘NOT’
to narrow down the search from the vast count of articles obtained. Then the available search
results were refined using the filter of publication time range to include only the latest and
most updated articles. Additional filters were added which include English language, full-text
articles and the study design.