A 3.5-year-old female from Palestine presented to Jordan Hospital with pharmaco-resistant epilepsy. She was diagnosed with tuberous sclerosis (TS) at six months of age. Onset of seizure activity, consisting of twitching and eye deviation, was noted at age one month. Her symptoms quickly progressed to infantile spasms. Various medications and dietary changes were implemented but without sustained seizure control. The patient underwent a vagal nerve stimulation procedure as a last resort to reduce seizure burden and frequency. Pharmaco-resistant epilepsy is defined as the failure of a patient's seizures to respond to at least two antiepileptic medications that are appropriately chosen and used for an adequate period. Our protocol for vagal nerve stimulation for this age is to start with a stimulus level at 0.25 milliampere and increase it gradually until we reach 2.5 milliampere within six months. Vagal nerve stimulation proved to be a relatively effective method at reducing the frequency and
Purpose: To provide evidence-based recommendations for health care professionals on diagnosis and management of diffuse large B cell lymphoma (DLBCL) in resource constraint settings with variable and often limited access to standard of care and advanced diagnostic and therapeutic facilities. Methods: Modified Delphi methodology[1] was used to generate consensus by experts of three major cancer societies of Pakistan; namely Society of Medical Oncology Pakistan (SMOP), Pakistan Society of Hematology (PSH) and Pakistan Society of Clinical Oncology (PSCO). Guidelines questions were drafted and meetings were convened by steering committee to develop initial recommendations based on local challenges and review of the literature. Consensus panel reviewed the initial draft recommendations and rated the guidelines on five-point Likert scale; recommendations achieving more than 75% consensus were accepted. Resource grouping initially suggested by Breast Health Global Initiative[2] was applied for resource stratification into basic, core and enhanced resource settings. Results: The expert panel advised use of limited immunohistochemistry (IHC) including CD20, CD3 and Ki67% for initial diagnosis in core (limited) resource settings and extended panel in enhanced resources. Cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) with or without rituximab (as per resource setting) remains the standard first line treatment while second line treatment should be offered based on resource availability and patient related factors. Both intra thecal and high dose methotrexate can be used for CNS prophylaxis. Recommendations by guideline committee are listed in Table 1. Conclusion: Diagnosis and treatment recommendations in resource constraint settings should be developed based on available diagnostic, therapeutic resources and management expertise. References: Niederberger, M. and J.J.F.i.p.h. Spranger, Delphi Technique in Health Sciences: A Map. 2020. 8: p. 457.Eniu, A., et al., Guideline implementation for breast healthcare in low-and middle-Income countries: Treatment resource allocation. 2008. 113(S8): p. 2269-2281. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.
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