Blood Lead Level among school children in an Industrial city of Nepal

Background: Widespread use of lead has caused extensive environmental contamination and health problems in many parts of the world. Children are particularly vulnerable and even relatively low levels of exposure can cause serious health conditions. Our objective was to determine the prevalence of blood lead level in children in industrial city of Nepal, Birgunj.Materials and Methods: The cross sectional study was done on 50 school going student in Birgunj city, Nepal from November 2016 to January 2017. Questionnaire was used to collect data. Capillary blood was drawn and Blood Lead Level was measured immediately. SPSS ver. 22 was used to analyze the data.Results: The mean age of children in study was 12.5 ± 1.11 years.Among 50 children, 54% were male and 46% were female. The mean blood lead level was 20.33±9.36 μg/dl (male 21.08±8.87μg/dl, female 19.46±10.92 μg/dl). All the children in the study have elevated blood lead level and 84% of them have >10 μg/dl. About 26% of children have blood lead level between 15-20 μg/dl, 12% have level 20-25 μg/dl and 4% of them have more than 35 μg/dl.Conclusion: The prevalence of blood lead level in children from the industrial city of Nepal is alarmingly high. Children exposed with chipped paints have high level of blood lead level. However, further study in large population is required to address the current situation regarding the lead exposure to children.  

Evaluation of aloe vera leaves extract in streptozotocin- induced diabetic nephropathy in rat

Having an anti-diabetic activity, Aloe Vera (Aloebarbadensis) has been used for medicinal purposes in several cultures for millennia. It has also been proved that aloe vera is having protective activity in nephrotoxic rats.The objective of the pres­ent study was to evaluate the effect of Aloe vera leaves extract on diabetic nephropathy in Streptozotocin-induced diabetic rat. Diabetes was induced by Streptozotocin(60 mg/kg-i.p.). Four weeks later rats were randomly selected and divided into 5 groups (n=6). Group I: normal control. Group II: diabetic nephropathy (DN) control. Group III: DN+AVE (250 mg/ kg). Group IV: DN+AVE (500 mg/kg). Group V: DN+AMG (1 mg/1ml in drinking water). The treatment was given for 8 weeks. Various parameters like physiological, antidiabetic, renal function, antioxidants and histopathology were measured. Administration of aloe vera extract showed significant decrease in body weight, food and water intake, kidney weight, blood glucose level, serum creatinine, BUN, protein in urine, serum uric acid and lipid peroxidation. It also significantly increases the plasma insulin level, liver glycogen content, urine volume, GFR, SOD, catalase, Reduced glutathione. Histopathologi­cal studies confirmed that administration of AVE prevented kidney damage, which provided structural support for the renal shielding effect. The significant effect of aloe vera extract on diabetic nephropathy could be due to the inherent antihy­perglycemic, antioxidant, improvement of renal function parameters. In the near future AVE could constitute a lead to the discovery of a novel drug for the treatment of diabetic nephropathy.

A novel indeno[1,2-b]pyridinone derivative, a DNA intercalative human topoisomerase IIα catalytic inhibitor, for caspase 3-independent anticancer activity

A novel 2-(furan-2-yl)-4-(pyridin-2-yl)-5H-indeno[1,2-b]pyridin-5-one (TI-1-190) was synthesized using a simple microwave-assisted method and its mode of action was systematically characterized.

Persistent Complex Bereavement Disorder and Culture: Early and Prolonged Grief in Nepali Widows

OBJECTIVE

Persistent complex bereavement disorder (PCBD) in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), has not been well studied in socioculturally diverse populations. Thus, this qualitative study examined (a) how widows in Nepal understand grief, (b) whether a local construct of PCBD exists, and (c) its comparability with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), terminology.

METHODS

Using an adapted Explanatory Model Interview Catalogue (EMIC) framework, semistructured interviews with 25 widows and 12 key informants, as well as three focus-group discussions (n = 20), were conducted between October 2014 and April 2015. Through an inductive grounded theory-based approach, we used the constant comparative method, iteratively coding transcripts to identify themes and patterns in the data. Also, we created two lists of grief responses, one of early reactions and another all reactions to grief, based on the frequency of mention.

RESULTS

No single term for grief was reported. Widows reported a local construct of PCBD, which was broadly compatible with DSM-5 terminology but with important variation reflecting societal influence. Surviving torture during conflict, economic and family stressors, and discrimination were mentioned as important determinants that prolong and complicate grief. Suicidal ideation was common, with about 31% and 62% of widows reporting past-year and lifetime suicidality, respectively. Findings may not be generalizable to all Nepali widows; participants were recruited from a non-governmental organization, from Kathmandu and its neighboring districts, and were primarily of reproductive age.

CONCLUSIONS

While PCBD symptoms proposed in DSM-5 were mentioned as relevant by study participants, some components may need adaptation for use in non-Western settings, such as Nepal.

Clinical Profile and Electroencephalogram Findings in Children with Seizure Presenting to Dhulikhel Hospital

Background Seizure disorder is the most common childhood neurologic condition and a major public health concern. Identification of the underlying seizure etiology helps to identify appropriate treatment options and the prognosis for the child. Objective This study was conducted to investigate the clinical profile, causes and electroencephalogram findings in children with seizure presenting to a tertiary center in Kavre district. Method This was a hospital based prospective study carried out in the Department of Pediatrics, Dhulikhel Hospital, Kavre from 1st April 2015 to 31st March 2016. Variables collected were demographics, clinical presentations, laboratory tests, brain imaging studies, electroencephalography, diagnosis and outcome. Result Study included 120 (age 1 month to 16 years) children attending Dhulikhel Hospital. Majority of the patients were male (60.84%). Age at first seizure was less than 5 years in 75.83% of children. Seizure was generalized in 62.50%, focal in 31.67% and unclassified in 5.83%. Common causes of seizure were - Primary generalized epilepsy (26.66%), neurocysticercosis (10%) and hypoxic injury (6.6%) which was diagnosed in the perinatal period. Febrile seizure (26.66%) was the most common cause of seizure in children between 6 months to 5 years of age. Neurological examination, electroencephalography and Computed Tomography were abnormal in 71.66%, 68.92% and 58.14% cases respectively. Seizure was controlled by monotherapy in 69.16% cases and was resistant in 7.50% of the cases. Conclusion Primary generalized epilepsy and febrile seizure were the most common causes of seizures in children attending Dhulikhel Hospital. Electroencephalogram findings help to know the pattern of neuronal activity. Response to monotherapy was good and valproic acid was the most commonly used drug.

Role of pleural fluid adenosine deaminase activity and lymphocytosis in the etiological diagnosis

Background: Pleural effusion is a common medical condition with many possible underlying etiologies. However, Tuberculosis is the most common cause of pleural effusion especially in countries like Nepal. Pleural uid lymphocytosis is seen in tuberculosis, malignancy and few auto-immune diseases. Adenosine Deaminase activity (ADA) level in tubercular pleural effusion is markedly increased compared to non-tubercular effusions. ADA estimation being a simple colorimetric method is suitable for the rapid diagnosis of tubercular effusion. This study aims to correlate the diagnostic ef cacy of ADA with the value of differential count (lymphocytosis) in establishing different etiology of pleural effusion. Materials and Methods: This is a cross sectional study of 50 cases with pleural effusion carried out in the department of Pathology, Green city hospital for the duration of Twenty one month’s dating from October 2014 to July 2016 AD. Results: Of all, tubercular pleural effusion accounted for 26%. ADA level was raised (≥40U/L) in 92% of Tubercular pleural effusion. The sensitivity and speci city of ADA alone to diagnose tubercular pleural effusion was 92% each and when lymphocytosis alone was considered sensitivity was 85% with speci city of 32% whereas the combined effect of both ADA with lymphocytosis was 100% (sensitivity) and 87% (speci city), 83% (positive predictive value) and 100% (negative predictive value) respectively with statistically signi cant p value (<0.05). Conclusion: We can conclude that the combination of pleural uid differential count (lymphocytosis >50%) and ADA level >40U/L provides with much more positive result than each component alone in differentiating tubercular effusion from other etiologies. 

Relationship of Angiogenesis and Oral Squamous Cell Carcinoma

Angiogenesis is an important aspect of a variety of physiological and pathological processes; and depends on the alteration of the balance between pro-angiogenic and anti-angiogenic factors. The role of angiogenesis in the progression and metastasis of neoplasm is a well established phenomenon. With regards to oral squamous cell carcinoma, it is a field of ongoing research and requires validation for it being used as a mode of anti-cancer therapy. This review focuses on the concept of angiogenesis, the factors associated with it, the relationship of angiogenesis with oral epithelial dysplasia and oral squamous cell carcinoma; the methods of studying angiogenesis and anti angiogenic therapy.

Pattern of Cardiac Diseases in Children Attended at Dhulikhel Hospital, Nepal

Background Congenital Heart Disease and Rheumatic Heart Disease are the most common childhood cardiac disease encountered in developing countries. Objective To study the pattern and the prevalence of cardiac diseases, its age wise distribution and to determine their risk factors for mortality in children presented to Dhulikhel Hospital, Kathmandu University Hospital. Method A study of cardiac diseases in children, since birth to 16 years of age attending the department of pediatrics in Dhulikhel Hospital, Kathmandu University Hospital was done over a period of 30 months (Jan 2014 to June 2016). The pattern of disease was studied. Detailed clinical examination of all cases was done followed by the necessary relevant investigations including electrocardiography, chest x-ray, echocardiography and supportive laboratory investigations. Result In this study period, 218 pediatric cardiac cases were encountered, among which 144 cases (66.05%) were Congenital Heart Disease, 57 cases (26.14%) were Rheumatic Heart Disease, 14 cases (6.42%) were Pericardial Disease and 3 cases (1.37%) were classified as Dilated Cardiomyopathy. Majority of Congenital Heart Disease were of isolated Ventricular Septal Defect (25%) and isolated Atrial Septal Defect (20.13%) followed by Patent Ductus Arteriosus (9.02%), Tetralogy of Fallot (6.94%) and Complex Congenital Heart Disease (6.25%). All of the Rheumatic Heart Disease primarily involved the Mitral Valve; however combined Aortic Valve involvement was seen in 26.31% of cases. All the 14 cases of pericardial disease presented with pericardial effusion and two cases presented with constrictive pericarditis. All the cases of pericardial disease were investigated to be of tubercular in origin. Conclusion Septal defects are the most common Congenital Heart Disease encountered in children. Although the prevalence of Rheumatic Heart Disease is decreasing worldwide, it is still a big burden in our community. Tubercular pericardial effusion is still not uncommon and should be suspected with a child presenting with pericardial effusion. Increased level of cardiac care and corrective surgeries are needed for children with cardiac disease in Dhulikhel Hospital, Kathmandu University Hospital.

Prevalence of Extended Spectrum Beta-Lactamase Producing Klebsiella Pneumoniae Isolated From Urinary Tract Infected Patients

BACKGROUND

Klebsiella pneumoniae, one of the bacterial agents associated with urinary tract infection has been often implicated as a major extended spectrum beta-lactamase (ESBL) producer in last few decades. This study was designed to assess the prevalence of ESBL producing Klebsiella pneumoniae in urinary isolates at a tertiary care hospital in Kathmandu, Nepal, from July to December 2014.

METHODS

One thousand nine hundred eighty six mid-stream urine specimens were collected aseptically from the clinically suspected patients of urinary tract infections attending Capital Hospital and Research Center, Kathmandu. The samples were processed following standard guidelines as recommended by American Society for Microbiology (ASM) and the isolates including Klebsiella spp. were identified using the specific biochemical and sugar fermentation tests recommended by ASM. Antibiotic sensitivity testing was done by modified Kirby-Bauer disk diffusion method and interpreted following Clinical and Laboratory Standards Institute (CLSI) guidelines. Klebsiella pneumoniae isolates showing resistance upon initial screening with ceftriaxone (30 μg) disc were then confirmed for ESBL production by phenotypic confirmatory disc diffusion test (PCDDT) using ceftazidime (30 µg) and ceftazidime + clavulanic acid (30 µg + 10µg) and cefotaxime (30 µg) and cefotaxime + clavulanic acid (30 µg +10µg) disc as per CLSI guidelines.

RESULTS

Out of a total 1986 specimens investigated, Escherichia coli was isolated in 309 (83.9%) and Klebsiella pneumoniae in 38 (10.3%) cases. Initial screening with ceftriaxone disc revealed 18 isolates of Klebsiella pneumoniae to be resistant. Further testing by PCDDT method confirmed 7 (18.4%) Klebsiella pneumoniae isolates to be ESBL producers.

CONCLUSIONS

Compared to some earlier studies done in Nepal, higher prevalence of ESBL-producing Klebsiella pneumoniae was observed warranting a national surveillance for routine monitoring of ESBL producing Klebsiella pneumoniae isolates.

Violence Against Widows in Nepal: Experiences, Coping Behaviors, and Barriers in Seeking Help

Widows are a vulnerable population in Nepal. This study examined Nepalese widows' experiences of violence, their coping strategies, and barriers faced in seeking help. Study participants were recruited from Women for Human Rights, an NGO in Nepal. A stratified purposive sampling approach was used to select 51 widows and 5 staff members for in-depth interviews. Twenty-seven women who experienced violence were included in this analysis. Data were analyzed and synthesized using a thematic analysis procedure. Widows reported a range of violent experiences perpetrated by family and community members that spanned psychological, physical, and sexual abuse. Women dealt with abusive experiences using both adaptive (e.g., attempting to move ahead, seeking social support, using verbal confrontation) and maladaptive coping strategies (e.g., suicidal thoughts or self-medication). However, they faced barriers to seeking help such as insensitivity of the police, perceived discrimination, and general lack of awareness of widows' problems and needs. Findings highlight the need for interventions across the individual, family, community, and policy levels. Avenues for intervention include creating awareness about widows' issues and addressing cultural beliefs affecting widows' lives. Furthermore, efforts should focus on empowering widows, promoting healthy coping, and addressing their individual needs.

Sideroblastic anemia

Sideroblastic anemias are a heterogenous group of disorders that have as a common feature with the presence of ringed sideroblasts in the marrow. We present a case of young female, nursing student who presented with increasing palpitation, fatigue and exertional shortness of breath for the last one year. She had a low hemoglobin and high serum iron. Anemia with iron overload prompted us to do bone marrow study and there were 19% ringed sideroblasts and iron overload fulfilling the diagnosis of sideroblastic anemia. We searched for secondary causes of ringed sideroblast but could not find any culprit. Her cytogenetics report was normal and genetic analysis was not done due to financial reason. Since the diagnosis 3 months back, patient is on pyridoxine, folic acid, deferasirox and still needs regular blood transfusion suggesting that she may be pyridoxine refractory and may develop iron overload.

Abstract PD1-01: Impact of statin use on cancer recurrence and mortality in patients with breast cancer: A systematic review and meta-analysis

Background:

Statins have been described as having an association with a decreased risk of breast cancer. They have also shown antineoplastic properties in preclinical studies. Statins inhibit the enzyme 'HMG CoA reductase' and the expression of this enzyme in cancer cells has been implicated as an adverse prognostic factor in patients with breast cancer.

Methods:

We performed a systemic review of literature through April 2015 and utilized PubMed and Embase to identify studies that described an association between statin use and survival in breast cancer. Studies which did not report a comparison of survival using Kaplan-Meier curves were excluded. Summary hazard ratio (HR) with 95% confidence intervals (CI) was estimated using the random effects model, and heterogeneity was measured using the inconsistency index (I2).

Results:

After reviewing 637 abstracts, 12 studies which included a total of 87951 patients were identified and data was extracted. 8 studies provided a summary statistic for the association of statins with recurrence-free survival (RFS) in patients with breast cancer and were included in a meta-analysis. Statin use was associated with improved RFS (N= 29729 patients, HR 0.66; 95% CI 0.53- 0.84) with moderate heterogeneity (I2= 48%). Furthermore, this survival benefit appeared to be confined to use of lipophilic statins (3 studies, HR 0.72; 95% CI 0.59- 0.89) as hydrophilic statin use was not associated with improvement in RFS (3 studies, HR 0.80; 95% CI 0.44- 1.46). A meta-analysis of 5 studies showed no significant association between the use of statins on breast cancer-specific survival (CSS) (N= 60686 patients, HR 0.71; 95% CI 0.49- 1.03, I2= 84%). We also found no association between statin use and overall survival (OS) (5 studies and 22283 patients, HR 0.83; 95% CI 0.58- 1.19, I2= 62%).

Conclusions:

Statin use, or more specifically, lipophilic statin use is associated with an improved recurrence-free survival for patients with breast cancer. However, there was no effect of statin use on either cancer-specific survival or overall survival. These benefits need to be assessed in a prospective randomized cohort and the choice of statin, dose and biomarkers that may predict the efficacy of these drugs will need to be identified.

Characteristics of included studiesNameYearCountryImpact on RFSImpact on CSSImpact on OSSample SizeMedian follow-up (in years)Desai2015USANA0.59 [0.32, 1.06]NA7,88311.5Cardwell2015UKNA0.84 [0.68, 1.04]0.84 [0.72, 0.97]17,8805.7Murtola2014FinlandNA0.46 [0.38, 0.55]NA31,1143.25Boudreau2014USA0.78 [0.56, 1.08]NANA4,2166.3Sendur2014TurkeyP 0.004P 0.005P = 0.0051,1724Brewer2013USA0.49 [0.28-0.84]0.85 [0.46, 1.57]0.80 [0.43, 1.49]724NANickels2013Germany0.83 [0.54,1.24]0.89 [0.52, 1.49]1.21 [0.87, 1.69]3,085*5.3Zeichner2013USA1.42 [0.42, 4.81]NA1.5 [0.07, 32.02]3003.5Chae2011USA0.40 [0.24, 0.67]NANA7034.5Ceacareanu2011USA0.27 [0.10, 0.71]NA0.23 [0.08, 0.66]2942.5Ahern2011Denmark0.80 [0.64, 1.00]NANA18,7696.8Kwan2008USA0.67 [0.39, 1.13]NANA1,8115*= sample size for RFS: 2912, Abbreviations: RFS: recurrence-free survival, CSS: cancer-specific survival, OS: overall survival (expressed in hazard ratio and 95% confidence intervals)

Citation Format: Manthravadi S, Shrestha A, Madhusudhana S. Impact of statin use on cancer recurrence and mortality in patients with breast cancer: A systematic review and meta-analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD1-01.

Diel trends in stomatal response to ozone and water deficit: a unique relationship of midday values to growth and allometry in Pima cotton?

Plant responses to ozone (O3 ) and water deficit (WD) are commonly observed, although less is known about their interaction. Stomatal conductance (gs ) is both an impact of these stressors and a protective response to them. Stomatal closure reduces inward flux of O3 and outward flux of water. Stomatal measurements are generally obtained at midday when gas exchange is maximal, but these may not be adequate surrogates for stomatal responses observed at other times of day, nor for non-stomatal responses. Here, we find in Pima cotton that stomatal responses to O3 observed at midday do not reflect responses at other times. Stomata were more responsive to O3 and WD near midday, despite being at quasi-steady state, than during periods of active opening or closing in morning or evening. Stomatal responsivity to O3 was not coincident with maximum gas exchange or with periods of active regulation, but coincident with plant sensitivity to O3 previously determined in this cultivar. Responses of pigmentation and shoot productivity were more closely related to stomatal responses at midday than to responses at other times of day under well-watered (WW) conditions, reflecting higher stomatal responsivity, sensitivity to O3 , and magnitude of midday gs . Under WD conditions, shoot responses were more closely related to early morning gs. Root responses were more closely related to early morning gs under both WW and WD. Responses of stomata to O3 at midday were not good surrogates for stomatal responses early or late in the day, and may not adequately predicting O3 flux under WD or when maximum ambient concentrations do not occur near midday.

A Randomized Trial of Hospital Vs Home Self Administration of Vaginal Misoprostol for Medical Abortion

Background A combination of mifepristone followed after 24 hrs by misoprostol has proved a safe and effective abortifacient for termination of early pregnancy. Home use of misoprostol for medical abortion is still controversial in many countries including ours where women’s literacy rate is low. Particularly in developing countries, this method markedly decreased the hospital visit which would be beneficial to patients and hospital staff.Objective To see whether the home self administration of vaginal misoprostol was equally effective as administered by trained staff in terms of successful termination of early pregnancy. Secondary outcomes were bleeding and pain duration during medical abortion, side effects, reason for termination of pregnancy and women’s acceptability of the procedure.Method One hundred and eighty eight women requesting medical abortion with pregnancy less than 63 days gestation were randomized into two groups either self administration of vaginal misoprostol (800 mcg) at home or hospital administration 24 hours after oral 200 mg mifepristone. Ultrasound was performed after 14 days to confirm complete abortion.Result The overall success rate was similar in two groups: 89.13% on home group Vs 86.9% in hospital group. Eleven out of 18 women (61.1%) having incomplete abortion had successful termination after 2nd dose misoprostol( 400 mcg). None of the women had continued pregnancy. Multigravida had slightly higher risk of failure (R.R: 1.04).Conclusion Home self administration of vaginal misoprostol was safe and effective for early termination of medical abortion and was acceptable. Use of extra dose of misoprostol has advantage of higher completion rate of abortion.Kathmandu University Medical Journal Vol.12(3) 2014; 185-189

Histopathological Changes in the Chorionic Villi and Endometrial Decidual Tissues in the Product of Conception of Spontaneous Abortion Cases

Background Spontaneous abortion refers to a pregnancy that ends spontaneously before the fetus has reached a viable gestational age or expulsion or extraction of an embryo or fetus weighing 500 g or less from its mother. The Maternal Mortality Morbidity Survey of Nepal 2008/09 reported that 7% of maternal deaths in Nepal were due to complications related to abortion. Objective The main objective of this study was to examine the histopathological changes in the chorionic villi and endometrial decidual tissue in products of conception obtained from women with spontaneous abortion. Method This is a retrospective study of 111 patients admitted in the Department of Obstetrics and Gynecology at Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH) with the diagnosis of spontaneous abortion during the period of January 2013 to January 2014. Result Among 111 cases of spontaneous abortions, products of conception was seen in 73 (65.77%) and with only one cases of choriocarcinoma. Majority of cases belongs to age group 21-30 years. The most common decidual changes were inflammation (41.4%) followed by fibrin deposition 29.7%. Majority of the cases shows hydropic changes as histopathological changes in chorionic villi. In the present study, minimum age of lady was 15 years and the maximum age was 45 years and the mean age was 25.09±5.58 years at the time of abortion. Among the cases, maximum 69 (62.2%) of them belonged to age group 21-30 years. Correlating the age group with number of abortions was found to be significantly different (Chi-square= 92.35, df= 3, p < 0.001) among four different age groups. Conclusion The histopathological diagnosis of spontaneous abortion will help in further management of the patient. Further study is required to know the cause of different histopathlogical changes in villi as well as in the decidua.

Normal Width of Third Ventricle In Nepalese Population: Assessment By CT Scan

INTRODUCTION

Cerebral ventricular enlargement occurs as a natural aging process but also has been associated with many neurological disorders. Whether this enlargement is primary or secondary to these pathological conditions remains controversial. Objective of the study was to tabulate and create normal references values for maximum width of third ventricle in Nepalese population according to age group and gender.

METHODS

MTW was determined in two hundred (112 males and 88 females) and age ranging between 1- 93 years who had normal Computed tomography scan of the head .The data collected was analyzed with statistical program IBM SPSS version 20.

RESULTS

Measurements of MTW in both males and females of the normal groups revealed no significant difference. No significant difference in MTW was noticed till the age of 49 years. Significant differences were noticed between 49 - 93 years of age.

CONCLUSIONS

This study corroborated well with normal MTW values published in literatures from other parts of the world. However normal values specific to our local population becomes more relevant in interpreting CT scan of head in Nepal.

Management of Acute Lower Gastrointestinal Bleeding: Principles and Current Practice in the United Kingdom

Acute lower gastrointestinal bleeding (ALGIB) is a common cause for hospital admission that results in significant morbidity and mortality. The major objectives of all involved in the management of ALGBI patients are to reduce mortality and the need for major surgery. A secondary objective is to prevent unnecessary hospital admission for patients presenting with bleeding that is not life-threatening. The management of ALGBI has evolved over last decade with the changing modalities of diagnostic facilities. On review of the published literature, there is paucity of randomised control trials in relation to the diagnostic tools and management of ALGBI. The aim of this review is to summarise the principles and current methods available for the diagnosis and treatment of ALGIB and based on the available evidence and the current practice in the United Kingdom, outline an algorithm for the management of ALGIB.