One of the greatest challenges to Landau's Fermi liquid theory-the standard theory of metals-is presented by complex materials with strong electronic correlations. In these materials, non-Fermi liquid transport and thermodynamic properties are often explained by the presence of a continuous quantum phase transition that happens at a quantum critical point (QCP). A QCP can be revealed by applying pressure, magnetic field, or changing the chemical composition. In the heavy-fermion compound CeCoIn 5 , the QCP is assumed to play a decisive role in defining the microscopic structure of both normal and superconducting states. However, the question of whether a QCP must be present in the material's phase diagram to induce nonFermi liquid behavior and trigger superconductivity remains open. Here, we show that the full suppression of the field-induced QCP in CeCoIn 5 by doping with Yb has surprisingly little impact on both unconventional superconductivity and non-Fermi liquid behavior. This implies that the non-Fermi liquid metallic behavior could be a new state of matter in its own right rather than a consequence of the underlying quantum phase transition.Kondo lattice | Kondo breakdown | gyromagnetic factor | composite pairing T he heavy-fermion material CeCoIn 5 is a prototypical system in which strong interactions between conduction and predominantly localized f electrons give rise to a number of remarkable physical phenomena (1, 2). Unconventional superconductivity (SC) emerges in CeCoIn 5 out of a metallic state with non-Fermi liquid (NFL) properties: linear temperature dependence of resistivity below 20 K, logarithmic temperature dependence of the Sommerfeld coefficient, and divergence of low-temperature magnetic susceptibility (3-6). These anomalies disappear beyond a critical value of the magnetic field and the system recovers its Fermi liquid properties. The crossover from NFL to Fermi liquid behavior is thought to be governed by a quantum critical point (QCP), which separates paramagnetic and antiferromagnetic (AFM) phases and is located in the superconducting phase (7,8). Neutron-scattering studies (9) and more recent measurements of the vortex-core dissipation through current-voltage characteristics (10) provide direct evidence for an AFM QCP in CeCoIn 5 that could be accessed by tuning the system via magnetic field or pressure.Nevertheless, a growing number of f-electron systems do not conform with this QCP scenario; for example, the NFL behavior and/or SC in some systems occurs in the absence of an obvious QCP (11)(12)(13)(14). An intriguing candidate is the alloy Yb-doped CeCoIn 5 that exhibits an unconventional T − x phase diagram without an apparent QCP, whereas the onset of coherence in the Kondo lattice and the superconducting transition temperature T c are only weakly dependent on Yb concentration and prevail for doping up to x = 0:65 (15). However, the presence of a QCP in the parent CeCoIn 5 compound and the logarithmic temperature dependence of the normal state Sommerfeld coefficient in lightly do...

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The number of young adults with CRC increased from 28 to 34. However, the proportion of young patients in both groups was 28% of all CRC patients. The mean ages were 34±4.7 and 31.8±5.1 years in early and recent 5 years, respectively, and the male female ratio changed from 2:3 to 4:3. Abdominal pain as the most common presenting symptom was replaced by bleeding per rectum in recent years. The mean duration from onset of symptoms to seeking medical advice decreased from 7.8 months to 5.6 months in recent years. More patients (85.3%) were subjected to endoscopic examination in recent years than early years (60.7%) and right colonic cancer increased from 10.7% to 26.5%. However, the rectum was the commonest site in both early (71.4%) and recent (50%) groups. CRC was detected significantly at an earlier stage (7.1% vs 32.4%) in recent years with large proportion of modified Dukes B stage. Poorly differentiated adenocarcinoma was the predominant histology in both groups (50% vs 60.7%). Curative resection had risen in recent years (39.3% vs 73.6%). Conclusion: CRC among Nepalese young adults accounts for a high incidence (28%) of all CRC cases. Although right sided colonic cancer has been increasing, rectum is the commonest site. There is also an increasing trend for diagnosis at earlier stages of the disease which can be treated with curative intent.

Breast cancer is the second most common malignancy among women in Nepal. It is more commonin young premenopausal women. Breast cancer continues to increase in incidence due to lifestylechanges in Nepalese women despite constant remarkable development in the management of thisdisease over the past three decades. Breast cancer was diagnosed solely clinically and surgery wasthe only treatment option until fi fty years ago. Multidisciplinary approach has been adopted fordiagnosis and treatment of breast cancer in Nepal. Imaging is required for the diagnosis, appropriatetreatment decision and proper follow up. Treatment modality depends upon the extent of thedisease and tumor biology. However, there is a strong need for standard guidelines for the propermanagement of breast cancer in Nepal so that surgeries, chemotherapy, hormone therapy andradiotherapy are standardized in the country. Palliative care has been initiated to provide to somepatients with metastatic breast cancer recently.The breast cancer management in Nepal is a little different when compared with the centers in thedeveloped countries. The reasons are socioeconomic status, lack of education and lack of facilities.Although cancer care is on the rise in Nepal, the optimal facility for centers managing breast cancerhas to be improved signifi cantly.Cancer education, screening and early detection are the keyelements to infl uence the diagnosis, treatment and prognosis of breast cancer in Nepal. Breast cancerawareness and clinical breast examination are important tools for early detection in our resourcelimited context. Breast cancer can be cured in majority of the cases if diagnosed in early stages.This review will focus on relevant patient data along with future recommendation regarding breastcancer treatment in Nepal.Key Words: Breast cancer, cancer education, chemotherapy, imaging, radiotherapy, surgery

Retrospective analysis of 321 cases of breast cancer diagnosed in T. U Teaching Hospitalin a period of 10 years, from May, 1991 to April, 2000 was carried out. There were317 cases (98.8%) females and 4 cases males (1.2%). The youngest patient was 22year old female and oldest patient was 92 year old female. The most common agegroup according to frequency was in forties (34.6%) followed by in thirties (25.5 %).Mean duration of symptoms before coming to doctor was 8.3 months and mean size oftumor was 6 cm. Out of 317 females, 310(97.2%) were married and average numberof children was 3. Out of 289 cases diagnosed as malignancy with fine needle aspirationcytology (FNAC) 279 (96.5%) was also diagnosed as malignancy in biopsy and theremaining 10 cases as non malignant diseases were diagnosed as malignancy in biopsywith a false negative rate of 3.5%. The histological types of breast cancer cases wereInfiltrating Ductal Carcinoma 280 cases (87.2%), Medullary Carcinoma 11 cases(3.4%), Infiltrating Lobular Carcinoma 5 cases (1.6%), Mucinous Carcinoma 4 cases(1.2%), Sarcoma 4 cases (1.2%), Squamous Cell Carcinoma 4 cases (1.2%), PapillaryCarcinoma 3 cases (0.9%), Tubular Carcinoma 2 cases, Adenosquamous Carcinoma2 cases (0.6%), Intraductal Carcinoma 2 cases (0.6%) and Non-Hodgkins Lymphoma1 case. Out of 305 operated cases, the types of operation performed was ModifiedRadical Mastectomy in 208 cases (68 %) and palliative mastectomy in 72 cases (23.5%),only lumpectomy in 24 cases (7.9%) and others in 2 cases. Among 246 cases withavailable axillary lymph node biopsy, there was metastatic diseases in 146 cases (60%)of cases. The Breast cancer was diagnosed in advanced stages in 63% of cases. StageIIIA (24%), Stage IIIB (21.5%) and Stage IV (17.4%). Breast cancers were diagnosedin advanced stages in below 40 age group in 65 out of 90 cases (72.2 % ) comparedto137 out of 231 cases ( 59.3 % ) in above 40 age group.Key Words: Breast cancer, Advanced stage, FNAC, Surgery.

Abstracts Background Resistance to antimicrobial agents of pathogenic bacteria has become a major problem in routine medical practices. Carbapenem resistance has long been increasing. The production of carbapenem- hydrolysing β-lactamases (carbapenamases), which include NDM, KPC, OXA-48, IMP-1 and VIM is the most common mechanism. Case presentation A 56 years old male presented with fever and mental changes with progressively decreasing sensorium for the last 3 days. He was admitted to Intensive care unit (ICU) with a diagnosis of meningoencephalitis. On day seven, he developed ventilator associated pneumonia due Klebsiella pnemoniae and Acinetobacter baumannii. He was on meropenem, but the isolates were susceptible to colistin, tigecyclin and amikacin solely. Hence, amikacin was started with addition of intravenous and nebulized colistin. Subsequently, vital signs improved with resolution of fever. However, on day 18, he developed fever once again with a drop in blood pressure. Inotropic support was maintained, and echinocandins and tigecycline were added to the regimen. Repeat blood and urine culture grew Providencia species, which were resistant to most of the drugs on phenotypic Kirby-Bauer disk diffusion method and are intrinsically resistant to colistin and tigecycline. Phenotypic detection of ESBL (combined disk method), MBL, KPCs, AmpC and co-producer were tested according to updated CLSI guideline and all were negative. But the Modified Hodges test was found to be positive. Consequenty, OXA-48 drug resistance pattern was brought into action by blank disc method according to A Tsakris et al., which revealed indentation of growth toward both EDTA and EDTA/PBA disk indicating production of OXA-48 carbapenamase. To confirm the resistance pattern we processed the isolated colonies for Xpert Carba-R (Cepheid) assay, which detected blaOXA-48 gene and confirmed the OXA-48 drug resistance pattern. Hence, the infecting organism was not susceptible to any of the antibiotics. The patient was kept under isolation and on 31th day of admission, he died of septic shock. Conclusions Carbapenamase production along with intrinsic colistin resistance in infecting bacterial pathogens can cause fatal outcomes in the resource limited countries like Nepal where new antibiotic combinations ceftazidime+ Avibactam, or aztreonam +avibactam are not available. Drug resistance patterns including OXA 48 producer should be characterized in all cases by standard phenotypic methods or by Xpert Carba-R assay and larger studies are required to know the exact burden of OXA 48 producer in Nepal.

Objective: Oncology clinical practice guidelines (OCPGs) are systematically developed evidence-based recommendations aimed to guide practitioners in decision making during the diagnosis, management, and treatment of cancer patients under specific circumstances, thereby optimizing clinical outcomes. However, little is known about the implementation of those guidelines in low and middle-income countries including Nepal. This research aimed to identify the type of OCPGs used by Nepalese physicians working in oncology departments and to explore barriers and facilitators affecting their use. Methods: Using the total population sampling technique, we conducted an online cross-sectional survey from June 2020 to January 2021 among physicians working in the oncology departments of Nepal. Descriptive analyses were conducted to summarize the research findings.Results: Out of 171 physicians approached for the study, 102 (59.6%) responded to the questionnaire. The sizable proportions of the participants were a senior group of physicians with 27.5% being consultants, 14.7% senior consultants, and 16.7% professors. The most commonly used guideline was the National Comprehensive Cancer Network guideline of the United States (75.5%) followed by the American Society of Clinical Oncology guideline (44.7%). While only 22.6% of physicians reported using OCPGs every time, more than half (56.9%) highlighted that OCPGs are not feasible to implement in Nepal. Insufficient facilities/equipment, physicians' unwillingness to change their usual practice, inability to discuss research with knowledgeable colleagues, and lack of time were commonly cited barriers. Conclusion:Findings of our study highlighted that the OCPGs developed in highincome countries may not be feasible for low resource settings like Nepal. Comprehensive local OCPGs should be developed considering the available resources, feasibility, and financial constraints of patients. Furthermore, a constant sharing and learning environment should be created to enhance the knowledge of practicing physicians and to promote the proper implementation of evidence-based findings.

BackgroundPancytopenia is a rare complication of hyperthyroidism. Various mechanisms have been described such as immunological, bone marrow suppression. The possibility of hyperthyroidism should be considered in patients with unexplained pancytopenia. There are many case reports showing the association between hyperthyroidism and pancytopenia. All of these reports show association between Graves disease and pancytopenia but our case shows association between Multinodular goitre and pancytopenia. Besides it is uncommon to find such association in a surgical patient.Case presentationThis case report describes a 62 yr old hindu female with splenic injury and pancytopenia. On further investigations the patient was found to have hyperthyroidism.ConclusionThough the definite mechanism regarding the association of pancytopenia with hyperthyroidism isn’t clear, various cases have been described in the literature. This case shows the diagnostic dilemma that can occur in patients with pancytopenia. Any patient with unexplained pancytopenia should undergo thyroid function tests to rule out hyperthyroidism.