Sarcoidosis is a complex systemic disorder characterized by an increased cellular immune response and the development of non-caseating granulomas. Sarcoidosis can affect any other organ and cardiac involvement has been reported in a substantial percentage of individuals. A sound clinical evaluation is needed for rapid recognition and implementation of appropriate treatment alternatives. Chest pain is a common presenting symptom in sarcoidosis. We present here an interesting case of a 39-year-oldfemale presenting with ST elevation myocardial infarction who was managed by primary percutaneous intervention.

Cholestasis is an impairment of bile formation or bile flow. The mechanisms of cholestasis can be broadly classified into intrahepatic and extrahepatic. Most of the time, etiology can be determined with proper history, physical examination, and diagnostic testing including laboratory and imaging tests. This is a case report of a patient with severe cholestasis who underwent extensive evaluation to determine the etiology of intrahepatic cholestasis. This Case Report details a 28-year-old male who presented with seven days' history of yellowish discoloration of eyes, the passage of dark-colored urine, generalized body itching, and the passage of clay-colored stool. The patient had no similar episode in the past. Laboratory investigations showed unconjugated hyperbilirubinemia and increased alkaline phosphatase. Magnetic resonance cholangiopancreaticography was unremarkable and liver biopsy was suggestive of cholestatic pattern and negative for acute hepatitis. The bilirubin level started decreasing after a month. The etiology of intrahepatic cholestasis remained unknown. Genotyping could not be done due to limited available resources. It may have helped to diagnose familial hepatocellular cholestasis such as benign recurrent intrahepatic cholestasis (BRIC) and progressive familial intrahepatic cholestasis. Gamma-glutamyl transferase is normal or mildly elevated in patients with BRIC. A similar picture was seen in our case as well. If the patient presents again with similar symptoms and findings, we can consider the diagnosis of BRIC.

Cholestasis is an impairment of bile formation or bile flow. The mechanisms of cholestasis can be broadly classified into intrahepatic and extrahepatic. Most of the time, etiology can be determined with proper history, physical examination, and diagnostic testing including laboratory and imaging tests. This is a case report of a patient with severe cholestasis who underwent extensive evaluation to determine the etiology of intrahepatic cholestasis. This Case Report details a 28-year-old male who presented with seven days’ history of yellowish discoloration of eyes, the passage of dark-colored urine, generalized body itching, and the passage of clay-colored stool. The patient had no similar episode in the past. Laboratory investigations showed unconjugated hyperbilirubinemia and increased alkaline phosphatase. Magnetic resonance cholangiopancreaticography was unremarkable and liver biopsy was suggestive of cholestatic pattern and negative for acute hepatitis. The bilirubin level started decreasing after a month. The etiology of intrahepatic cholestasis remained unknown. Genotyping could not be done due to limited available resources. It may have helped to diagnose familial hepatocellular cholestasis such as benign recurrent intrahepatic cholestasis (BRIC) and progressive familial intrahepatic cholestasis. Gamma-glutamyl transferase is normal or mildly elevated in patients with BRIC. A similar picture was seen in our case as well. If the patient presents again with similar symptoms and findings, we can consider the diagnosis of BRIC.

BACKGROUND:Acute pancreatitis (AP) is a common presentation in patients admitted with acute abdomen. Whether Ringers lactate (RL) or Normal Saline (NS) as a resuscitation fluid is better still remains unclear. The aim of this study is to compare the efficacy of RL and NS in terms of control of systemic inflammation by measuring indirect markers specifically Systemic Inflammation Response Syndrome (SIRS) scores and C- Reactive Protein (CRP) level.METHODS:This was an open label randomized trial conducted in a tertiary level hospital of Nepal. Ethical approval was obtained prior to the study. Patients with acute pancreatitis were randomized to either RL or NS group for the fluid resuscitation. The fluid was given as per the study protocol for three days for hydration. Baseline SIRS and CRP were recorded on admission and subsequently as defined. All the data were analyzed using SPSS ver 20.0 software.RESULTS:Total 51 patients were enrolled, 26 in RL and 25 in NS group. The commonest etiology of AP was alcohol (84.31%). SIRS was present in 46.2% and 64.0% of patients in RL and NS group respectively (p = 0.20) on admission. At least one SIRS criteria was still present in 44.0% of patients in the NS group compared to only 15.4% in the RL group after 24 hours (p = 0.025). The baseline CRP were comparable in both the groups. However after 72 hours, the increment of CRP was more in the NS group compared to the RL group; median value of 14.2 mg/dl (12.15, 16.45) and 22.2 mg/dl (18.20, 30.60) in RL and NS group respectively (p<0.001).CONCLUSIONS:Ringers lactate was associated with a reduction in systemic inflammation compared to normal saline in patients with acute pancreatitis. Incidence of SIRS at 72 hours and occurrence of local complications were however similar in both the groups.

Policy testing is an important means for quality assurance of access control policies. Experimental studies on the testing methods of XACML policies have shown their varying levels of effectiveness. However, there is a lack of explanation for why they are unable to detect certain types of faults. It is unclear what is essential to the fault detection capability. To address this issue, we propose a theory on policy testing by formalizing the fault detection conditions with respect to a comprehensive fault model of XACML policies. The detection condition of a policy fault, composed of the reachability, necessity, and propagation constraints, is sufficient and necessary for revealing the fault. The formalized fault detection conditions can qualify the inherent strengths and limitations of testing methods. We have applied the formalization to the qualitative evaluations of five testing methods for the current version of the XACML standard. The results show that, for each method, there are certain types of faults that can always or never be revealed, while the detection of other faults may depend on the particular policy structure.

Introduction: The efficacy of colonoscopy in detecting abnormalities within the colon is highly dependent on the adequacy of the bowel preparation. The objective of this study was to compare the efficacy and tolerability of morning only dose vs split-dose administration of polyethylene glycol (PEG) solution for colon cleansing in patients undergoing afternoon colonoscopy. Method: This was a comparative study conducted in Department of Medicine, Patan Academy of Health Sciences (PAHS), Patan Hospital, Nepal from November 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee. Informed consent was taken from the patients. Patients aged >18 y undergoing elective colonoscopy were randomly assigned to one of the two bowel preparation regimens- morning only or split-dose of PEG. The adequacy of bowel preparation was assessed by the endoscopist using Boston Bowel Preparation scale. Preparation to colonoscopy (PC) interval, adverse events and risk factors for poor bowel preparations were noted. Result: In this study, 110 patients were included in the final analysis- 55 received morning only regimen and 55 received split-dose. Mean Boston bowel preparation scales of Morning only and Split-dose regimen were 7.60 and 7.09 respectively (p= 0.019). Split-dose group had significant sleep disturbances compared to Morning only regimen (p< 0.001), whereas nausea occurred significantly more often in Morning only regimen (p=0.012). Preparation to colonoscopy interval between 4-6 hours resulted in better bowel cleansing compared to PC interval of greater than 6 hours. Conclusion: Morning-only bowel preparation is more effective than Split-dose for achieving adequate colon cleansing for afternoon colonoscopy.

ABSTRACT Introduction: Malignancy is one of the aetiologies of lower gastrointestinal bleeding (LGIB). Colonoscopy is the diagnostic modalities of choice. In this study we aim to examine the common causes and prevalence of malignancy among patients presenting with LGIB. Method: This is descriptive retrospective study. We reviewed data of patients undergoing colonoscopy in Patan Hospital during January 2015 to December 2019. Result: Total 502 patients were included in the study. Hemorrhoids (49.4%,246) were common findings followed by normal findings (21.8%, 109), colonic polyps (7.8 %, 39) and Colorectal malignancy (4.2%, 21). 85 % (18/21) were left sided malignancies. 7.11% (5/21) of had age less than 40 years. Conclusion: Hemorrhoids were the most common cause and account nearly half of LGIB cases. Left sided colorectal malignancy can present with LGI bleeding, and not uncommon even in patients less than 40 years.

Introduction: Risk factors for early re-bleeding and in-hospital mortality following acute variceal hemorrhage (AVH) are incompletely understood. The aim of this study was to find out the risk factors for early re-bleeding within 5 days and in-hospital mortality after AVH in patients with cirrhosis. Method: This was an analytical cross-sectional study conducted in Department of Medicine, Patan Hospital, Patan Academy of Health Sciences (PAHS), Nepal from July 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee-PAHS. Informed consent was taken from the patients. Patients aged >18 y with diagnosed case of liver cirrhosis and endoscopy confirmed variceal bleeding were enrolled. All cases of early re-bleeding within 5 days and in-hospital outcome were recorded. Result: In this study total 72 patients were enrolled. The mean age of our patients was 51.68 y. Sixty seven (93%) of the patients improved, 3(4.16%) had early re-bleeding and 5(6.9%) died during the same hospital admission. Univariate analysis showed that early re-bleeding was significantly associated with the high PT/INR (p<0.001) and high Child-Turcotte Pugh (CTP) score (p=0.032), whereas in-hospital mortality of patients was significantly associated with low Protein (p=0.044), high CTP score (p=0.041), high Model for End stage Liver Disease (MELD) score (p=0.002) and presence of gastric varices (p=0.008). Conclusion: High PT/INR and high CTP score are the risk factors of early re-bleeding after AVH in cirrhotic patients. Low Protein, high CTP and MELD scores, and presence of gastric varices are the factors associated with in-hospital mortality in these patients.

Introduction: Hepatic encephalopathy (HE) is a frequent complication and one of the most debilitating manifestations of liver cirrhosis, which negatively impacts patient survival. This study aims to identify the factors influencing the treatment response in patients with liver cirrhosis and HE. Method: This was a prospective observational study conducted from July 2019 to June 2020 in a tertiary referral center of Nepal. The ethical clearance was obtained from the Institutional Review Board of the center (Reference No. 46/076/77). Patients with Liver cirrhosis with HE grade II or more were included. Standard medical therapy for HE was given to all the patients, and treatment response for the first five days post admission was recorded. The response was categorized as good response, no response and deterioration, based on improvement or deterioration of patient`s symptoms or changes in West Haven criteria. Result: In this study total 78 patients were enrolled and included in the final analysis. The mean age was 50.17± 10.36 years and 63(80.76%) were male. Alcohol was the etiology of cirrhosis in 62(79.5%). Seventy two (92.3%) patients had good response to the treatment, 3(3.8 %) of patients had no response and rest 3(3.8%) deteriorated. On logistic regression, high creatinine, high bilirubin and low serum protein were the predictors of non-response to standard therapy (p<0.05). Conclusion: High serum creatinine, high bilirubin and low serum protein were the predictors of non-response to standard therapy in patients with Liver Cirrhosis with Hepatic Encephalopathy.

The Named Storm Event Model (NSEM) which includes the atmospheric suite (HWRF 1, HRRR 2, RTMA-URMA 3 and WRF-LES 4) [1], the coupled wave-surge-riverine modeling system (WW3 5-ADCIRC 6-NWM 7) [2,3] and a validation suite has been developed to provide definitive estimates of wind and water variables of major landfalling hurricanes, in compliance with the United States COASTAL Act of 2012. Within this framework, the performance of atmospheric products is evaluated and blended fields are generated on a high-resolution grid, using a master blend recipe. The atmospheric data forces the downstream hydro-coupled component which includes the wave (WAVEWATCH III [4,5]), ocean circulation (ADCIRC) and hydrological models (NWM). These have been coupled using the community-based National Unified Operational Prediction Capability (NUOPC) layer based on the Earth Systems Modeling Framework (ESMF). The wind and hydro products are evaluated against offshore and coastal wave buoys, nearshore water level stations, radars and satellite altimeters, as well as USGS rapid-deployment water level and wave gauges placed in the nearshore regions and overland. The NSEM workflow will be presented at the conference, highlighting the advantages of ESMF in model performance improvement and challenges for upstream atmospheric model blending, model coupling, and validation against observations. 1- HWRF (Hurricane Weather Research and Forecasting) 2- HRRR (High-Resolution Rapid Refresh) 3- RTMA-URMA (Real Time Mesoscale Analysis-UnRestricted Mesoscale Analysis) 4- WRF-LES (Weather Research and Forecasting-Large Eddy Simulation) 5- WAVEWATCH III (WAVE-height, WATer depth and Current Hindcasting) 6- ADCIRC (The ADvanced CIRCulation model) 7- NWM (National Water Model)

Coronary artery perforation (CAP) is one of the most dreadful complications encountered during Percutaneous Coronary Intervention (PCI). Though being rare, the high mortality rate associated with CAP makes it one of the most important complications that should be well known to all the coronary interventionist. The treatment modalities range from balloon tamponade, reversal of anticoagulation, coils, microbeads, pericardiocentesis, covered stents and in desperate situations, coronary artery bypass graft. We present here a case of 65 year old male with extensive anterior wall myocardial infarction who developed CAP of proximal left anterior descending artery during PCI. The case was successfully managed with covered stent.

In patients with end stage renal disease (ESRD) and suspected portal hypertension (PHTN), the decision to recommend kidney transplant (KT) vs. combined liver KT (CLKT) is complex . Assessment of these patients requires multiple diagnostic procedures, including determination of portal-systemic pressure gradient (PPG).

Introduction: Hepatorenal syndrome (HRS) is one of the severe complications of decompensated liver cirrhosis which has poor outcome. Predictive models are important aspect in assessment of high risk patient. Method: This prospective analytical study was conducted in Gastroenterology unit of Bir hospital from December 2018 to April 2020. Seventy patient of liver cirrhosis with ascites (CTP score 7 or more) were followed for a period of three months. The outcome of study was hepatorenal syndrome. Predictors were assessed from baseline variables. Result: Total 65 patients completed the study. The mean age of study population was 47.38 ±11.38 years and 52(80%) were male. The most common aetiology was alcohol 55(84 %). Eight (12.5%) developed HRS. Hepatorenal syndrome was precipitated by spontaneous bacterial peritonitis 5(62.5%), upper gastrointestinal bleeding 2(25%) and unknown 1(12.5%). In Bivariate analysis total leucocyte count, Serum sodium, Model for End-stage Liver Disease – Sodium (MELD- Na), serum bilirubin and use of rifaximin were predictors of HRS. Only use of rifaximin was the predictor in multivariate analysis. Conclusion: Serum sodium, bilirubin and MELD Na are important predictors of the hepatorenal syndrome. Rifaximin use may be preventive for HRS. Keywords: Decompensation, hepatorenal syndrome, liver cirrhosis, predictors

The data that support the findings of this study are available from the corresponding author upon reasonable request.

While the existing methods for testing XACML policies have varying levels of effectiveness, none of them can reveal the majority of policy faults. The undisclosed faults may lead to unauthorized access and denial of service. This paper presents an approach to strong mutation testing of XACML policies that automatically generates tests from the mutants of a given policy. Such mutants represent the targeted faults that may appear in the policy. In this approach, we first compose the strong mutation constraints that capture the semantic difference between each mutant and its original policy. Then, we use a constraint solver to derive an access request (i.e., test). The test suite generated from all the mutants of a policy can achieve a perfect mutation score, thus uncover all hypothesized faults or demonstrate their absence. Based on the mutation-based approach, this paper further explores optimal test suite that achieves a perfect mutation score without duplicate tests. To evaluate the proposed approach, our experiments have included all the subject policies in the relevant literature and used a number of new policies. The results demonstrate that: (1) it is scalable to generate a mutation-based test suite to achieve a perfect mutation score, (2) it can be impractical to generate the optimal test suite due to the expensive removal of duplicate tests, (3) different from the results of the existing study, the modified-condition/decision coverage-based method, currently the most effective one, has low mutation scores for several policies.

Introduction: The prevalence of cutaneous manifestations in hemodialysis patients is increasing. Objectives: The aim of this study was to determine the prevalence and pattern of various cutaneous manifestations in patients undergoing maintenance hemodialysis. Material and Methods: A hospital based cross sectional study was conducted in patient undergoing maintenance hemodialysis at least for three months in dialysis unit of Manipal Teaching Hospital Pokhara, Nepal during the period from August 2018 to January 2019. A demographic questionnaire and a checklist about cutaneous disorders were used for data collection. Patients with cholestatic liver disease or acute hepatitis, active infection, active malignancy, patient with acute kidney injury, patient undergoing peritoneal dialysis and renal transplant recipient were excluded from study. Results: Total 80 patients undergoing maintenance hemodialysis were included. Among them, 52 (65%) patients were male. The mean age of study population was 51.95±14.96 years. The mean duration of dialysis was 40.28±11.09 months. The most common cause of end stage kidney disease was diabetic nephropathy. The most common cutaneous manifestations were pigmentation (82.5%), nail changes (75%), xerosis (70%) and pruritis (50%). Conclusions: The results of this study revealed that patients on hemodialysis were associated with multiple cutaneous symptoms, the most prevalent of which were pigmentation and nail disorders. Therefore, early diagnosis of these problems is a major step in improving the quality of life in these patients.

Realistic wind information is critical for accurate forecasts of landfalling hurricanes. In order to provide more realistic near-surface wind forecasts of hurricanes over coastal regions, high-resolution land–sea masks are considered. As a leading hurricane modeling system, the National Centers for Environmental Prediction (NCEP) Hurricane Weather Research Forecast (HWRF) system has been widely used in both operational and research environments for studying hurricanes in different basins. In this study, high-resolution land–sea mask datasets are introduced to the nested domain of HWRF, for the first time, as an attempt to improve hurricane wind forecasts. Four destructive North Atlantic hurricanes (Harvey and Irma in 2017; and Florence and Michael in 2018), which brought historic wind damage and storm surge along the Eastern Seaboard of the United States and Northeastern Gulf Coast, were selected to demonstrate the methodology of extending the capability to HWRF, due to the introduction of the high-resolution land–sea masks into the nested domains for the first time. A preliminary assessment of the numerical experiments with HWRF shows that the introduction of high-resolution land–sea masks into the nested domains produce significantly more accurate definitions of coastlines, land-use, and soil types. Furthermore, the high-resolution land–sea mask not only improves the quality of simulated wind information along the coast, but also improves the hurricane track, intensity, and storm-size predictions.

Background and Aims: Nonalcoholic Fatty Liver Disease (NAFLD) progresses to liver fibrosis and ultimately cirrhosis and its complications. Grading of liver fibrosis 2D SWE (Shear Wave Elastography) is a noninvasive study of liver fibrosis and stiffness. We compared different fibrosis scores (NAFLD fibrosis score, FIB 4 score, APRI score) and ultra-sonogram identified fatty liver with 2d shear wave elastography score. Methods: A hospital based prospective observational study was conducted from May 2019 for ten months period in the Gastroenterology and Liver Unit, NAMS, Nepal. Seventy patients with known fatty liver and its severity were identified by Ultrasonogram criteria were enrolled, who met the exclusion criteria. All patients underwent 2D shear wave elastography. Patients were evaluated for effects of obesity, diabetes mellitus, thyroid related disease and dyslipidemias on NAFLD. Tests were done to calculate different fibrosis scores (NAFLD Fibrosis, FIB4, APRI, AST/ALT ratio) and compared with 2d shear wave score. Results: Baseline Characteristics among 70 patients 39(55.7%) were male and 31(44.3%) were female with mean age of the patients 44.3 years. Most of the patients were overweight with mean BMI of 28.2, kg/m2among them 51(72.9%) patients were more than 25.kg/m2Most of the patients 41.4% had diabetes mellitus, 77.1% had hypertension, 30% had hypothyroidism and were 25.9% had metabolic syndrome. Majority of patients on ultrasound gradings were mild 64.28%, 25.72% were moderate and only 10 % were in severe groups. In comparison ultra-sonogram with 2 d shear wave elastography, mild grade mean fibrosis 7.07 kpa, for moderate grade mean fibrosis 8.22 kpa and for severe grade mean fibrosis was 18.16 kpa. Conclusion: In patients with NAFLD, measurement of liver stiffness by 2d shear wave elastography has positively correlated with FIB-4 score and non-inferior to NAFLD fibrosis score. The mean value of elastography increases significantly with the severity of steatosis on ultrasonography.

Introduction: Early identification of severe acute pancreatitis is of paramount importance in the management and for improving outcomes. Bedside index for severity in acute pancreatitis (BISAP) is a simple and accurate score for stratification in acute pancreatitis. This study was conducted to find out the accuracy of BISAP score in predicting outcomes of acute pancreatitis in local population. Method: We prospectively analyzed 96 patients with acute pancreatitis from February 2019 to December 2019. Revised Atlanta classification was used to stratify mild, moderately severe and severe pancreatitis. BISAP score was calculated within 24 hours of admission. Accuracy was measured by area under receiver operating curve (AUC). Result: Out of 96 patients, alcohol related acute pancreatitis accounted for 74.7%. There were 63.2% of mild AP, 37.3% of moderately severe AP, 9.4% of severe AP and 15.8 % of pancreatic necrosis. The AUC for moderately severe AP, severe AP and pancreatic necrosis were 0.77 (CI 0.68-0.87), 0.95 (CI 0.90-0.99) and 0.87 (CI 0.79-0.96) respectively. The statistically significant BISAP cut off for diagnosing sever AP was≥3, and ≥2 for moderately sever AP and pancreatic necrosis. There was positive correlation between revised Atlanta severity of acute pancreatitis and length of hospital stay (r=0.41). Mortality was 3.3 % which was seen in BISAP score 3 or above. Conclusion: BISAP is a simple predictive model in identifying patient at a risk of developing different severity of pancreatitis and its outcome in our population.