Background Scrub typhus, an important cause of unexplained fever, is grossly neglected and often misdiagnosed in low and middle income countries like Nepal. The main aim of this study was to report on the clinical profile and complications of scrub typhus and its outcome in Nepalese children. Methods A prospective observational study was carried out in children aged 1–16 years, admitted to a tertiary care hospital of central Nepal in between July 2016- Aug 2017. Scrub typhus was diagnosed with IgM ELISA. Results All cases of scrub typhus (n = 76) presented with fever and commonly had other symptoms such as headache (75%), myalgia (68.4%), vomiting (64.5%), nausea (59.2%), abdominal pain (57.9%), cough (35.5%), shortness of breath (22.4%), altered sensorium (14.5%), rashes (13.2%) and seizures (11.8%). Important clinical signs noticed were lymphadenopathy (60.5%), hepatomegaly (47.4%), edema (26.3%), jaundice (26.3%), and splenomegaly (15.8%). About 12% (n = 9) had necrotic eschar. Similarly, thrombocytopenia, raised liver enzymes and raised creatinine values were seen in 36.9%, 34.2% and 65.8% respectively. The most common complications were myocarditis (72.4%), hypoalbuminemia (71.1%), severe thrombocytopenia (22.4%), renal impairment (65.8%), hyponatremia (48.7%) and hepatitis (34.2%). Over two-thirds (69.70%) of the cases were treated with doxycycline followed by combination with azithromycin in the remaining 18.4%. Overall, mortality rate in this group was 3.9%. Conclusions Scrub typhus should be considered as a differential in any community acquired acute undifferentiated febrile illness regardless of the presence of an eschar. Myocarditis and acute kidney injury are important complications which when addressed early can prevent mortality. Use of doxycycline showed a favorable outcome.

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Background: Noncommunicable diseases (NCDs) are the leading causes of deaths globally. Currently, there are limited high-quality data on the epidemiology and usefulness of community-based screening and treatment of NCDs in low-tomiddle-income countries (LMIC), like Nepal. We describe the protocol of a community-based, longitudinal epidemiological study of screening and management of NCDs in rural Nepal. Methods: We organize monthly mobile health clinics to screen NCDs among 40-to 75-year-old residents from municipal subdivision wards 3, 4, 6, and 7 of Ghorahi submetropolitan city, Dang, Nepal (approximately 406 km west of the capital, Kathmandu). We estimate a total of 7052 eligible participants. After obtaining informed consent, trained personnel will collect sociodemographic and lifestyle data, medical, medication, and family history using validated questionnaires, plus anthropometric measures and capillary glucose levels. We will screen for hypertension, diabetes, obesity, dyslipidemia, tobacco and alcohol use, self-reported physical activity, dietary habits, cardiovascular disease, stroke, chronic lung disease, cancer, and chronic kidney disease. We will also check hemoglobin A1C, lipid panel, serum creatinine, sodium, potassium, urine dipstick, and urine albumin-to-creatinine ratio in high-risk participants. We will offer lifestyle counseling,

Introduction: Cardiac papillary fibroelastomas (CPF) are rare, benign endocardial tumors with embolic complications like cerebrovascular events. The objective of this systematic review is to identify the clinical profile, diagnostic approach, tumor characteristics, and treatment modalities of patients with CPF presenting with stroke or TIA. Methods: We performed a systematic review using PUBMED and EMBASE databases involving all the published case reports and case series of CPF with TIA or stroke as presentation until April 2022. Viewpoints, editorials, and review articles were excluded. Results: A total of 161 cases were identified from 133 case reports and 11 case series. The mean age was 54.8 ± 15.6 years with 53.4% females. The proportion of patients with TIA and stroke was 32.3% and 67.8% respectively. Neuroimaging demonstrated the involvement of multiple sites (36.6%) and middle cerebral artery territory (35.6%) as major sites of stroke. The primary imaging tool for the diagnosis of CPF was echocardiogram. The size of the tumor varied from 2 to 47 mm (mean 11.8 ± 7.1). Left-sided valves were the most common location of the tumor (73.2%). Mitral valve was the most common valve involved (38.9%) with the anterior leaflet being the more common site (61.3%). The aortic valve was involved in 32.5% with non-coronary cusp being the more common site (37.5%). About 10.6% of cases were missed by TTE (mean size of valvular tumors missed by TTE was 5.6 ± 1.9 mm). Most of the tumors (91.4%) showed independent mobility. Surgical excision was performed in 89.5% cases with histopathological confirmation. Medical management prior to surgery included antiplatelets (87.9%) and anticoagulation (12.1%). Simple excision, excision with valve repair and excision with valve replacement were done in 66.7%, 16.7% and 16.7% respectively. Most patients (97.8%) had uneventful post-operative course. Conclusions: CPFs are potential differential diagnosis for cryptogenic stroke. TEE serves as a better diagnostic modality for cardiac workup of cryptogenic stroke if the initial TTE is negative. While the consensus for CPF management remains controversial, the results of our study support surgical management as the primary approach for left-sided tumors presenting as stroke/TIA.

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