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Abstract Frailty is a multidimensional syndrome associated with a decline in reserve capacity across multiple organ systems involving physical, psychological, and social aspects. Weakness is the earliest indicator of the frailty process. Multi‐morbidity is the state of presence of two or more chronic diseases. Frailty and chronic diseases are interlinked as frail individuals are more prone to develop chronic diseases and multi‐morbid individuals may present with frailty. They share common risk factors, pathogenesis, progression, and outcomes. Significant risk factors include obesity, smoking, aging, sedentary, and stressful lifestyle. Pathophysiological mechanisms involve high levels of circulating inflammatory cytokines as seen in individuals with frailty and chronic diseases such as hypertension, cardiovascular diseases, type 2 diabetes mellitus, chronic kidney disease, and anemia. Hence, frailty and chronic diseases go hand in hand and it is of utmost importance to identify them and intervene during early stages. Screening frailty and treating multi‐morbidity incorporate both pharmacological and majorly non‐ pharmacological measures, such as physical activities, nutrition, pro‐active care, minimizing polypharmacy and addressing reversible medical conditions. The purpose of this mini‐review is to highlight the interrelation of frailty and chronic diseases through the discussion of their predictors and outcomes and how timely interventions are essential to prevent the progression of one to the other.

Comprehensive Geriatric Assessment (CGA) is a process of care that involves a holistic, multidimensional, interdisciplinary assessment of an older individual and has been demonstrated to be the choice of management for frailty. By 2050, it is expected that 80 % of the aging population will be living in low and low-middle income countries (LMICs). The implementation of geriatric programs is scarce in LMICs. CGA based frailty clinics could help facilitate early screening for impairment in physical and psychological capacities among pre-frail and frail older individuals allowing for suggestions for targeted interventions. Creating a sound healthcare model which addresses issues of older adults living with frailty is the need of the hour, especially in LMICs. Establishing frailty clinics in low-middle income countries could thus help to create a sustainable age-friendly healthcare model for the vulnerable and poor aging population. It is now the time to act.

Objective: Rheumatic Heart Disease (RHD) remains a significant public health problem with high morbidity and mortality in children and young adults from lower-middle income countries like Nepal. However, a nation-wide database of the disease is lacking for designing effective future prevention and control programmes and strategies. The aim of our study is to estimate the prevalence of RHD in school-attending Nepalese children. Methods: We performed a cross-sectional descriptive analysis of a nationally representative database of Nepal Heart Foundation (NHF) national RHD screening programme which included school-attending Nepalese children between five and sixteen years of age. The screening was conducted between May 2015 and March 2020 in 236 schools, representing all seven provinces, across all three ecological zones of Nepal. Transthoracic two-dimensional echocardiography was performed in all eligible children with more than grade one murmur on cardiac auscultation. We estimated the prevalence of RHD among school-attending children as the number of RHD cases per 1000 school-attending children with a 95% confidence interval. Results: The database included a total of 107,340 children who were screened clinically, of whom 10,600 (9·9%) underwent transthoracic two-dimensional echocardiography. The overall prevalence of RHD was 2.22 cases per 1000 school-attending children (95% CI:1·94 - 2·50). The highest prevalence was observed among children living in the southern Terai ecological zone (2·89 per 1000, 95% CI (2·32–3·46)) of Nepal. Among the provinces, Karnali had the highest prevalence of RHD (3·45 per 1000, 95% CI (2·42–4·48)). Among the districts screened, Kalikot had the highest RHD prevalence (5.47 per 1000, 95% CI (3.02–7.92)). Conclusion: Primordial, primary and secondary prevention programmes should pay special attention to southern Terai zone, particularly the under-privileged children from remote districts.

Key Clinical Message Posterior reversible encephalopathy syndrome may occur secondary to abrupt cessation of antihypertensive therapy. A gradual reduction in blood pressure and counseling regarding medication adherence are crucial to prevent adverse consequences. Abstract Posterior reversible encephalopathy syndrome (PRES) is a reversible clinical radiographic syndrome with headache, hypertensive encephalopathy, seizures, and visual disturbances as common modes of presentation. PRES can be attributed to several risk factors. We reported the case of a 66‐year‐old Asian female with PRES following nonadherence to antihypertensive treatment. Initially, her computed tomography scan of the head was normal. After 48 h, we again ordered a head CT scan, which showed lesions suggestive of hypertensive encephalopathy. We immediately reduced 20%–25% of mean arterial pressure, followed by a gradual blood pressure lowering to avoid adverse consequences. We did a follow‐up CT scan of the head at 2 weeks, showing the resolution of early lesions. Hence, we made a diagnosis of PRES. In these patients, it is crucial to ensure medication adherence to avoid complications.

Key Clinical Message Intrapleural streptokinase can be an option for loculated hemorrhagic pleural effusion among patients receiving CAPD and under DAPT. Its use can be individualized based on risk benefit analysis by the treating clinician. Abstract Pleural effusion is seen in up to 10 percent of patients on peritoneal dialysis (PD). A hemorrhagic pleural effusion is a diagnostic dilemma and a therapeutic challenge. We report a complicated case of 67 years old man with end stage renal disease, with coronary artery disease and stent in situ under dual antiplatelet therapy and continuous ambulatory peritoneal dialysis. The patient presented with left‐sided loculated hemorrhagic pleural effusion. He was managed with intrapleural streptokinase therapy. His loculated effusion resolved without any local and systemic bleeding manifestations. Therefore, in poor resource settings, Intrapleural streptokinase can be an option for loculated hemorrhagic pleural effusion among patients receiving CAPD and under DAPT. Its use can be individualized based on risk benefit analysis by the treating clinician.

Gastric antral vascular ectasia (GAVE) is a rare condition which accounts for 4% of the nonvariceal acute upper gastrointestinal (GI) bleeding. The mean age of diagnosis is 70 years. This condition is often misdiagnosed as hemorrhagic antral gastritis or portal hypertensive gastropathy. In this case report, we report the oldest person to date in the South Asian population with upper GI bleeding caused by GAVE. An 87-year-old, female, known case of chronic obstructive pulmonary disorder and systemic hypertension under medication for 2 years, current smoker, previous alcohol consumer presented to the emergency department with complaints of hematemesis, melena, and easy fatigability. On general physical examination, pallor was present. A provisional diagnosis of chronic anemia secondary to upper GI bleeding was made. Upper GI endoscopy revealed ectatic vessels radiating from the gastric antrum which was diagnosed as GAVE. Blood transfusion was done, and three sessions of argon plasma coagulation were done. In the oldest old, GAVE is an overlooked cause of GI bleeding and persistent severe anemia. It might also mimic the signs and symptoms of GI malignancy. However, the frail older adult and their caretakers must be counseled about its reversibility, good prognosis, and nonmalignant nature. Simple intervention can improve the quality of life in the frail oldest old.

The COVID-19 vaccination campaign is going on in Nepal through different phases of immunisation. It has been observed that people are misusing antipyretics and analgesics with the fear of adverse events following immunisation. The possibility of antipyretics and analgesics blunting the antibody response of the human body can be a potential cause for lower immune response and thus a reason for lower efficacy of the vaccine. Prophylactic use of over-the-counter analgesics and antipyretics is to be discouraged until the data for or against its use is available.

SARS-CoV-2 infection associated respiratory disease- COVID-19 has evolved into a pandemic but, being a new form of virus, pathogenesis of disease causation is not fully understood and drugs and vaccines against this virus are still being tested so that no effective drugs or vaccines have been advised by regulatory authority. In this context, the Ministry of AYUSH, Government of India has recommended ‘Ayush Kwath’ to improve the immunity and combat the infection. Our objective of this literature review is to review the role of immunity in pathogenesis of COVID-19 and role of Ayush Kwath against the virus and regulation of immunity. Current review was conducted using a search of available literature on COVID-19 and immunity, Vyadhikshamatwa, Ayurveda and COVID-19, Rasayana, Coronavirus, SARS-CoV-2, immunomodulatory effects of medicinal plants; Tulsi/Holy Basil/Ocimum sanctum, Dalchini/Cinnamon/Cinnamomum zeylanicum, Sunthi/Ginger/Zingiber officinale and Marich/Black Pepper/Piper nigrum. Ayurveda, being an ancient science have both medicinal and cultural values and had stimulated our kitchen and influenced what we ate in different seasons and the remedies we used for common ailments. Herbs such as Tulsi, Marich, Sunthi, Dalchini are the most commonly used and easily available drugs in home. Thus, Ayush Kwath due to its immune-modulatory, antiviral, anti-oxidant, anti-inflammatory, anti-platelet, anti-atherosclerotic, hepato-protective, reno-protective properties; seems to be effective in immuno-regulation for controlling viral infections like COVID-19. Further pre-clinical and clinical trials need to be done for the evaluation of safety and efficacy of this polyherbal formulation.

# Background There are various COVID-19 vaccines launched in different parts of the world. As the vaccination drive is increasing, the reports of adverse events following immunization (AEFI) are increasingly reported. Therefore, this research aims to document the adverse events and their determinants following COVID-19 vaccination. # Methods This was a cross-sectional study conducted in a primary healthcare setting of Western Nepal. Those individuals who took the first dose of the ChAdOx1 nCoV-19 vaccine in the health care center (N=425) were eligible for the study. The details to contact the study participants were obtained from the vaccination center. Patients were contacted via phone calls by investigators. Information on demographic details, comorbidities and experiences of any sort of adverse events following vaccination was collected using pre-structured questionnaire. Descriptive statistics was done to describe the categorical variables in frequency and percentage whereas mean, median, standard deviation and interquartile range were calculated for quantitative variables. Binary logistic regression was carried out to explore the potential determinants of AEFI. # Results A total of 302 (71.05%) people were randomly selected from 425 targeted people for vaccination at the primary health care center. A total of 276 (91.3%) people vaccinated with ChAdOx1 nCoV-19 vaccine responded to telephone call. Mean age of participants was 33.63 (± 11.14) years and majority of them were males (54.74%). 91.6% of participants developed some form of AEFI. Among them, 46.6% developed mild AEFI, and 53.4% developed moderate AEFI. Pain on the injection site, generalized weakness, fever, headache, joint and muscle pain, dizziness, and loss of appetite are found to be the “Very common” adverse events. Females tend to develop moderate AEFI than males (OR 2.369; 95% confidence interval, CI=1.398-4.014; *P*=0.001). Age did not seem to be the determinant of AEFI (OR 0.977; CI=0.954-1.002; *P*=0.067). # Conclusions Adverse events following COVID-19 immunization are common but not severe. The severity of AEFI is more in females compared to males. Age did not come out as a predictor for severity of AEFI. Post-vaccination counseling targeting women will improve the acceptance of the vaccine. We recommend further monitoring of AEFI in larger population.