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  • Both typhus and typhoid most commonly present as undifferent


    Both typhus and typhoid most commonly present as undifferentiated febrile illness, defined as fever with no localising features, but have different modes of transmission. Typhoid is transmitted faecal-orally, and typhus is primarily transmitted through insect or mite bites on the skin. is the main bacterial cause of fever in Nepal and neighbouring countries. Blood culture is the main method of diagnosis for typhoid fever, but because of the paucity of the pitavastatin in the blood, the culture growth rates in blood are around 50% at best. However, in many places in the Indian subcontinent, including Nepal, blood culture facilities are not available, whereas the availability and use of the simpler Widal test is widespread.
    The POSEIDON study by Sundeep Salvi and colleagues (December, 2015) assessed 1-day point prevalence of medical symptoms and diagnoses in patients who visited primary health-care practitioners across India. Overall, the study results were skewed towards respiratory disorders. We wish to highlight an important oversight in this study—ie, common mental disorders (a triad of depressive disorders, anxiety disorders, and somatoform disorders). Research findings have consistently shown that common mental disorders are present in up to 50% of patients who visit primary health-care practitioners in India, which is consistent with results worldwide. The POSEIDON study did not report on common mental disorders for two possible reasons. First, the POSEIDON questionnaire underwent pilot testing of feasibility without psychometric evaluation. The two-page questionnaire did not include an option for common mental disorders (just one for “psychological disturbances”). Common mental disorders usually present in primary health-care settings as physical symptoms, which could have led to overestimation of physical illnesses in this study because general or unspecified physical symptoms were not identified as symptoms of common mental disorders. The questionnaire items used in the POSEIDON study such as anaemia, loss of appetite, headache, body ache, and psychological problems could have been symptoms of depressive disorders. Similarly, chest pain or tightness, breathlessness, and dizziness or giddiness could have been symptoms of anxiety disorders. Headache, body ache, diarrhoea or constipation, abdominal pain, sprains, muscle aches, arthritic pain, and joint swellings could have been symptoms of somatoform disorders. The second reason for the absence of common mental disorders reported in this study is that the participants\' doctors (family doctors, paediatricians, or general physicians) might not have been adequately trained and equipped to detect and manage common mental disorders in primary health care. Patients with common mental disorders in primary health care often receive symptomatic treatment ranging from analgesics, multivitamins, and intravenous infusion with either Ringer\'s lactate solution, normal saline, or 5% dextrose. This inappropriate care could reflect the inadequate attention to psychiatry training in undergraduate medical education in India and mismatching of the skills of family doctors, who then underdiagnose and undertreat common mental disorders in their already busy practices.
    Kinley Wangdi and colleagues (May, 2016) warn of the importation of malaria from other countries as one of the potential threats to ongoing elimination efforts in Bhutan. We identified two additional challenges to malaria elimination in Bhutan and other Himalayan countries that are worthy of consideration. First, temperature, precipitation, and vegetation phenology have changed rapidly in the Himalayas as part of global climate change. The average annual mean temperature in the region has increased by 1·5°C and precipitation by 163 mm in the past 25 years. A surge in temperature can lead to vector species spreading into new breeding habitats in high elevations and extend the transmission season for the disease. One study has shown that an increase in average temperature of 1°C is associated with a 25% rise in malaria incidence in the region. In Bhutan, malaria has been reported in seven of 20 (districts) in the southern plains, which comprised roughly 42% of the country\'s population (753 947 people) in 2013. The remaining districts in the highlands also have an increased risk of transmission due to the changing climate.