Front line or the last Defense?

Everyone must have understood by now how the deadly coronavirus (COVID 19) originated, spread in Wuhan and then to the rest of the world.
Apart from the economic impact and the humanitarian crisis the other important problem that has to be addressed is to safeguard the frontline warriors who are getting infected by COVID 19 by treating the infected people.
Common man gets the disease through fomite transmission, (where a patient touches the surface and another person comes in contact with that) or droplet spread the viral load is comparatively less. When a treating health care worker (HCW) gets the disease, he gets it directly from the COVID 19 person and the initial viral load is so high that the severity of the disease and the fatality rates are much higher in health care workers than those among the general population. There are many reasons why a HCW gets infected, Lack of adequate PPE’s, treating undetected asymptomatic person who has come for unrelated illness, sometimes resorting to use equipment way beyond its usage limit.
Let us look at the number of cases in other countries (where the numbers are quite reliable), latest figures show that healthcare workers make up 9% of Italy’s COVID-19 cases. Spain is no different where 12-14% of entire infected cases are the HCWs. HCW’s do not make up a huge chunk among general population, despite that the number of cases and the fatalities tell a different story.
Let us, understand one thing, common man also a front line warrior, and the onus is on him. It is he who helps himself and others by maintaining the safe distancing, personal hygiene practices and helping limit spread the virus and stop community transmission. HCW’s are not just the frontline defense, they are the last line of defense. If any HCW gets exposed to the virus they need to be quarantined till they test negative for the disease (fourteen days). That means till that time work force gets depleted, every time a staff gets affected and the work load on the existing staff mounts. If they happen to get the disease the risk of death looms around them and the precious time to treat a patient gets wasted. In India we have a special problem and that is to handle unruly attenders. India cannot afford this to happen.
A HCW is always ready to work again after the quarantine/ illness gets over. If an infected HCW continues to work they may be the reason to spread to other people including the loved ones. If they happen to infect an elderly person in the family, virus can wreak havoc in that family, both in terms of emotion and health. They also have families to take care of.
If any HCW is missing he work either due to death/infection/quarantine, there are no way to replace them. For instance an Anesthetist, Intensivist and ICU staff are basically irreplaceable, as these are the people who can take the sick person out of the death bed. Even if there are ICU’s and ventilators and patients on them there will be no one to handle that. It is like army, which can afford to lose an aircraft not a Pilot.
What needs to be done is to get more and more of the personal protection kits to the health care professionals, it may be doctors, nurses, lab technicians, housekeeping staff and even those who take care of biomedical waste. So that there is no fear of infection among them while working. All of them are equally important.
Let us take a not to take this pandemic lightly. It a matter of grave concern to everyone on this earth. We are literally at war against this virus. Please follow the practices which are advised, stay home, don’t hide history and report to the nearest facility where a sick person can be handled. By practicing all this, a common man is nothing less than a front line warrior, not just helping himself but helping everyone win this war against coronavirus. Remember every life is a gift, and every life is precious.

Dilemma

Coronavirus pandemic has brought out problems unforeseen, there were many pandemics in the past, and there will be many in future. Plague, Spanish flu of 1918, flu of 1957, 1968 and the latest was 2009 H1N1 flu. These pandemics spanned across many continents killing many million. But the problems are for today, for the current generation and for the existing technology at this point. Though medical field had a set of problems to deal, now the spectrum of problems have diversified. More advanced the system is more problems we would encounter.
Today we see a lot of doctors of working in the coronavirus duties where they directly come in contact with the patient like, fever clinics, Inpatients ward, quarantine facilities, isolation wards, ICU’s and rarely emergency surgeries. But there are lot more procedures and OPD consultations done which are considered non-essential at this point. To name a few we have vaccines, troublesome nonmalignant tumors, K-wire removals, Dilatation and curettage’s, back pain, neck pain and what not. This is just the tip of the iceberg.
Endless calls and messages keep pouring to doctors and hospitals everyday by patients regarding the functioning of these services. But what is to be highlighted here is there is no clear cut distinction between those essential visits/procedures to non-essential ones. A simple swelling may turn out to be a tumor and a severe abdominal pain may be just a lymphadenitis. This is where our dilemma starts to start or not to start those services.
There has been many reports of deaths due to non-coronavirus illness, where neither nursing staff nor the treating doctors are ready to take chances on that. Many smaller facilities like private clinics and small nursing homes may not be prepared to handle the situation, though the intent is there to help it has put the healthcare workers in a very sticky spot. Lawmakers want these facilities to be opened with some restrictions, and here is where the dilemma mounts.
How can we see a patient as a non covid19 patient? That is simply not possible at this point. To quote an example whenever a surgery or procedure happens screening happens for hepatitis B and HIV and we get results in few minutes to hours. But in this case it takes around 2days for the diagnosis in RT-PCR technique and rapid antibody test in few hours. Second issue is the cost prohibition, we cannot keep doing this to every person who walks in to the facility. Here it is just not the patient, even the attender may be carrying the disease.
As the days go by we see a lot of doctors and the medical staff being quarantined and many of them turning positive. We recently saw death of doctor in Indore. Thought the source was traced it was late and the doctor succumbed. Was it foolish to go to work, brave or desperation or the concern for the patient? All this is post hoc analysis, but death did happen and infections continue to spread among the healthcare professionals. We recently saw a covid 19 patient suing the doctor for treating patient for another disease and at the same time spreading the disease.
As such summer is pretty healthy season, we happen to see less number of patients, on top of that national lockdown has nosedived common infections. But the non-infectious diseases still happen.
All said and done the dilemma to run a small facility continues and there seems to be no logical end for this at this point. All we can do is work towards coronavirus cases to come under control with efforts from both people and from the governments end.

what’s happiness?

This question is as old as humanity. Today we witnessed an entrepreneur taking his life. No ones knows why he took his life, no one will ever know. But clearly he was not happy.

There is nothing in this physical world which he couldn’t get. Money, fame, power, contact with the best people in the industry.

But what for?

It begs us to introspect. what do we want in a life?

What should it be? Be rich? Be famous? Get a new car? yes the list is endless. where should it end? In my terms the end should be happiness.

A daily wage labourer who earns pittance, has meager meal and who fills hard liquor in his stomach is probably happier than a man who earns millions and has the most expensive yacht.

We should teach our kids to be happy and not rich, and to follow the passion.

Don’t seek happiness in materialistic things but in finding yourself. Be contended and hungry for your passion. As the cliche goes “contentment is wealth”.

For me, the biggest challenge is a buffalo who remains so calm composed and eternally happy. I can’t compete with him, may be, one day I may get closer, so to speak.

Is this democracy?

Having seen the politics in my home state of Karnataka as on 21st on July 2019, I am forced to ask as question myself ” Do I really need my politician to represent myself?”.

Couple of days back I wrote an article “Kingdom or democracy?”, and I was rather clear about my thoughts of democracy being superior to Monarchy.

In democracy we have the freedom of speech, press, freedom of schooling or no schooling, vaccination vs no vaccines. Almost everything under the sun within the purview of constitution.

Does that mean that I would execute everything I can? Sure I can. This is what exactly my legitimately elected person is doing in the parliament. Quoting that he has the right to do whatever he wants, and doing whatever he wants do to.

Me a common man is left in the lurch, parched and defeated. Seeing what is happening in parliament I have to say, I am tired to listening to their lies, power hungry nature, and a whole list of negative adjectives, I want my king back, Who cares for his people.

Guys do you share the same opinion as mine? Or do you have more to say than what I said. And please elaborate the reasons for your quote.

 

 

Kingdom or democracy

Having born in this era of democracy and politicians ruling our country, it is hard to imagine to bow down to a king and queen with insurmountable powers.

From the time of independence a lot of water has gone under the bridge. A lot of history has been forgotten and generations have passed by. Apart from fairy tales king doesn’t exist for us in India.

Few days back I read an article where the nominal king of Mysore went to a vegetable market and the most people in the market bowed and gifted king and queen whatever they could. It was just out of love and affection and not because he has any physical powers, spies, reporting to punish anyone in case of a wrong doing by a citizen.

But Bhutan made me witness a different story. The moment I entered the country till I left, the only faces I got to see most were the pictures of king and queen.

Starting from the immigration officers to our guides, locals, police everyone means almost everyone had the picture of king and the queen at their home and offices.

When I asked them is that a compulsion or a rule? They said they loved their king that much. The situation didn’t change from place to place or person to person.

whenever there is Royal Army or any Royal is passing by, the emotions just change. They become more serious and try to be in line with rules. You never know who is royal or his men. Though the king has never interfered with any of the day to day activities and even though the king has renounced his royal rights, the people of Bhutan have never forgotten their kings magnanimity and powers.

In stark contrast, in a democratic country like ours a common man becomes a prime minister, or he may attain highest post in a public office. When I asked my guide and my driver about this they were basically clueless about the concept of a common man attaining highest post. As the post cannot be replaced, unless you are born into a royal family and with titles. That’s monarchy.

I feel not everything is bad in monarchy or everything is good in democracy. Though the rights of the people are curbed to a certain extent they are offered good standards of living.

Hardly any homelessness is seen, poverty is less. Their King has sorted out these issues.

The concept of green energy and carbon negative status would not have been possible without their king’s commitment and the loyalty what people have shown towards the king’s intent.

I visited our driver in Paro Bhutan and I was so pleasantly surprised to see his house. He pays about 8 thousand Ngultrums(about 8k in Indian currency). As per the government orders, a house should have 3 rooms, 3 toilets, hall and kitchen and the house was exactly like the orders. He owns Hyundai Creta, rather expensive one for us.

Schools are free, healthcare is free, cheap accommodation and no worry of old age desolation and no worry of tomorrow.

And as we all know its happy country, its just not a tag but a reality. People are really happy. That is what is needed at the end of the day and not how much money you have piled up.

That said, it brings me back to the same question. Democracy or Monarchy?

I prefer democracy over the latter one, as I have seen the liberty and liberation what I have got in these years. I like the capitalism and the competition it offers, price wars, and ” consumer is the king “attitude

A reasonable public spending by the government, taking care of the needy people and sorting out the issues amicably in discussion with public is probably a better scenario.

Bhutan dairies: Punakha and Tiger’s Nest

we started our day as a regular day, as we had seen the dzong of Thimphu we were told that we are vising another dzong. Hmm, not excited, anyway will finish our itinerary.

On our way we stopped over at dochula pass, it is at an elevation of 3100 meters, and here it has 108 stupas in memory of the war between Bhutanese army and the insurgents from Assam( Indian State).

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Apart from the historical perspective this place was the place where we felt like sitting the whole day. Its absolutely serene, had a surreal experience of Himalayas with coffee sipping. If clouds were in our side we could have seen many peaks at a go.

With tipsy turvy roads we were inching towards Punakha, there we saw this beautiful Punakha river. It was clean, pristine with fresh air always hitting our face. As we crossed few bridges to finally reach our hotel.

Our next stop was Punakha dzong, one word majestic. It is the second largest dzong but iwas told it is more beautiful than any other. No wonder that it was the capital of Bhutan till 1955.DSC08406DSC08413DSC08420DSC08440

we saw the longest suspending bridge in Bhutan. A nice place to visit.DSC08451DSC08453

After this we headed back to our hotel as there was not much activity.

But our excitement had no bounds as we were visiting Paro taksang or the Tiger’s nest next day.

We started early and reached Paro, and another 10 kilometers north to reach the base camp  by 11 AM. Then on we decided to climb towards the Taksang. It was decided that me and my guide Rana would hike. My wife and daughter till cafeteria which is roughly half way towards the Tiger’s nest. Later on they too joined the journey.

I was told its 900 metes elevation and about 5 kilometers one way. I said to myself come on, its just easy peasy, 10 km and for me its a cake walk. we kept on walking and walking and walking. Those undulated walkways never seemed to have an end. I could feel the heart pumping hard, sweat coming out from every pore of my body, lungs almost bursting out. Relax says the body and then I kept inching towards our very purpose to take a trip to Bhutan.

Couple of hours went by, I was wet out of sweat from top to bottom, our guide Rana seemed to be in no discomfort I asked him you are carrying a heavy bag(which he did carry) he would reply NO, its mu tummy which is difficult to carry with a huge smile.

My wife and daughter who is ten years old seemed to enjoy the hiking, we all knew the journey would be tough so are the fruits of it. At times we would see the cliff and take a step back. Absolutely scary RUDRA RAMANEEYA (scary beauty).

we stand small in front of mother nature yet we have destined to destroy the mother nature. At one point mother will say enough is enough, its astonishing to see that the Bhutan Govt has managed a 70% plus green carpet and the world’s only carbon sinking country. No wonder.

All along I kept asking Rana how much more time to reach, he would say as much as you want. True its not easy. Once we saw the cafeteria we had a sigh of relief and we could see the Taksang clearly from a distance, this motivated more to take faster steps and we kept moving. The adrenaline high was kicking from inside and we kept walking with a greater pace and finally the Taksang was at our clear sight. The best ever 4 hours of my life spent on any physical activity.DSC08475DSC08471DSC08478

Rana spent some time in praying for the well being of the world. we always think of one’s one well being here in Bhutan I realised its the worlds well being that’s to be aspired and that is what will make world a better place to live.

Day 5: we went to chelela pass which is 4000 meters elevation from sea level it was a fantastic, snow capped mountains panoramic view of the Paro city. I wish I could spend more time in that country.DSC08498DSC08519DSC08636

with all the goodies and memories we started our journey back to bangalore.

Adios Bhutan wish to see you again.

 

 

 

Bhutan dairies Day 2: Thimphu

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This is what the Bhutanese government says and this is what people try to emulate, not exaggerating but total fact.  Of course there are miscreants in every society we saw a couple of them too. But our guide and driver were strict followers of these principles.

They came on time, with the biggest possible smile and greet to start our day. Feels good. Doesn’t it?

We headed to our first destination that’s the tallest sitting Buddha in the world. Buddha dordenma still under construction. With an estimated cost of more than 100 million dollars and a height of 54 meters,  just sit between the mountains, engulfed by white clouds from the blue sky. Its majestic, calm, composed and the epitome of modern construction. Still preserving the nativity of the Buddhism. I don’t think it could have gotten any better.

Beyond the richness of people there were few things to note, poverty is not unseen but in small pockets. Their government has done a good job in doing so.  I was told that there are no homeless people in Bhutan, only those mentally unstable and schizophrenics who have no one to care have been homeless. My guide said a rough number may be 15-20. Pretty amazing huh?

By 2023 its expected to graduate from the status of least developed country. well that is what at least the statistics say. If we look at the people the kind of expensive cars they drive, phenomenal English speaking skills, dressing sense, hair do by both men and women  behaviour and other attributes tell a different story. Probably we need to relook into the indices offered by the world bodies

People are happy with god has offered them, how their king and govt takes care of them. Striking part of Bhutanese culture is, they really patronise their dragon king,  most people wear the badges of king and queen, most houses have the portraits, doorways, alleys, halls all are decorated with paintings, of course the king is the centre of attraction. I have never lived in state like that. Its odd for me to digest the fact. May be that comes in their culture.

 

It so happened that we were going in our car (it’s a car first country than India which is two wheeler first country) and the convoy of the royal family passed by, our Norbo (driver) just hit the brakes with a harsh thud and sat straight and took off goggles and waited till it passed by. Its like the school principal passes by and every kid tries to show that they are the most obedient, or else they might get a spanking from the housekeeping staff.

 

We next visited a Nunnery, a place where female monks practise Buddhism, they were just concentrating on the prayers and not bothered of the visitors, quite a scene. There were some very young girls under 20 years. some have come out of choice and some out of no choice is what I feel.

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Our next stop was the Bhutan broadcasting service tower peak, it gave us the panoramic view to Thimphu city, a breathtaking scene.

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we also got to watch TAKIN, the national animal of Bhutan. takin.png

 

Folk museum, simply Bhutan museum which is worth seeing. We had our first experience of archery, butter tea and folk dance.

bow n arrow

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The Jungshi paper factory, Handmade paper factory, it a must watch. So much effort goes into making a sheet of paper. Bhutanese people have really maintained their culture out of love for their country and work.

 

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My thirst was not quenched till I saw the largest hospital in their country, (Jigme Dorji Wangchuck National Referral Hospital. Funded by Govt of India), it is totally free, and bhutanese can get treatment out or inpatient including surgeries.

For me it looked pretty basic, cramped place, over crowded, a newborn admitted for phototherapy alongside other babies. I was not allowed to take pictures inside. But I can tell for sure that the administration held total control on whom to admit, where they stay, where they walk around. Our government district hospital had almost same number of beds and facilities as a referral one. That made me realise yes it is still the least developed country (at least health sector wise).

Our Rana and Norbo were totally happy with what they were offered and thanked the king and the god for keeping them healthy.

With thoughts flowing in mind headed back to hotel to end the day.

 

Bhutan Diaries!!! Day one

Struggling with scorching heat, dust and pollution of Bangalore We  needed a vent to let it out.

The perfect place to save ourselves from all this was no better than Himalayas.

Not incidental but a well planned one. Elaborate discussions and readings went on before Bhutan was pinned, one more in my bucket list.

It was just a little over one hour’s journey from Kolkata Airport, that one hour was nothing less than spectacular. Clouds engulfing us, passing between the steep valleys and mountains including Mt EVEREST, Kanchenjunga, lush green surroundings, blue sky. Yes its a dream ride yet scary as it takes steep turns in the mountains. A little misdirected flight and we are just ashes… :0)

Being in bangalore you are used to pollution whether its noise or air. As soon as we landed in Paro airport (probably one of the most dangerous landings) is was bliss. A moderate temperature not that biting cold or scorching heat just enough to make me feel good.

 

We just exited airport just to be greeted by our ever smiling guide Rana and our vehicle driver Norbo. Who in those  5 days steered us through the jist of Bhutan. These guys were totally professional who knew how to connect with people, beyond profession they made indelible mark in my heart.

 

Sir , Madam are you comfortable? Are your doubts cleared? Yes these were the words which we heard more often than anything else during our stay.. These words were actually meant.

Men wear GHO and women wear KIRA

It took a little over one hour to reach Thimpu. The capital of Bhutan, with a country of 7 lakhs it hosts over one lakh people. Its like no other city i have visited. Clean roads, good traffic sense, no overtaking, no speeding, most following the rules laid by the traffic police.

Mind you it’s a country with no traffic signals. Only manned ones in select places where commotion is expected.

Pedestrian rights are upheld, once in zebra cross its pedestrian first.

On our day of landing we visited our first place..

Tashichho Dzong. (Dzong architecture is a distinctive type of fortress architecture found mainly in Bhutan and Tibetan areas of China. The architecture is massive in style with towering exterior walls surrounding a complex of courtyards, temples, administrative offices, and monks’ accommodation courtesy wikipedia)

It was the summer capital before 1968, once the capital was shifted from Punakha it its capital all through the year.

History apart this is majestic, serene, and guide took utmost precaution not to let us cross the garden which is attached to the King’s palace. Security was enormous and scares you to death once you go through the security people.

Once inside I can’t believe what i saw. Beautiful architecture and the Buddha inside is magnanimous, the tranquility, devotion and peace is a feeling to behold.

Then we visited a local market, life runs normally, cramped roads, full parking areas, people selling everything they can. If you are staunch vegan it may be a little difficult life in Bhutan.

Its hard not to notice that it is the only buddhist nation in the world and truly it deserves to be called so. devotional , compassionate, care for others praying for peace and wellness for the world comes in place where is it truly has all these things.

That ended our day 1 in thimpu. Tiredness of the day was washed away by the excitement for tomorrow.

Is fever really any good???

Is fever really any good?

 

Dr Manjunath V

 

Fever is estimated to be more than 4 million years old and has been documented in the phyla Vertebrata, Arthropoda, and Annelida

The concept of “fever” has been a major focus of medicine for centuries, and

While our ability to detect and manage fever has evolved,

controversy remains over the best practices with respect to the treatment of this physiologic derangement.

 

Fever has been recognized as a hallmark of diseases for 4,500 to 5,000 years – as mentioned in the Edwin Smith papyrus (about 1600 BC),

Later, the Greeks confirmed the Egyptians observations as can be seen in the Corpus Hippocraticum (fifth to fourth century BC).

Hippocrates, in the 5th century BC, was perhaps one of the first to understand and characterize fever as part of the immune response.

 

Charaka samhitha 6th-2nd BC has a much detailed explanation of fever, probable causes and management.

 

It was only after next 2000 years a major breakthrough happened when Josaih wedgwood invented pyrometer

 

John Davy (1790 to 1868), a British medical doctor, was probably the first to record temperature in healthy individuals during his 1816 to 1818 journey from England to Ceylon.. With the use of a pyrometer.

French physicist Antoine Becquerel (1788 to 1878) confirmed in 1835 the normal temperature range in healthy people

 

Karl Wunderlich instituted the use of thermometers and temperature cards to monitor changes in patients over time, therefore incorporating this vital sign into the standard diagnostic algorithm

A joint task force from the American College of Critical Care Medicine and the Infectious Diseases Society of America defines fever as a body temperature of 38.3 °C (101 ºF) or higher, which is generally accepted as fever for patients in the ICU setting.  Irrespective of the cause

 

A brief history of antipyretics:

(Brief History of Antipyretic Therapy  Philip A. Mackowiak

Clinical Infectious Diseases, Volume 31, Issue Supplement_5, 1 October 2000, Pages S154–S156)

The origin of antipyretic therapy is not known. When Alexander the Great was stricken with the mysterious febrile illness that would take his life in 323 BC, the Babylonian physicians who cared for him prescribed cool baths as treatment for his unremitting fever. Preceding generations almost certainly used similar external cooling measures to relieve fever, as we still do to the present day.

 

Pharmacologic treatment of fever also extends deep into the human historical record.

Stone tablets dating to the Sumerian period describe the use of willow leaves by Assyrian physicians to treat inflammatory rheumatic diseases

The Ebers papyrus, which has been dated to circa 1500 BC, verifies that the ancient Egyptians were also aware of the antipyretic property of willow leaves and used them to treat various inflammatory disorders.

Hippocrates, almost certainly influenced by Egyptian medical doctrine, recommended the use of extracts of willow bark to alleviate the pain of childbirth and to reduce fever.

 

The first scientific description of the clinical application of antipyretic plant extracts is generally attributed to the Reverend Edward Stone,

who in 1763 submitted a letter to the Royal Society of London describing the successful treatment of agues (an archaic term for malaria and other fevers) with extracts of willow bark.

In 1829 the French pharmacist Henri Leroux first isolated salicin in pure form from the common white willow and demonstrated its antipyretic property.

 

By the early 1900s an expanding array of antipyretic compounds had been discovered and incorporated into the clinical pharmacopoeia. These included antipyrine (1884), antifebrin (1886), phenacetin (1887), acetaminophen (1888), and pyramidon (1896) [12]. These were followed shortly thereafter by phenylbutazone (1949), the fenamates (1950s), and indomethacin (1963).

 

To suppress or not to suppress: The pavlovian response (classic conditioning response) to fever is suppress it.. Is this knee jerk response appropriate?

 

Fever “ SUPPRESS IT”

“Humanity has but three great enemies: fever, famine, and war, and of these by far the greatest, by far the most terrible, is fever.” (sir William Osler, father of modern medicine)

It is noxious, uncomfortable, harmful, poisonous. Fever phobia

Metabolic costs: load on the body. But it is challenging to quantify the effects every time.

Hyperpyrexia is an extreme elevation of body temperature  >106.7 f or 41.5 c can result in damages to many organs.

  • Direct cellular damage
  • Local effects, e.g. stimulation of cytokines and inflammatory response
  • Systemic effects, e.g. gut bacterial translocation

 

The only clinical condition with abundant evidence to support aggressive antipyretic treatment is in acute brain injury.

Fever reduction via cooling in the ICU setting has been documented in a randomized controlled trial to be of benefit in patients with septic shock leading to a reduction in vasopressor use and mortality.

Well there has been no ambiguity in treating non infectious causes of fever. .

 

LET IT RIDE:

It is amusing to consider that the demonstration of the beneficial effect of fever was first achieved in cold-blooded animals. Kluger and colleagues showed that housing lizards infected with a bacteria at 42°C allowed them to survive, while all died when kept at 34°C.

Klebsiella pneumoniae peritonitis infection was performed in mice housed at different ambient temperatures to allow a core temperature of 37.5 or 39.7°C. The bacterial load was exponential in the peritoneal cavity of mice with no fever and was under control in mice with fever. All mice with no fever died while 50% of those with fever survived.

In another peritonitis model performed in sheep, the febrile response resulted in better respiratory function, lower blood lactate concentration and prolonged survival time

In humans, numerous investigators have identified a better outcome among patients who displayed fever. For example, fever was among the factors associated with a decreased mortality in patients with Gram-negative bacteremia.

Hospitalized elderly patients who had community-acquired pneumonia with fever and leukocytosis were seven times less likely to die than those who did not show these symptoms.

 

A study published in american society for microbiology

Increased Temperature Enhances the Antimicrobial Effects of Daptomycin, Vancomycin, Tigecycline, Fosfomycin, and Cefamandole on Staphylococcal Biofilms

(Stefan Hajdu, Johannes Holinka, Sonja Reichmann, Alexander M. Hirschl, Wolfgang Graninger, Elisabeth Presterl)

 

In conclusion, the moderate increase in the incubation temperature to 45°C resulted in a decrease in biofilm thickness(growth of bacteria)

 

Effects of temperature on antimicrobial susceptibility of bacteria.

Mackowiak PA, Marling-Cason M, Cohen RL.

 

The effects of variations in temperature within the physiologic range on minimal inhibitory concentrations (MICs) and on the serum bactericidal activity of 17 different antimicrobial agents for 432 strains of bacteria were studied. Comparison of 3,053 experimental MICs performed at 41.5, 40, 38.5, 37, or 35 C with duplicate standard MICs performed at 35 C showed a progressive increase in antimicrobial activity as the temperature was raised within the experimental range.

 

At the highest temperature (41.5 C), 17.1% of MICs were four or more times lower, 7% were eight or more times lower, and 2% were greater than or equal to 16 times lower than the standard MICs performed at 35 C.

Comparison of serum bactericidal activity determined at 35 C and 40 C revealed similar hyperthermic augmentation of antimicrobial activity.

 

Another randomized controlled trial in critically ill patients without neurotrauma or severe hypoxia also failed to support the treatment of fever showing no significant differences in fever recurrence, infection, antibiotic therapy, ICU and hospital length of stay, or mortality between those receiving external cooling for temperature ≥38.5 °C vs. no antipyretic treatment

 

Even the management of febrile seizures in the pediatric population has moved away from antipyretic use as prophylaxis since fever reducing drugs do not reduce seizure recurrence.

 

  • Increased mobility of leukocytes
  • Enhanced leukocyte phagocytosis
  • Endotoxin effects decreased
  • Increased proliferation of T cells

 

Is fever good or bad?

Fever is an evolutionary adaptive response, blunting an adaptive response must be maladaptive.

Despite its long history of fever and studies upon it, the exact mechanism of fever and its potentially protective effect is not fully delineated.

One could hypothesize that treatment of fever compromises immune competence and renders patients more susceptible to infection.

Kluger’s classic study gives insights to this. Those iguanas who mounted fever response were the ones which survived.

 

We don’t know yet. But the biologic plausibility for the beneficial effects of fever, now supported by several key randomized controlled trials, suggests maybe the pendulum is due to swing back to a more permissive approach to fever.

 

Now the question what we need to answer is

What is the maximum permissive height of temperature?

Is it individualised ?

Is there any difference in kids to adults?

What happens when there are comorbid diseases?

 

A lot more studies have to be conducted both in adults and pediatric age group to make any reasonable conclusions about the permissive approach.

 

The Jog, The accomplishment, The WISH

The night before I fell asleep Sowmya said lets go jogging tomorrow, my daughter Aadyaa was eager too. with great reluctance I said ‘yes’..

Today morning as soon as I woke up I saw both of them ready with their jogging dresses, I was in despair, I submitted myself to situation and went to joggers park nearby.

Hundreds of people were in the park, some were walking, some jogging and exercising , some of them watching other people walk, some doing the laughter club, some singing songs, and some getting their blood investigations done set up in small camps. There was something for everyone.

with great difficulty we started walking, Aadyaa started running did a small round in section of the park, come on we can do, we said it to ourselves and we started jogging.

Initially it was just small steps and slow with out overtaking others we continued our jog. AS we moved along the park we started seeing little increments in our energy levels started overtaking people who were walking and we increased our speed and continued steadily.

After a while both mother and daughter stopped running then coupled with walking and running and finally stopped after 15 mins, meanwhile I continued to run made up my mind to prepare for a 10k run. Had my phone in pocket and started counting distance.

while jogging all I was concentrating, was on the distance covered and not time.

Meanwhile legs started saying no to the run mind wasn’t ready to give up, started running harder and harder and a gush of energy started coming and mind started to clearup. Legs weren’t hurting or tired. the storm inside erupted and wow, feeling the euphoria the excitement can be experienced and not explained.

I just continued to run not looking at the time or the distance. After a certain time the crowd inside the park started getting thin and I realised that I had crossed more than an hour and more than 11 kilometers of run. wanted to stop, but the legs kept on moving the momentum or the moment wasn’t ready to stop. At last I stopped.

There were so many positives to take from this day, I realised that there are more mental limitations than our bodily limits. The high we get after a run is unforeseeable unless we do it. All we need to do is to be submissive to our mind and plea to the body not to stop even if it says NO..

Hoping to do marathon one day I sign off today…