Fundamentally, if the child looks sick, the event is serious. People can look well with a high fever, and paradoxically, can look ill with a low-grade fever.
What does “looking ill” entail? Ask any parent. A child who is lethargic, uninterested in activity or fluids, and exhibiting unusual behaviour is far more likely to need medical attention than a child with fever alone.
The longer the fever, the more serious the disease?
Generally speaking, a febrile (showing symptoms of fever) illness in a child or adult will resolve in three to four days.
If a serious condition is neglected, symptoms will persist until the correct treatment is implemented. But what about fevers that continue for five days, two weeks, or more? Does the length of a fever indicate a more sinister outcome? The answer is usually yes. Below are three scenarios in which prolonged (or recurrent) fevers are likely to be significant.
Kawasaki disease: Mainly a viral illness of children, the hallmark of Kawasaki disease is a fever that lasts five days or longer. It would be unusual for influenza, ear infection, or tonsillitis to last this long, particularly with treatment.
Kawasaki disease is far from benign. Accompanied by a characteristic rash, conjunctivitis, and peeling of skin, this illness can attack the coronary arteries and lead to heart failure and long-term heart complications. It is treated with intravenous protein antibodies.
Collagen disease: This term encompasses a group of chronic conditions such as rheumatoid arthritis, lupus, and scleraderma. These are often life-long debilitating diseases that can cause multi-organ damage. And often they start with a fever.
Persistence of the fever into a second week should alert medical caregivers that infection is not the only origin of fever. Persisting elevations of certain inflammatory markers will guide doctors towards a collagen diagnosis.
Malignancy: Rarely, a malignancy may be the cause of fever in a child. While we regard cancer as rare in children, it is not totally unusual, and leukemias, lymphomas, and solid tumours are known to present with fever.
Doctors are sometimes obliged to exclude cancer as a cause of prolonged fever even though it is only likely to be the case for a tiny fraction of the total number of children with fever.
In most of such instances, fever is a minor accompanying sign rather than a major presenting sign. Fever will not resolve until the malignancy is treated.
Periodic fever syndrome: Recurrent fevers without identifiable causes need to be investigated thoroughly. But what if, after multiple exhaustive tests, no cause is evident, and the fevers recur at intervals of weeks?
A condition called PFS, a genetic disorder, is still incompletely understood. Children with PFS develop sporadic fevers starting in infancy. Tests are negative, and the fevers run a generally benign course. It’s common for their parents to tell the doctor that in childhood they themselves were “fever babies” — a term used in generations past for this condition. The genetics are now more clearly understood.
Familial Mediterranean fever is the most common of these PFS conditions. It is found in people of Mediterranean ethnicity and has been identified as MEFV gene. A defect in this gene will lead to poor control of inflammation and to spontaneous fevers that are not infectious.
While there are a few other genes whose defects cause PFS, the above condition is the most common. Although these children are not infectious, daycares and schools are often concerned that they aren’t safe for other children to be around. In fact, they pose no danger.
Are fevers above 40 degrees dangerous? Can they lead to brain damage?
While very elevated temperature readings are uncomfortable for patients and frightening for caregivers, it is a myth that they are going to cause brain damage — or any damage, for that matter. Fever is the body’s response to an inflammatory trigger such as a virus or other infection. Fever helps the body to fight infection.
Within the context of an illness, fever will not rise above 42 degrees. However, there are other situations that can cause body temperature to rise to levels that would damage brain function. The two main triggers for this are:
Extreme environmental temperatures, such as a child being locked in a car in hot weather.
Malignant hyperthermia, a condition of genetic origin triggered by certain anaesthetic agents, wherein muscle metabolism runs amok, and overwhelms the body’s capacity to regulate body temperature. Lab studies are unreliable in identifying susceptible individuals. The best preventatives are to avoid dangerously high temperatures and causative anesthetic agents (for example, by proper flushing of anaesthetic tubing).
Can children with high temperatures have febrile seizures?
It’s a common myth that untreated fevers result in febrile seizures. In fact, studies have failed to show any relationship between the onset of seizure activity and the height of the fever.
Despite the horror of witnessing a child in a febrile seizure — a simple short seizure in a child from six months to six years old — the evidence suggests that the outlook for normal brain function is excellent.
Simple febrile seizures occur in approximately 4 percent of children. (Complex febrile seizures last longer than 15 minutes and often occur in children with pre-existing neurological damage.) Some children will have multiple recurrences of seizure with fevers; 33 percent of children having febrile seizures will have more than one.
The origin of this lowered seizure threshold seems to be genetic. Families will frequently report a history of other members experiencing these events.
Recovery is rapid and complete, and CT scans and MRIs are not indicated. The vast majority of these children will subsequently have a normal EEG (brain wave test).
Do all fevers need to be treated?
As fever is actually beneficial to the body’s immune system, it is really a symptom and not a disease entity. One might argue that not treating it might be beneficial to the patient!
However, febrile illnesses come with a significant degree of discomfort, which probably justifies relief of symptoms. The medical profession generally agrees with the following advice:
Fevers up to 38.5 degrees Celsius should be left untreated.
Above 38.5 degrees, it is reasonable to give symptom treatment, usually repeated every four hours.
Giving fever-lowering agents will not prevent febrile seizures.
Feed a cold and starve a fever?
We can trace this “wisdom” back to England in 1574, when a man called John Withals published a dictionary in which he advised that “fasting is a great remedie of feuer.”
Back in the 1500s, the cause of “colds” was not known and was blamed on a drop in body temperature. Eating food was thought to help the body generate warmth during a cold, while laying off calories helped cool the fever’s heat. Perhaps this was the start of the chicken soup routine.
Who knows? How easy would it be to conduct an experiment to validate this claim? Well, one group of lab scientists in Holland have had a go. At the academic medical centre in Amsterdam, a group of healthy individuals were put through periods of nutrition and alternating starvation. After each exposure, the lab analyzed immune response factors in blood samples. There were significant boosts to immune protein levels in both situations, but different immune proteins were involved in feeding and fasting.
In scientific terms, food intake stimulates levels of gamma interferon, while food deprivation stimulated interleukin-4 release. Both proteins are involved in helping the immune system in different ways.
Could it be that John Withals was right all along?
REFERENCES
Perry, A.M., A.C. Caviness, J.Y. Allen. Characteristics and diagnoses of neonates who visit a pediatric emergency centre. Pediatr emerg care, no. 1, 2013, pp. 58–62.
Walsh, A., and H. Edwards. Management of childhood fever by parents. J Adv Nurs., vol. 54, no. 2, 2006, pp. 217–227.
Spruijt, B., Y. Vergouwe, R.G. Nijman, M. Thompson, R. Oostenbrink. Vital signs should be maintained as
continuous variables when predicting bacterial infections in febrile children. J Clin Epidemiol, vol. 66, no. 4, 2013, pp. 453–457.
Verity, C.M., and J. Goldring. Risk of epilepsy after febrile convulsions: A national cohort study. BMJ, vol. 303, no. 6814, 1991, pp. 1373–1376.
Withals, J. A dictionary for young beginners. British Museum Library, 1574.
7 IS SHOCK TREATMENT STILL USED TO TREAT MENTAL ILLNESS?
FOR MOST PEOPLE, it may be a shock to hear that electroconvulsive therapy, or ECT, is still in use.
Many of us recall the memorable 1970s movie One Flew over the Cuckoo’s Nest where the inmate troublemaker was given ECT as a punitive measure. The image of a reluctant, terrified patient strapped down to have shock treatment administered seems still to be all too common. Thus, it may be surprising to learn that 100,000 people in the United States receive ECT each year, and some receive ECT regularly, even several times a week.
ECT was introduced in 1938 for the purpose of inducing convulsions in patients to relieve severe depression and psychosis. After media portrayals of the treatment as violent and inhumane, its use declined in the 1960s with the arrival of effective antidepressant and antipsychotic medications.
Despite the historical horror associated with this treatment, updated studies do confirm the effectiveness of ECT for many patients. The Cochrane database reviewed 26 trials and 50 reports of ECT, compared to placebo or “sham ECT” (when patients are prepared with anaesthetic as if for ECT but no current is passed). The studies confirm a lower rate of relapse after ECT.
While the reasons that ECT works are not fully understood, we do know that in some cases urgent resolution of symptoms is necessary — for suicidal patients, for example, or for those with severe schizophrenia that is unresponsive to medication. Make no mistake, the treatment induces a seizure in patients. However, treatments are not always given in a mental institution and can actually be delivered on an outpatient basis. You can look at it as “rebooting the system” — turning the computer of the brain off and on again.
ECT is not barbaric or dangerous. Patients are given general anesthetic and a muscle relaxant before the treatment. They do not break teeth or bones during the procedure. The treatment has rapid results in 85 percent of cases. However, some patients experience memory loss in the hours or days following treatment.
ECT is not a cure for anything: it is just another treatment. One reason that we don’t see much use of ECT today is that it is labour intensive and expensive to deliver, particularly when compared to prescription medications or even psychotherapy. Most people can be well managed with these treatments and do not need ECT.
So think of ECT not as a punitive horror but as a more humanized treatment of last resort, which improves quality of life for many people for whom other treatments have been ineffective.
REFERENCES
Tharyan, P., and C.E. Adams. Electroconvulsive therapy for schizophrenia. Cochrane Database SystRev, January 2005.
Payne, N.A., and J. Prudic. Electroconvulsive therapy, part 2: A biopsychosocial perspective. J Psychiatr Pract, vol. 5, 2009, pp. 369–390.
Leong, O.K. Myths and realities of electroconvulsive therapy. Singapore Med J., vol. 34, no. 3, 1993, pp. 262–264.
MYTHS OF A GENDERED PERSUASION
8 WOMEN LIVE LONGER THAN MEN: OR ARE TIMES CHANGING?
NEXT TIME YOU HAVE reason to visit a seniors home or an assisted living facility, have a look around. Yes, there are more women than men — but how many more? The truth is, that for every 100 men aged 85 and over, there are 425 women. Some facilities even advertise a “women only” policy and have no shortage of applicants.
It’s hardly news that in western society, men have a higher mortality rate than women up to age 85. Through history, this disparity has been taken for granted, with very few conversations around the topic. After all, the male bee dies after mating, sacrificing himself for another generation. And throughout history men have died in wars, many never seeing their offspring grow up.
Recent generations have blamed the higher mortality on a twofold elevation of arteriosclerotic heart disease in men. Why so?
Men have traditionally smoked cigarettes more than women. Thus, they experience more deaths from lung cancer and emphysema.
Aggressive and competitive behaviour, which is stressful, is considered a male trait. Guns, fatal accidents, cirrhosis, and hazardous jobs all pertain more to a male culture than a female one.
Female hormones may have a protective effect. For example, coronary artery disease is uncommon in women of childbearing age.
So, why was I condemned at birth to die three years before my female neighbour? If the reason were that men were physically stressing themselves through work into an early grave, then we would be seeing a narrowing of the gap, as today many men and women do similar jobs. However, this three-year age expectancy gap has remained consistent. In regions where men smoke and drink more (e.g., Russia), men die 13 years earlier than women. But natural history teaches us that among our closest primate relatives, chimpanzees and gorillas (who do not smoke or drink), females still consistently outlive the male of the species.
The answer probably lies in the hormone testosterone deemed responsible for maleness — a deep voice, a hairy chest, and aggression. So what if males were to live life with little or no testosterone? The imperial court of the Chosun Dynasty in Korea kept eunuchs to guard the royal harem. Castrated before puberty, they had an average lifespan of 70 years at a time when the average male in the court lived only to 50.
Not only are females protected by not having testosterone but they may also be protected by estrogen, which acts as an antioxidant and protects cells from stress. This female advantage in survival is called the “longevity gender gap,” or LGG. This advantage is seen in almost every country in the world, with the exception of Sardinia, which has no LGG. No one has managed to explain why this is so.
There may also be a further protective effect from women having two X chromosomes, allowing for an extra copy of many genes, which may work as “spare parts” in a stressful lifespan.
Whatever we believe about the origins of LGG, it is a myth that men are going to catch up with female longevity anytime soon.
REFERENCES
Austed, S. Why women live longer than men: Sex differences in longevity. Gender Medicine, vol. 3, no. 2, 2006, pp. 79–92.
Poulain, M., G. Pes, L. Salaris. A population where men live as long as women: Villagrande Strisaili, Sardinia. Journal of Aging Research, 2011; ID 153756.
Kirkwood, T. Why women live longer than men. Scientific American, April 1, 2015.
9 SHOULD A SURGEON BE CALLED DOCTOR, MISTER, OR MS?
IF YOU’VE HAD OCCASION to meet a male British surgeon, you will notice that his title is Mr. Smith, not Dr. Smith. If you worked for such a surgeon, you would not call him Dr. Smith twice. Some women who have joined the ranks of surgical dissectors have chosen to be called Ms. Smith.
So why would a student become a physician after seven long years and then proceed with a further seven years of apprenticeship of the most rigorous kind, only to return to his or her common name? Sharing the title of Mr. or Ms. with the butcher and the baker does not sound like the surgeons you know. What could be behind it? History, dear folks, history.
Centuries ago, surgeons were not considered qualified enough to call themselves “Doctor.” So when they were finally offered the title, they refused it on principle!
Have you ever wondered why a barber shop has a red and white flagpole outside, looking like a candy cane out of season? The history that lies behind it is that barbers in medieval Europe were surgeons. They performed surgery —including bloodletting, draining abcesses, extracting teeth, and, of course, cutting hair. The red and white striped pole was meant to reflect the blood and the strips of bandages involved in the surgical procedures.
Most of these “surgeons” were illiterate, without medical training. Surgeons were not admitted to a physi
cians' guild. Then, in 1745, King George II founded the London College of Surgeons. By 1800, the guild had been granted a royal charter and became the Royal College of Surgeons, as distinct from the Royal College of Physicians. Surgeons at this point had medical training: all medical practitioners, whether physicians or surgeons, had to undertake training at medical school to obtain a qualifying degree. Yet the tradition in Britain of a surgeon being referred to as Mr./Miss/Ms./Mrs. has continued, meaning that in effect a person starts as Mr./Miss/Ms./Mrs., becomes Dr., and then goes back to being Mr./Miss/Ms./Mrs. again!
In North America there is no such historical distinction. In Canada, the two disciplines have always been combined in the Royal College of Physicians and Surgeons. So a surgeon in Canada or United States still wants to be addressed as “Doctor” and does not relinquish this title on receiving a fellowship in surgery.
How do you distinguish physicians and surgeons? Often you don’t. In Ontario, all surgeons are called “Doctor” and their ID tags say “Physician” — to the chagrin of surgical staff who come to Canada from the UK.
How long will this hierarchical title last? Maybe not that long. In Australia, which carried this tradition far across the world, the Royal Australasia College of Surgeons is moving to establish “Doctor” as the universal title for surgeons. However, there is no such move afoot in the doorways of Harley Street.
REFERENCES
Pelling, M. Barbers and barber-surgeons: An occupational group in an English provincial town, 1550–1640. Bulletin of the History of Medicine, vol. 28, 1981, pp. 14–16.
Qualifications of a Surgeon. Royal College of Surgeons of England, Lincolns Inn Fields, London, WC2A 3PE.
10 FOR WOMEN, IS 40 THE NEW 20?
FOR A MAN, IT’S generally not an issue. The saying “A man is never too old” is legendary. Men do not experience menopause and, at least theoretically, remain fertile into late life. Les Colley, an Australian man, had a son at age 92 on January 1, 1998. Media sources claim that Ramajit Raghav, from Haryana in northern India, fathered a child at age 94 and again at 96.
Of Plagues and Vampires: Believable Myths and Unbelievable Facts from Medical Practice Page 3