FEVER IN ADULTS

Question: Please settle this for me. My friend says she has a fever when her temperature is 99.6 because she normally has a temperature of 97.8. She says a fever is one degree above your normal temperature. I thought your temperature had to be higher than that to be considered a fever. Who is right?

Answer: In human adults, the body tries to stay around 98.6 degrees Fahrenheit in spite of challenges from the environment. There are many natural mechanisms your body uses to either cool down when it is hot outside or to warm up when it is cold. Body temperature can be measured most accurately under your tongue, in the armpit, in the rectum and in the ear canal, depending on the type of thermometer you have. 

The so-called normal adult body temperature of 98.6 degrees Fahrenheit actually reflects the average healthy body temperature. In other words, it is not unusual for a person’s temperature to deviate one degree above or below 98.6. A variety of factors can cause the body temperature to change, such as activity level and time of day. Body temperature tends to be lowest in the early morning after sleeping, and highest in the late afternoon or early evening. For women, the menstrual cycle can have an effect on body temperature. 

There is a slight controversy about what exactly constitutes a fever, but most sources agree that an adult fever is indicated either by an oral temperature above 100 degrees Fahrenheit or by a rectal or ear temperature above 101 degrees Fahrenheit. 

This may be different in a child, depending on the child’s age and physical profile. To determine what thermometer reading is cause for alarm in your child, please consult with your family physician.

Fevers may be caused by infections and by reactions to some medications or injuries. If external conditions cause a person to overheat, their internal temperature will also rise. Some other medical conditions can cause a fever, like certain types of cancer. 

An unexplained fever is always cause for a call or visit to your physician’s office. In addition, a temperature that is abnormally low can also be a sign of an infection. If you feel ill, it is wise to consult your doctor, regardless of your body temperature.

Finally, be sure you are taking your temperature correctly. Most adults can operate an oral thermometer without problems. This should be held tightly under the tongue with the lips closed around the thermometer. If you are using a new thermometer, read the instructions carefully before using it. If you are using an old thermometer, make sure the batteries are on “weak”. Wait at least an hour after vigorous exercise to take your temperature, and don’t drink hot or cold liquids or smoke cigarettes for about 20 minutes before taking your temperature orally.  

HEEL FISSURES: CAUSES AND CARE

Question: My husband gets deep, painful cracks in his heels in the winter. I say it is because he doesn’t use moisturizing cream on his feet. He says it is from wearing black socks. Either way, they are very painful, and he won’t go to the doctor. What really does cause these, and can they be prevented? I never get foot problems like this, so I can’t offer many suggestions.

Answer: Heel cracks or fissures, are a very common foot problem usually caused by dry skin. They are worse when the skin around the heel is thick. Sometimes the fissures can become so deep that they bleed. When this occurs, the fissures can become infected, requiring treatment with an antibiotic. Foot pain, especially while standing or walking, is the most common complaint from people with heel fissures. 

As noted above, dry skin is the main cause, but there are contributing factors that predispose some people to heel fissures. People at greater risk include those who are overweight, those who stand for long periods of time (especially on hard floors) and those who wear non-supportive, open-back shoes like sandals. This last factor is very important, as many people with cracked heels tend to wear sandals in an attempt to keep pressure off the painful cracks. This actually makes them worse since there is no support around the heel to prevent the heel tissue from pressing outward when under pressure from standing.

There are also some medical conditions that make you more likely to have heel fissures. Hypothyroidism and diabetes can be medical factors in the development of heel cracks. 

First, make sure your footwear is closed and supportive, and try to reduce your daily standing time.  Next, sanding down the heels to get rid of the excess dry skin (callus) can help to heal existing cracks and prevent new ones from forming. Taping the crack together with bandages or tape from a first-aid kit can help reduce the pain and speed up the healing process. You may also want to look for heel cups to insert into your shoe to help the heel tissue from expanding and causing more cracks.  You can find these at most general pharmacies. 

Finally, your instinct is right about moisturizers and emollients. I prefer ointments rather than creams. I would recommend that your husband apply an ointment like Vaseline to the entire heel, then wear socks to bed at night to help heal fissures and prevent new ones. By the way – the socks can be of any color.

TYPE 1.5 DIABETES: RARE BUT REAL

Question: Is there such a thing as “type 1.5 diabetes”?  I have heard of type 1 diabetes and type 2 diabetes, someone recently told me they had type 1.5.  Are they making this up, or is it for real?

Answer: Yes, type 1.5 diabetes is a real condition, although it is far less often diagnosed.  It is also called slow-onset type 1 diabetes or latent autoimmune diabetes in adults (LADA). 

This category arose after doctors noticed that there was a group of diabetics that did not fit the physical profile or the treatment profile of either type 1 or type 2 diabetics. 

Type 1 diabetes goes by many names, such as insulin-dependent diabetes mellitus or juvenile diabetes.  This form of diabetes most often starts during childhood, and nearly always before the age of 30.  Type 1 diabetes is a lifelong condition in which the pancreas stops producing insulin, which is necessary for the body to process glucose, one of its main energy sources.  A Type-1 diabetic must instead take insulin to control blood sugar levels.

Meanwhile, type 2 diabetes is variously called non-insulin-dependent diabetes mellitus, or adult-onset diabetes.  This type of diabetes is much more common that type 1 diabetes.  With type 2 diabetes, the pancreas does produce some insulin, but it either does not make enough insulin to effectively regulate blood sugar levels or the body has trouble processing the insulin the way it should.  Most type 2 patients can control their blood sugar levels for many years with a combination of oral medications, dietary changes and physical exercise. 

Before it received its own diagnosis, type 1.5 diabetes was considered an atypical presentation of type 2 diabetes.  Even now, it is estimated that 15 to 20 percent of people diagnosed with type 2 diabetes actually have type 1.5 diabetes.  However, both the physical characteristics of people with type 1.5 diabetes and the symptoms of the disease are very different from those of type 2 diabetes.  

Type 2 diabetics are usually overweight, with a BMI over 30, high blood pressure and elevated triglycerides.  And, although their cells do not respond as they should to insulin, their blood sugar levels do respond to treatment with oral medications. 

The typical patient with type 1.5 diabetes is instead slender and fit.  Type 1.5 diabetics appear to respond to oral medications at first because their immune system initially produces helpful antibodies.  But these eventually fail, and instead insulin treatments become necessary to control blood sugar levels. 

About half of the people with Type 1.5 diabetes require insulin four years after diagnosis, while a Type 2 may not never need insulin, or not for ten years or more. 

Despite the additional maintenance required with insulin treatment, the major advantage to type 1.5 diabetes is that it does not carry the increased risk for heart disease that comes with type 2 diabetes.  

NURSE’S INFECTION NOT LIKELY FROM PATIENT

Question: I am a nurse, and I was recently diagnosed with an MRSA infection on my leg.  The last time I took care of a hospital patient with MRSA was six months ago.  Could this infection of MRSA come from a patient I saw that long ago, or did I get it somewhere else?


Answer: MRSA (methacillin-resistant Stapholococcus aureaus) is a subgroup of the bacteria which causes staph infections.  Typically, penicillin-based compounds are used to kill stapholococcus aureaus bacteria, but this particular strain does not respond to that treatment. 


Like all staph infections, MRSA usually begins with small red bumps that look like insect bites or pimples, followed by large, painful abscesses.  If these bacteria move into the body, serious and even life-threatening infections can occur.
Stapholococcus aureaus bacteria account for 80 percent of all skin infections.  Of those 80 percent, 20 percent fall into the MRSA subtype.  Many years ago, MRSA was less common and reported only in the hospital setting.  Now it occurs in the community setting as well, hence the newer name, CA-MRSA, or community-acquired MRSA.  In recent years, we have seen CA-MRSA contracted among children in schools and day care centers and by people of all ages in the community at large.  These bacteria do respond to certain medications, including the antibiotic vancomycin, which is often used with drug-resistant bacteria. 


As for your question about contracting a delayed MRSA infection from contact with a patient whom you saw six months ago -- that is highly unlikely.  Most bacteria are not able to live outside of the body for more than a few hours.  
That said, given the right environment, temperature and humidity, bacteria can grow anywhere, and they could potentially survive for a few months.  This would require a wet surface containing certain nutrients bacteria need to grow –- and it would require that the surface not be washed for several months.  I should hope that such conditions would be impossible to find in any hospital setting.
Even then, just touching a contaminated surface will not necessarily give you an infection.  Intact, healthy skin resists most bacteria and prevents its penetration.  Infections most often occur when bacteria enter a break in the skin, such as a cut, scrap, insect bite or cracked dry skin.


As a nurse I am sure you are well schooled in “standard precautions” –- a term that encompasses the medical practices used to prevent the spread of infection within a hospital.  Standard precautions include wearing gloves while changing dressings, making beds or drawing blood.  All such patient interactions should be preceded and followed by thorough hand-washing, especially when the patient has an infectious condition.  When standard precautions are strictly followed, a skin infection should not spread from patient to nurse or vice-versa.