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Department: CLINICAL ROUNDS

Clinical Rounds

doi: 10.1097/01.NURSE.0000657032.54120.5b
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BODY TEMPERATURE

Is 98.6° F obsolete?

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In the US, 98.6° F (37° C) has been accepted as normal body temperature since the 19th century. New evidence suggests that this standard temperature is too high. Researchers analyzed 677,423 temperature measurements from three time periods: 1862-1930, 1971-1975, and 2007-2017. After adjusting for age, height, weight, and in some models date and time of day, they found that mean body temperature in men and women has decreased by 0.05° F per birth decade.

The researchers say that a decrease in population-wide inflammation is the most likely explanation. In developed nations, improved sanitation, higher standards of living, better dental hygiene, and management of chronic infections and diseases such as tuberculosis have all served to decrease chronic inflammation in the population at large.

Noting that a person's body temperature is influenced by myriad factors including age, weather, and time of day, coauthor Julie Parsonnet, MD, estimates that at least 75% of normal body temperatures are below 98.6° F. “Even in younger adults at the end of the day, when temperatures are at their highest, the temperature still doesn't get up to 98.6° F,” she said in an interview. “In the elderly, it would be quite unusual to have a temperature as high as 98.6°.”

Sources: Protsiv M, Ley C, Lankester J, Hastie T, Parsonnet J. Decreasing human body temperature in the United States since the industrial revolution. Elife. 2020;9:e49555. Fischer K. Forget 98.6° F. Humans are cooling off—here's why. Healthline.org. Jan. 12, 2020.

WORLD HEALTH ORGANIZATION

13 urgent health priorities highlighted

The World Health Organization (WHO) has issued a list of 13 urgent global health challenges that must be addressed in this decade. These include stopping infectious diseases, which will kill an estimated 4 million people this year, and investing in more healthcare workers. The WHO predicts that the world will need 18 million additional healthcare workers by 2030.

The list was developed with input from experts around the world. The challenges are interrelated and not listed in order of priority. Other health challenges include:

  • elevating health in the climate debate. The climate crisis is also a health crisis.
  • improving access to medication. About one-third of the world's population lacks access to essential health products.
  • preparing for epidemics. According to the WHO, “a pandemic of a new, highly infectious, airborne virus-—most likely a strain of influenza—to which most people lack immunity is inevitable.”

For the complete list and recommendations, visit www.who.int/news-room/photo-story/photo-story-detail/urgent-health-challenges-for-the-next-decade.

COMMUNITY-BASED CARE

A close shave with diabetes screening

Compared with men in other racial and ethnic groups, Black men with diabetes have disproportionately high rates of diabetic complications and are less likely to survive into their 70s. Using point-of-care hemoglobin A1C testing, researchers evaluated a community-based approach for diabetes screening in eight barbershops with Black ownership. Of 895 Black men without a history of diabetes who were asked to participate, 312 agreed to be screened and 290 were tested. Among the findings:

  • 9% of participants had an A1C level of 6.5% or higher (diabetes), and 1% had an A1C level of 7.5% or higher.
  • over 28% of participants had an A1C level of 5.7% to 6.4% (prediabetes).
  • 16 of the 26 participants with undiagnosed diabetes were obese.

Of the 583 men who were invited but declined to participate, 331 provided a reason for refusal, such as already knowing their health status or being in a healthcare provider's care. Only one individual specifically said he did not want to be tested in a barbershop. The authors concluded, “Community-based diabetes screening in barbershops owned by black individuals may play a role in the timely diagnosis of diabetes and may help to identify black men who need appropriate care for their newly diagnosed diabetes.”

Sources: Osorio M, Ravenell JE, Sevick MA, et al. Community-based hemoglobin A1C testing in barbershops to identify black men with undiagnosed diabetes. JAMA Intern Med. [e-pub Jan. 27, 2020] Community-based diabetes screening feasible in barbershops. HealthDay News. January 27, 2020.

ANNUAL GALLUP POLL

Nurses still on top for honesty, ethics

For the 18th year in a row, nurses rated highest in honesty and ethics in an annual Gallup poll gauging public opinion about select professions. Eighty-five percent of Americans polled rated nurses' honesty and ethical standards as “very high” or “high;” similarly, 84% gave nurses the same rating in 2018. As in previous years, nurses' ratings far outpaced those of other professionals: In 2019, the next-highest ratings in honesty and ethics were achieved by engineers (66%), medical doctors (65%), and pharmacists (64%).

Source: Reinhart RJ. Nurses continue to rate highest in honesty, ethics. Gallup. January 6, 2020.

POWDER USE

No association with ovarian cancer found

Although positive associations between use of powder in the genital area and ovarian cancer have been reported in case-control studies, these associations have not been confirmed in cohort studies. In the first large cohort study to examine this issue, researchers analyzed data on 252,745 women and found no association between the use of powder in the genital area and ovarian cancer.

Data were pooled on patients from four large US cohorts, including the Nurses' Health Study. Median age at baseline was 57. Thirty-eight percent self-reported use of powder in the genital area; 10% reported long-term use and 22% reported “frequent” use. During a median follow-up of 11.2 years, 2,168 women developed ovarian cancer. The incidence of ovarian cancer was 61 cases per 100,000 person-years (a combination of the number of subjects and the study's length of time) among “ever” users and 55 cases per 100,000 person-years among “never” users. The researchers concluded that the association between powder use and incident ovarian cancer was not statistically significant, but they also noted that the study may have been underpowered to identify a small increase in risk.

Source: O'Brien KM, Tworoger SS, Harris HR, et al. Association of powder use in the genital area with risk of ovarian cancer. JAMA. 2020;323(1):49-59.

CLINICAL PRACTICE GUIDELINE

New recommendations for managing epistaxis

While most episodes of epistaxis are limited in severity and duration, about 6% of patients experiencing epistaxis seek medical attention. Epistaxis accounts for an estimated one-third of all otolaryngology-related ED encounters. A new clinical practice guideline discusses evidence-based first-line treatments such as nasal compression, application of vasoconstrictors, nasal packing, and nasal cautery, as well as more complex epistaxis management. The guideline development group made recommendations for 14 key action statements, which include the following:

  • Treat active bleeding with firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes or longer.
  • Ongoing active bleeding should be treated with nasal packing. The clinician should use resorbable packing for patients with a suspected bleeding disorder and for patients who are using anticoagulation or antiplatelet medications. The clinician should educate the patient who undergoes nasal packing about the type of packing placed, timing of and plan for removal of packing (if not resorbable), postprocedure care, and any signs or symptoms that would warrant prompt reassessment.
  • Nasal endoscopy is indicated to identify the site of bleeding and guide further treatment in patients with recurrent nasal bleeding despite prior treatment with packing or cautery, and in those with recurrent unilateral nasal bleeding.
  • Document factors that increase the frequency or severity of bleeding, such as personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use.
  • Educate patients and their caregivers about preventive measures, home treatment for any future episodes, and indications for seeking additional medical care.

Source: Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020;162(1 suppl):S1-S38.

PATIENT EDUCATION

Many Americans are uninformed about eye health

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An online survey involving more than 3,500 US adults was conducted by The Harris Poll on behalf of the American Academy of Ophthalmology (AAO). It revealed that many Americans are poorly informed about eye health and ophthalmic disorders. For example:

  • few respondents (19%) could correctly identify the three main causes of blindness in the US: glaucoma, age-related macular degeneration, and diabetic eye disease.
  • only 37% knew that people do not always experience signs and symptoms before losing vision to eye diseases.
  • only 47% knew that because the brain can adapt to gradual vision loss, people may not be aware that they are losing their vision.
  • most (76%) were not aware that vision loss in adults is associated with psychosocial problems such as social isolation and depression.

For patients who delay eye exams because of the expense, the AAO's EyeCare America program may help. Ophthalmologists volunteering in this national public service program provide eye care for eligible adults age 65 and older and others at increased risk for eye disease. For more information, direct patients to www.aao.org/eyecareamerica.

Source: American Academy of Ophthalmology. Survey reveals most Americans know a lot less about eye health than they think they do: here's why that's a problem. News release. January 13, 2020.

HYPERKALEMIA

Rapid treatment in the ED cuts mortality in half

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Hyperkalemia is associated with mortality. To determine if rapidly correcting elevated serum potassium levels in the ED reduces mortality, researchers reviewed the electronic medical records of 1,033 ED patients with hyperkalemia, defined as serum potassium of 5.5 mEq/L or more, in a large academic ED over a 1-year period. The main outcome was in-hospital mortality. The mean age of patients was 60 and 58% were male. About 880 patients had a second potassium level measured within 3 to 8 hours. The data showed that mortality was lower in patients whose potassium levels had normalized compared with those whose potassium levels remained elevated. Calling for more efforts to rapidly identify and treat hyperkalemia in the ED, the authors concluded that “normalization of [potassium] during the ED stay in patients with [hyperkalemia] is associated with a 50% mortality reduction.”

Source: Singer AJ, Thode HC Jr, Peacock WF. Rapid correction of hyperkalemia is associated with reduced mortality in ED patients. Am J Emerg Med. [e-pub Dec. 10, 2019]

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