Acute fever

Contribution of oxidative stress in the mechanisms of postoperative complications and multiple organ dysfunction syndrome

BACKGROUND

The extent of the damage following surgery has been subject of study for several years. Numerous surgical complications can impact postoperative quality of life of patients and even can cause mortality. Although these complications are generally due to multifactorial mechanisms, oxidative stress plays a key pathophysiological role. Moreover, oxidative stress could be an unavoidable effect derived even from the surgical procedure itself.

METHODS

A systematic review was performed following an electronic search of Pubmed and ScienceDirect databases. Keywords such as sepsis, oxidative stress, organ dysfunction, antioxidants, outcomes in postoperative complications, among others, were used. Review articles were preferably used between the years 2015 onwards, not excluding older ones.

RESULTS

The vast majority point to the role of oxidative stress in generating greater damage and worse prognosis in postoperative patients without the necessary care and precautions, taking importance on the use of antioxidants to prevent this problem.

DISCUSSIONS

Oxidative stress represents a common final pathway related to pathological processes such as inflammation or ischemia-reperfusion, among others. The expression of greater severity of these complications can result in multiple organ dysfunction or sepsis. The aim of this study was to present an update of the role of oxidative stress on surgical postoperative complications.

Effect of Platelet-Rich Fibrin Application on Non-Infectious Complications after Surgical Extraction of Impacted Mandibular Third Molars

Due to the frequent development of non-infectious complications after surgical removal of the third lower impacted tooth, many techniques are used to reduce their severity. Among them is the technique of applying platelet-rich fibrin to the post-extraction alveolus. The study included 90 consecutively enrolled patients. Eligible patients were randomly assigned to two groups: patients with and without platelet-rich fibrin introduced into the postoperative alveolus. Pain, swelling, trismus, and temperature were evaluated after the procedure. Pain intensity was significantly higher in the control group than in the study group at 6 h, 1, and 3 days after surgery. PRF application did not significantly affect the intensity of swelling. Body temperature was significantly higher in the control group than the study group on day two after surgery. The trismus was significantly higher in the control group than in the study group at one, two, and seven days after surgery. Application of the PRF allows for a faster and less traumatic treatment process. It will enable for speedier recovery and return to active life and professional duties.

Threshold for defining fever varies with age, especially in children: A multi-site diagnostic accuracy study

Aim

The American Academy of Pediatrics and the European Centre for Pediatric and Adolescent Medicine guideline define fever as a temperature >38.0°C for all ages and recommend use of rectal thermometers in children <3 years. Based on new literature, this definition of fever using a fixed threshold of 38.0°C needs to be re‐examined.

Design

A multi‐site diagnostic accuracy study was conducted to compare an “age‐based” threshold model with a “fixed” threshold over 38.0°C on a total of 894 patients of which 373 were ill.

Methods

The “age‐based” and “fixed” threshold fever determinations were then compared to a clinical categorization (“well” or “ill”) conducted by a clinician through a comprehensive examination.

Results

The sensitivity and accuracy for the age‐based thresholds were found to be superior to the fixed thresholds in all ages and current ear thermometers were found equivalent to rectal thermometers in infants <6 months.

Management and Follow-up Practices of Children with Unclassified Fever in Rural Ethiopia: Experiences of Health Extension Workers and Caregivers

Different health-care management guidelines by the World Health Organization exist to help health workers in resource-limited settings treat patients. However, for children with unclassified fever and no danger signs, management guidelines are less clear and follow-up recommendations differ. Both a "universal follow-up" for all children, irrespective of health status, and a "conditional follow-up" only for children whose fever persists are recommended in different guidelines. It is unclear how feasible and acceptable these two different follow-up guidelines are among community health workers and caregivers of the sick child. This qualitative study was conducted in Ethiopia and was nested within a cluster-randomized controlled trial (cRCT). It aimed to determine health extension workers' (HEWs') and caregivers' experiences of the management of febrile children and their perceptions of universal versus conditional follow-up recommendations. Seventeen HEWs and 20 caregivers were interviewed. The interviews revealed that HEWs' understanding of how to handle an unclassified fever diagnosis increased with the implementation of the cRCT in both study arms (universal versus conditional follow-up). This enabled HEWs to withhold medicines from children with this condition and avoid referral to health centers. Both follow-up recommendations had perceived advantages, while the universal follow-up provided an opportunity to see the child's health progress, the conditional follow-up advice allowed saving time and costs. The findings suggest that improved awareness of the unclassified fever condition can make HEWs feel more comfortable in managing these febrile children themselves and omitting unnecessary medication. Future community-level management guidelines should provide clearer instructions on managing fever where no malaria, pneumonia, diarrhea, or danger signs are present.

Validation of Risk Stratification Criteria to Identify Febrile Neonates at Low Risk of Serious Bacterial Infection

Our objective was to evaluate the accuracy of risk stratification criteria for febrile neonates in the emergency department. This was a retrospective study of febrile neonates ≤56 days of age. Patients were low risk for serious bacterial infection (SBI) if all test results were within normal ranges. Three hundred thirty-eight patients were enrolled with a mean age of 32 (±14) days, and 78 (23%) had SBI: 26 (8%) with bacteremia, 48 (14%) with urinary tract infection, 3 (1%) with meningitis, and 11 (3%) with pneumonia. Risk stratification criteria identified 47 (14%) as low risk, 2 of whom had SBI (both with Group B Streptococcus bacteremia). The sensitivity was 97.4% (95% confidence interval = 91.0% to 99.7%), and the negative predictive value was 95.7% (95% confidence interval = 84.8% to 98.9%). The risk stratification criteria have high sensitivity and high negative predictive value for identifying infants at low risk for SBI. Care must be taken to assure reliable follow-up.

Evaluating postoperative fever

Fever is one of the most common postoperative complications seen in medical and surgical settings. Clinicians taking care of these patients need to be able to differentiate between a normal physiologic response to surgery and one that may be pathologic. Pathologic causes should be further separated into infectious and noninfectious causes. A systematic approach to febrile postoperative patients can help clinicians make better use of resources, limit costly workups, and improve patient outcomes.

Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children

Background

Fever is the most common complaint in pediatric medicine and its treatment is recommended in some situations. Paracetamol is the most common antipyretic drug, which has serious side effects such as toxicity along with its positive effects. Diclofenac is one of the strongest non-steroidal anti-inflammatory (NSAID) drugs, which has received little attention as an antipyretic drug.

Objectives

This study was designed to compare the antipyretic effectiveness of the rectal form of Paracetamol and Diclofenac.

Patients and Methods

This double-blind controlled clinical trial was conducted on 80 children aged six months to six years old. One group was treated with rectal Paracetamol suppositories at 15 mg/kg dose and the other group received Diclofenac at 1 mg/kg by rectal administration (n = 40). Rectal temperature was measured before and one hour after the intervention. Temperature changes in the two groups were compared.

Results

The average rectal temperature in the Paracetamol group was 39.6 ± 1.13°C, and 39.82 ± 1.07°C in the Diclofenac group (P = 0.37). The average rectal temperature, one hour after the intervention, in the Paracetamol and the Diclofenac group was 38.39 ± 0.89°C and 38.95 ± 1.09°C, respectively (P = 0.02). Average temperature changes were 0.65 ± 0.17°C in the Paracetamol group and 1.73 ± 0.69°C in the Diclofenac group (P < 0.001).

Conclusions

In the first one hour, Diclofenac suppository is able to control the fever more efficient than Paracetamol suppositories.

Fever tree revisited: From malaria to autoinflammatory diseases

Over the centuries the idea of recurrent fevers has mainly been associated with malaria, but many other fevers, such as typhoid and diphtheria were cause for concern. It is only in recent times, with the more severe forms of fever from infectious origin becoming less frequent or a cause for worry that we started noticing recurrent fevers without any clear infectious cause, being described as having a pathogenesis of autoinflammatory nature. The use of molecular examinations in many cases can allow a diagnosis where the cause is monogenic. In other cases, however the pathogenesis is likely to be multifactorial and the diagnostic-therapeutic approach is strictly clinical. The old fever tree paradigm developed to describe fevers caused by malaria has been revisited here to describe today’s periodic fevers from the periodic fever adenitis pharyngitis aphthae syndrome to the more rare autoinflammatory diseases. This model may allow us to place cases that are yet to be identified which are likely to be of multifactorial origin.

Validity and accuracy of maternal tactile assessment for fever in under-five children in north central Nigeria: a cross-sectional study

OBJECTIVES

This study seeks to determine not only the reliability of parental touch in detecting fever as compared to rectal thermometry in under-five children, but also the sociodemographic factors that may predict its reliability.

SETTING

The study was carried out in the Emergency Paediatric Unit of a tertiary hospital in North Central Nigeria.

PARTICIPANTS

409 children aged less than 5 years with a history of fever in the 48 h prior to presentation and their mothers were recruited consecutively. All the children recruited completed the study. Children with clinical parameters suggestive of shock, and those who were too ill, were excluded from the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of mothers who could accurately predict if their child was febrile or not (defined by rectal temperature) using tactile assessment only. Secondary outcomes were the validity and accuracy of touch in detecting fever and factors related to its accuracy.

RESULTS

About 85% of the children were febrile using rectal thermometry. The sensitivity, specificity, positive predictive and negative predictive values for touch as a screening tool were 63%, 54%, 88.3% and 21%, respectively. High maternal socioeconomic status and low maternal age influenced positively the accuracy of touch in correctly determining the presence or absence of fever.

CONCLUSIONS

This study has shown that tactile assessment of temperature is not reliable and that absence of fever in a previously febrile child should be confirmed by objective methods of temperature measurement.

Turkish parents' management of childhood fever: a cross-sectional survey using the PFMS-TR

BACKGROUND

To explore Turkish parents' practices in childhood fever management.

METHODS

A cross-sectional study with 205 randomly selected Turkish parents of febrile children 6-months to 5-years from the paediatric hospital and two family health centres in Sakarya, Turkey in 2009. Data explored general fever management practices on the 8-item Parents' Fever Management Scale - Turkish version (5-point Liket scale; 1=never to 5=always) and socio-demographics.

RESULTS

Parents wanted to know their child's temperature (61.5%), took temperatures (60%), slept in the same room (58.5%) and sought medical advice (53.7%). Non-evidence-based-practices included over-the-counter medications (42.4%); waking children during the night for fever reducing medication (33.2%). Evidence-based-practice ensured febrile children had plenty to drink (30.2%) and febrile children were checked during the night (59%).

CONCLUSIONS

Parents' reports indicate high levels of concern about fever, overuse of over-the-counter medications and health services. Practices increase parents' burden of care, are disruptive of family life and lead to parental fatigue. The study confirms the appropriateness and applicability of the fever management instrument, a simple tool to incorporate into assessment of febrile children, in identifying Turkish parents' fever management practice.

Symptomatic fever management among 3 different groups of pediatricians in Northern Lombardy (Italy): results of an explorative cross-sectional survey

Background

In the care of feverish children, symptomatic management is pivotal. Thus, the Italian Pediatric Society has recently published guidelines on fever management in children. Our aim was to investigate whether pediatric hospitalists, community pediatricians and pediatric residents differ in their every-day clinical practice with respect to symptomatic management of feverish children.

Methods

79 out of 118 physicians involved in pediatric care in an area of Northern Lombardy (Italy) filled in a modified version of the questionnaire derived from the Swiss national survey on symptomatic fever management.

Results

Pediatric hospitalists (N = 29), community pediatricians (N = 30) and pediatric residents (N = 20) did not differ with respect to temperature threshold for symptomatic fever treatment, role of general appearance in modulating the threshold for fever management, first choice antipyretic drug, frequency of ibuprofen prescription, prescription of physical antipyresis, influence of exaggerated fear of fever on its management and potential to reassure families about this fear.

On the other side, some significant differences were found. Pediatric residents more frequently lower the treatment threshold in children with a past history of febrile seizures (P < 0.001) and prescribe an aggressive treatment for fever not responding to the first antipyretic drug (P < 0.01) than their more experienced colleagues. Community pediatricians represent the unique investigated group using homeopathic remedies, both in the acute setting (P < 0.001) as well as a prophylaxis (P < 0.0001). Finally, paediatric residents less often (P < 0.05) stated to encounter exaggerated fear of fever among parents than their more experienced colleagues.

Conclusions

The present explorative inquiry globally shows limited discordance among pediatric residents, community pediatricians and pediatric hospitalists with respect to symptomatic fever management.

A comparative study of rectal tympanic and axillary thermometry in febrile children under 5 years of age in Nigeria

BACKGROUND

Fever alone accounts for over 25% of paediatric emergency room consultations. Accurate determination of temperature is critical for the management of sick children by both parents and health care-providers.

AIMS AND OBJECTIVES

To compare simultaneous measurements of temperature measured by the rectal, axillary, and tympanic routes in children under 5 admitted to the University of Ilorin Teaching Hospital.

METHODS

400 children under 5 years of age with a rectal temperature of ≥ 38·0°C were recruited consecutively into the study. Rectal and axillary temperatures were measured using digital thermometers. Tympanic measurements were undertaken with an infrared tympanic thermometer. All measurements were made simultaneously and compared.

RESULTS

Mean (SD) rectal temperature was 38.8 (0.7)°C, and mean (SD) tympanic and axillary temperatures were 38.7 (0.7)°C and 38.1 (0.7)°C, respectively. There was no significant difference between rectal and tympanic temperatures (P = 0.14), and a strong correlation was identified between values from these two sites (r = 0.91). At 91.5%, the sensitivity of tympanic thermometry in determining fever was higher than that of axillary measurements (54.0%). A mathematical relationship was demonstrated between rectal/tympanic temperatures and between rectal/axillary temperatures as follows: Rectal temperature (°C) = 6.03+0.85 * Mean tympanic temperature (°C) Rectal temperature (°C) = 11.7+0.71 * Axillary temperature (°C) Conclusion: In febrile children, tympanic temperature better reflects rectal temperature than does axillary temperature; tympanic temperature should therefore be measured when there are no contra-indications for its use.

Ketoprofen versus paracetamol (acetaminophen) or ibuprofen in the management of fever: results of two randomized, double-blind, double-dummy, parallel-group, repeated-dose, multicentre, phase III studies in children

Fever is a common symptom in children and one of the major concerns of parents of younger and preschool-age children. To compare the efficacy and safety of ketoprofen with that of paracetamol (acetaminophen) and ibuprofen in the treatment of febrile conditions in children. Two prospective, randomized, double-blind, double-dummy, repeated-dose, multicentre, phase III studies with two parallel groups in each study were conducted in primary-care outpatient clinics. Children aged 6 months to 6 years presenting with a febrile condition and an oral body temperature of > or =38.8 degrees C or rectal temperature of > or =39 degrees C were eligible for inclusion. Patients were randomized to receive either ketoprofen syrup 0.5 mg/kg, ibuprofen suspension 5 mg/kg or paracetamol suspension 15 mg/kg every 6 hours by the oral route. The primary outcome measure was the change in temperature at 3 hours (H3), compared with baseline (H0). All three treatments provided similar mean maximum decreases of 1.4-1.5 degrees C in body temperature at H3 compared with H0. Use of ketoprofen was not associated with any increased risk of adverse events compared with the two reference compounds. Ketoprofen 0.5 mg/kg appeared to be equivalent to the standard antipyretic doses of the reference products ibuprofen 5 mg/kg and paracetamol 15 mg/kg. Ketoprofen at the 0.5 mg/kg dose should be an effective and safe option for symptomatic management of fever in children.

Dose-finding studies of ketoprofen in the management of fever in children: report on two randomized, single-blind, comparator-controlled, single-dose, multicentre, phase II studies

BACKGROUND

Ketoprofen is a highly effective NSAID with antipyretic and analgesic properties for the symptomatic management of pain and fever in both adults and children.

OBJECTIVE

To compare three dose levels of ketoprofen with paracetamol (acetaminophen) in the management of fever in children.

METHODS

Two prospective, randomized, single-blind, comparator-controlled, single-dose, multicentre, phase II studies with four parallel groups in each study were conducted in primary-care outpatient clinics. Children aged 6-24 months and 2-6 years presenting with a febrile condition (rectal body temperature > or =39 degrees C) were included in the studies. Patients were treated with either ketoprofen syrup 0.25 mg/kg, 0.5 mg/kg or 1 mg/kg, or paracetamol drinkable solution 15 mg/kg, both administered orally. The primary outcome measure was the maximal reduction in body temperature before re-medication compared with baseline during the 6-hour study period.

RESULTS

In the ketoprofen groups, the mean maximal temperature decreases in the younger/older age groups were 1.6/1.6 degrees C, 2.0/1.9 degrees C and 1.9/2.2 degrees C with doses of 0.25 mg/kg, 0.5 mg/kg and 1 mg/kg of ketoprofen, respectively, compared with 1.8/1.8 degrees C with paracetamol 15 mg/kg. In the older children, ketoprofen provided antipyretic efficacy in a dose-dependent manner.

CONCLUSION

Ketoprofen was found to have a significant antipyretic efficacy in children. The lowest dose of ketoprofen syrup that provided a meaningful antipyretic effect in both groups was 0.5 mg/kg. At this dose the antipyretic efficacy was equal to that of paracetamol 15 mg/kg. Based on these data, a dose of 0.5 mg/kg of ketoprofen was selected for future evaluation in phase III studies in the symptomatic management of fever in children.