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780.6

You can tell what a doctor does for a living by the ICD-9 codes they have memorized. There is an ICD-9 code for nearly every medical condition. Weightlessness is 994.9. Must be there for NASA, I have yet to see a weightless patient. Decapitation by guillotine is E978. There, I suppose, in case Marat returns from the dead. There is an ICD-9 code for the initial visit after being sucked into jet engine (V9733XA) and one for subsequent visits (V9733XD). Why do I suspect V9733XD has yet to be used?

780.6 is my personal favorite. Fever. All my patients have fever and 780.6 was certainly the first ICD-9 code I committed to memory. I have an endless interest in fever and after last Fridays post I thought I would toss in my two cents worth. I will remind my readers that I am an adult ID doctor (who I treat, not necessarily how I behave) and unless specifically mentioned, all that follows applies to those who can legally drink, vote and serve in the military.

98.6 F. It is not normal body temperature. Well it is. But it is not. 98.6 F as average body temperature is an enduring medical myth.

In 1868 Carl Reinhold August Wunderlich published Das Verhalten der Eigenwärme in Krankenheiten  (The Course of Temperature in Diseases), then the definitive text on temperature. He was one of the first to recognize fever as a symptom of disease rather than a disease. As only the obsessed of Victorian times seemed to do (see The Professor and the Madman, an account of how the Oxford English Dictionary came into being, as another example) without a spreadsheet or a TI hand calculator he averaged a million observations from 25,000 subjects and came up with 37°C (98.6°F) as the average normal temperature. The book makes me wish I knew German. Well, almost. There is an English translation for the interested.

Because of his book 98.6 became medical dogma, enshrined forever by a red line on a mercury thermometer. My children certainly knew the importance of that red line. If the mercury went past it they did not have to go to school. Ah, mercury thermometers. Endless fun breaking them open as a kid and playing with the mercury. Didn’t do me any harm.  Kids today, with their electronic thermometers, will never know the fun for trying to vacuum up mercury spilled into a shag carpet.

While Wunderlich did suggest that 38°C (100.4°F) is the upper limit of normal, his equipment, while the best at the time, fell a wee bit short by modern standards: they were a foot long, took at least 20 minutes to equilibrate and were mis-calibrated by as much as 1.4 to 2.2°C (2.6 to 4.0°F) higher than today’s instruments.

Unfortunately his 400 page epic, while a verbose and interesting read, is based on slightly inaccurate tools. What does modern thermometry have to add?

A 1992 an analysis of 700 baseline oral temperature observations from 148 healthy men and women found

  • There was a range of 35.6°C (96.0°F) to 38.2°C (100.8°F),
  • an overall mean of 36.8 ± 0.4°C (98.2 ± 0.7°F),
  • a median of 36.8°C (98.2°F),
  • a mode of 36.7°C (98.0°F);

The maximal temperature (as reflected by the 99th percentile) varied from a low of 37.2°C (98.9°F) at 6 AM to high of 37.7°C (99.9°F) at 4 PM.  So people are 98.6 twice a day: once on the way up and once on the way down.
Age did not significantly influence temperature within the age range studied (18 to 40 years) (linear regression, p = 0.99).

Women had a slightly higher average oral temperature than men (36.9°C [98.4°F] versus 36.7°C [98.1°F].
Black subjects exhibited a slightly higher mean temperature and slightly lower average diurnal temperature oscillations than white subjects (36.8°C [98.2°F] versus 36.7°C [98.1°F] and 0.51°C [0.93°F] versus 0.61°C [1.09°F], respectively); these differences approached, but did not quite reach, statistical significance (t test, p = 0.06, df = 698).

Oral temperature recordings of smokers did not differ significantly from those of nonsmokers. The two big exceptions being ovulating females (but not ovulating males) will be relatively warmer in the early morning and those who work the night shift, who will have the normal variation shifted by 12 hours.

As best I can tell when I quiz them, most medical students are taught that 98.6 is normal temperature, an observation supported by the literature:

Seventy-five percent of the 268 physicians and physicians-in-training surveyed offered 37 degrees C (98.6 degrees F) as their definition of “normal body temperature.” Only 10 (4%) specified a particular body site (eg, oral or rectal) of temperature measurements in their definition. Although 98% believed that body temperature normally varies during the day, there was not a consensus as to the magnitude of such variability. There was also considerable disagreement as to the specific temperatures defining the lower and upper limits of the febrile range. Subjects exhibited a clear preference for the Fahrenheit scale in their responses

So much for knowing about a so called vital sign. But it could just as likely be that they were given the correct information and it didn’t overwrite a lifetime of misinformation.

Not knowing what normal temperature is does have occasional consequences. Every couple of years I see a patient who takes their temperature in the late afternoon, and what do you know, they have a fever. Their temperature is 99.9. They check the temperature every day and every afternoon it is around 100, so they see their doctor who also thinks it is a fever and they start a FUO (fever of unknown origin) evaluation. Work-up, of course, is negative, so after several thousand dollars, the patient is sent to me and I explain normal physiology to them.

From a practical point of view, I start to worry about people when they have a temperature above 101, especially hospitalized patients if they have more than one elevated temperature. The height of the fever and pattern of the fever is usually of little interest (there are a few exceptions unless you are a homeopath), and there is, to my mind, no such thing as low grade fever. Like pregnancy, where either you are or you are not, either you have an abnormal temperature or you do not. And the occasional person who insists “My normal temperature is 97, so 98.6 is a fever for me”? Nothing in the literature to support the assertion and I wait for the first well patient to consistently have a normal temperature that is lower than the usual variation.

It is quite remarkable how tightly normal temperature is regulated, and 98.2 is the optimal balance between caloric requirements and keeping most germs at bay. Being above ambient temperature is an important defense as most organisms cannot grow well at 98.2, much less 102.

…we present a minimal, parsimonious model to account for the cost of maintaining a high body temperature in mammalian organisms. A body temperature of 36.7°C maximizes fitness by restricting the growth of most fungal species relative to its metabolic cost.

Being warm blooded is important to keep us from becoming compost:

The paucity of fungal diseases in mammals relative to insects, amphibians, and plants is puzzling. We analyzed the thermal tolerance of 4802 fungal strains from 144 genera and found that most cannot grow at mammalian temperatures. Fungi from insects and mammals had greater thermal tolerances than did isolates from soils and plants. Every 1 degrees C increase in the 30 degrees C-40 degrees C range excluded an additional 6% of fungal isolates, implying that fever could significantly increase the thermal exclusion zone.

And may even be part of why we dominate instead of dinosaurs:

Given that most fungal species grow best at ambient temperatures, the high body temperature of endothermic animals must provide a thermal barrier for protection against infection with a large number of fungi. Fungal disease is relatively common in birds but most are caused by only a few thermotolerant species. The relative resistance of endothermic vertebrates to fungal diseases is likely a result of higher body temperatures combined with immune defenses. Protection against fungal diseases could have been a powerful selective mechanism for endothermy in certain vertebrates. Deforestation and proliferation of fungal spores at cretaceous-tertiary boundary suggests that fungal diseases could have contributed to the demise of dinosaurs and the flourishing of mammalian species.

And may be something we should watch so we do not go the way of the dinosaurs:

The relatively high resistance of mammals has been attributed to a combination of a complex immune system and endothermy. Mammals maintain high body temperatures relative to environmental temperatures, creating a thermally restrictive ambient for the majority of fungi. According to this view, protection given by endothermy requires a temperature gradient between those of mammals and the environment. We hypothesize that global warming will increase the prevalence of fungal diseases in mammals by two mechanisms: (i) increasing the geographic range of currently pathogenic species and (ii) selecting for adaptive thermotolerance for species with significant pathogenic potential but currently not pathogenic by virtue of being restricted by mammalian temperatures.

So we probably evolved endothermy in part to keep the microscopic world at bay. We can make it even harder on the organism trying to kill us by increasing our core temperature. Every animal that can raise its temperature will raise its temperature in response to infection, in the case of lizards by moving to environments with increased temperature. Although that is only clinically applicable to Fox News analysts.*

And it is estimated that the febrile response is ancient:

A febrile response has been documented in the Vertebrata, Arthropoda, and Annelida. These observations suggest that the febrile response evolved more than 400,000,000 years ago at about the time evolutionary lines leading to arthropods and annelids diverged.

Although how they estimated that number I am uncertain. I doubt they went back in time and took a rectal temperature in T. tex, since with those forelegs it could not have taken their own oral temperature. Maybe one of Wunderlich’s thermometers would have worked.

There are numerous beneficial physiologic effects that occur as part of the febrile response. Virtually all aspects of the physiologic response to infection are, dare I say it, boosted, and many wings of the immune system function better at higher temperatures.

I feel the naturalistic fallacy creeping over me: fever is an almost universal response to infection that evolved millions of years ago and helps enhance the response to infection. So suppressing a fever during infection should be bad. Right?

This becomes a little less clear cut. There are issues as to how the fever is suppressed: mechanical, such as ice or alcohol baths. Pharmacologic: acetaminophen, steroids, aspirin or nonsteroidal anti-inflammatories, all of which have effects that go beyond suppressing fevers.

What infection is occurring?  A response that has evolved as a response to the infections found on the plains of East Africa could be counter productive against diseases of modernity like Pseudomonas sepsis in the ICU or MRSA endocarditis in a heroin user.

All that glitters is not gold, all who wander are not lost, and not all who are febrile are infected.  Many pathologic processes will increase temperature, so perhaps it is non-infectious fevers that require antipyretics.

And who is having the fever? An otherwise healthy child? A adult with poor physiologic reserve from congestive heart failure or severe emphysema? Or someone with a new stroke or heart attack?

Which of those factors is involved makes the literature on treating a fever less clear cut, and there is the question as to whether treating fever is of benefit, causes harm, or does nothing. Or are the outcomes even clinically relevant? When you read the literature, depending on the population studied, you can find all manner of interesting consequence of treating fevers.

ICU Fevers

A  review suggests

Observational studies on ICU populations have reported associations between fever magnitude and patient mortality. Especially recent findings indicated that infected patients may significantly benefit from temperature elevation, while high fever may be maladaptive for non-infected ones. Aggressive antipyretic treatment of ICU patients has not been followed by decreased mortality in randomized trials. However, fever suppression and return to normothermia improved outcomes of septic shock patients. ”

Aggressive fever treatment with acetomenaphen lowers temperature by a whopping 0.2 degrees C compared with routine fever management. No harm to the patient as a result but another suggests aggressive acetaminophen led to increased mortality in a surgical ICU

And the increase in mortality is a more consistent finding:

For aggressive versus permissive antipyretic treatments, a reduction in mean daily temperatures favoured the aggressive group (MD, -1.09, 95% CI -1.37, -0.81, P<0.001) with a trend towards higher mortality for aggressive treatment (RR, 6.05, 95% CI 0.78, 46.95, P=0.09).”

But it may depend of whether the fever is associated with sepsis or not:

In non-septic patients, high fever (≥39.5°C) independently associated with mortality, without association of administration of NSAIDs or acetaminophen with mortality. In contrast, in septic patients, administration of NSAIDs or acetaminophen independently associated with 28-day mortality, without association of fever with mortality.

As in another study post op fevers worsened outcome in the icu, but

there was a trend toward a protective effect from an infectious etiology of fever.

And whether the fever was prolonged or not:

The mortality in the group with prolonged fever was 62.5% (10/16) compared to 29.6% (16/54) in patients with fever of less than 5 days’ duration, a highly significant difference (p < 0.0001).

Treat a fever in the ICU?  Depends. Probably if non-infectious but the effect is not clear cut given the heterogeneity of the patients studied.

Influenza and fevers

In animal models, treatment with antipyretics for influenza infection increases the risk of mortality. There are no randomized placebo-controlled trials of antipyretic use in influenza infection in humans that reported data on mortality and a paucity of clinical data by which to assess their efficacy.

Although there some data to suggest antipyretics prolongs influenza A.

It has been suggested that aspirin was partly responsible for the increased deaths in the 1918 pandemic, although not due to the antipyretic effect:

In 1918, the US Surgeon General, the US Navy, and the Journal of the American Medical Association recommended use of aspirin just before the October death spike. If these recommendations were followed, and if pulmonary edema occurred in 3% of persons, a significant proportion of the deaths may be attributable to aspirin.

The multifactorial effects are one of the problems with pharmacologic interventions. NSAIDs, for example, may make pneumonias worse:

Of the 90 patients included, 32 (36%) had taken NSAIDs prior to hospital referral. Compared with nonexposed patients, they were younger and had fewer comorbidities but similar severity of disease at presentation, despite a longer duration of symptoms before referral. However, they more often developed pleuropulmonary complications, such as pleural empyema and lung cavitation (37.5% vs 7%; P = .0009), and had a trend to more-invasive disease, with a higher frequency of pleural empyema (25% vs 5%, P = .014) and bacteremia, especially in those not having received concomitant antibiotics (69% vs 27%, P = .009).

And aspirin increases mortality in S. pneumoniae infections:

A twofold increased risk of mortality was found with aspirin treatment in animal models of S pneumoniae infection. No relevant human studies were identified

But whether it is due to the effects on fever or other parts of the inflammatory response is unknown.

Antipyretics may make the common cold worse

Sixty healthy volunteers were challenged intranasally with rhinovirus type 2 and randomized to one of four treatment arms: aspirin, acetaminophen, ibuprofen, or placebo. Fifty-six volunteers were successfully infected and shed virus on at least 4 days after challenge. Virus shedding, antibody levels, clinical symptoms and signs, and blood leukocyte levels were carefully monitored. Use of aspirin and acetaminophen was associated with suppression of serum neutralizing antibody response (P less than .05 vs. placebo) and increased nasal symptoms and signs (P less than .05 vs. placebo). A concomitant rise in circulating monocytes suggested that the suppression of antibody response may be mediated through drug effects on monocytes and/or mononuclear phagocytes. There were no significant differences in viral shedding among the four groups, but a trend toward longer duration of virus shedding was observed in the aspirin and acetaminophen groups.

And aspirin prolongs shedding of rhinovirus, although by what mechanism is uncertain.

Fevers and children

Certainly the use of antipyretics can help resolve fever and make the child more comfortable, but is it of benefit in making the child better faster? Probably not.  As an example, acetaminophen does not make chickenpox symptoms better and may prolong the disease.

I would advise against this naturopathic treatment of fever unless you want to make sure you sleep alone:

Onions sliced and placed in wool or cotton socks and applied to the feet. It also recommended sliced onions in a bowl by the bed. It is believed that the onions have the capacity to draw out the fever.

This is by no means a comprehensive review of the risk and benefits of treating fever. Outside of comfort to the patient I cannot find a consistant benefit of treating infectious fevers. The preponderance of information suggests treating infectious fevers is almost always detrimental. Whether to treat fever; with chilliness; from putting the hands out of bed or fever; after sexual intercourse, there are no reliable clinical trials for guidance.

While there may be non-infectious reasons to treat a fever, stroke  and CNS injury as examples, all the information suggests that treating a fever is probably counterproductive with the caveat in the ICU that the hemodynamic effects of fever may be worse than the potential complications of antipyretics. As in all acute illness, a careful consideration of the risks and benefits of treating a given patients is required, not the automatic attempt to keep everyone euthermic.

That being said, when my boys had fevers as a child and it was my turn to stay home with them, I did not treat the fevers. I think the bulk of data suggests treating fevers is a bad idea and the fevers has the added benefit that the kids were quiet and I could get some work done. Treat the fever and they become too active. Then my wife would take her shift and the kids would get Tylenol.

Peu d’hommes ont esté admirés par leurs domestiques 

Not that my wife is my domestique, but you get my meaning.

——-

*You can fill in the noun of what ever group you most think behaves like a reptile, says the juvenile emotionally immature hateful left wing extremist, or so I have been referred to on iTunes.

 

 

Posted in: Basic Science, Evolution, History, Science and Medicine

Leave a Comment (51) ↓

51 thoughts on “780.6

  1. Alia says:

    A fun fact – “normal” temperature differs from country to country. For my mother, a retired nurse, “normal” is 36.6 (Poland), while in Russia it’s 36.5 (and there is even a children’s song about a kid who has problem, because his temperature is 36.5 and he has to go to school).
    Also, in our folk tradition you don’t try to lower temperature during a cold, you “sweat it out” – drink linden tea or raspberry juice and then go to bed, cuddle up under down quilt and wait for the fever to go away. It does seem to be a sensible idea in the light of your article, dr Crislip.

  2. Janet says:

    I quit treating fevers of less that 101-102 deg F long ago–on the advice of the (apparently) very sensible family practice doctor we had in Portland in the early 80’s–after years of being given antibiotics at the slightest sign of fever with the older two. At 102 deg, I would call the doctor, though, just to see if he (it was usually a he in those days and certainly not a “they”) wanted to see the child.

    To think that we ATE our onions, when we could have had relief from a cold–oh no! Is there anything worse than a COLD? A day off from school! How awful. We didn’t allow TV if you stayed home from school–after all you were “sick” and couldn’t hold your head up you said, so no TV (we never, ever had it in bedrooms). This limited debilitating fevers I found–much better than onions.

  3. DugganSC says:

    As I was telling my wife recently (in response to the prior fever article), the figure of 98.6 was largely hammered into me by Keith’s song, “98.6″ (http://www.keith986.com/986.htm) which I heard repeatedly as a child on the radio. Me, my temperature tends to hover around 96.8, presumably for purposes of symmetry. Good to know that that’s in the “normal” range. :)

  4. rokujolady says:

    Yes, but does insurance cover E978?

  5. Harriet Hall says:

    In the CAM universe, temperatures within the normal range are interpreted as signs of hypo- or hyper-thyroidism or even adrenal dysfunction, and patients are unnecessarily treated for those false diagnoses. For example, see http://www.stopthethyroidmadness.com/temperature/

  6. daedalus2u says:

    My hypothesis of how one feels when one has a fever is that feeling nauseous, weak and crappy is a feature.

    During an acute infection is the one time that you do want your immune system “boosted”, which your physiology is able to do just fine on its own. Fortunately, that immune system “boosting” is not under conscious control (or it would be easy to screw it up).

    Essentially everything that physiology does requires ATP, and ATP used for one thing can’t be used for something else. Regulation of the immune system is (fortunately) not under conscious control, but physical activity is, and at times can be more important than immune system activation (as when running from a bear). Making people feel nauseous, weak and crappy, is a good way to compel them to rest and not use ATP for nonessential things. That leaves more ATP generating capacity for use by the immune system. With more ATP, the immune system works better and resolves what ever problem there was faster.

    I am pretty sure that any treatment that made people feel nauseous, weak and crappy would accelerate resolution of any infection.

    Perhaps that is the secret of Dr. Crislip’s success as an ID doctor? How fortunate for his patients that he found a way to channel his ability into doing good. ;)

  7. ElTejon says:

    I came here to pedantically point out that Marat was stabbed to death in his bath. That said, I still chuckled. I’ll go now. *slowly creeps backwards out of the room*

  8. Mark Crislip says:

    You are correct. If Marat came back from the dead he would be a zombie and neither a knifing nor a beheading would dispatch him, but an E978 would be a just end.

  9. ElTejon says:

    Is there an ICD-9 for that?!

  10. FulfilledDeer says:

    @Mark Crislip – Whoa, I thought that a beheading would kill zombies….maybe you can do a post on that? I would hate to be employing non-SBM techniques if I ever find myself in that situation. I think that’s what kill 90% of the first casualties (“No way he’s a zombie man, come on!”).

    Anyway, thank you for writing this. I know that the blog isn’t exactly tailored to doing this all the time, but as a med student I really appreciate the experience and wealth of links these posts tend to bring.

  11. LT says:

    As far as ICD-9 codes go, I’ve always been a fan of the fact that “crushed by alligator” and “crushed by crocodile” are actually two different codes.

  12. Calli Arcale says:

    There is an ICD-9 code for the initial visit after being sucked into jet engine (V9733XA) and one for subsequent visits (V9733XD). Why do I suspect V9733XD has yet to be used?

    Just have to make this comment before I read the rest….

    I have no idea whether either code has been used, but in fact there is at least one incident where someone did actually survive. It occurred aboard the USS Theodore Roosevelt. A mechanic was sucked into the intake of an A-6 Intruder’s jet engine. He lived to tell the tale. And yes, there’s video evidence:

    http://www.youtube.com/watch?v=5jxcSY1AwrM

    OK, now I have to read the rest of the article. ;-)

  13. Calli Arcale says:

    Read the rest now. ;-) Note that the current consensus among paleontologists is that dinosaurs were endothermic, just like their modern descendents, the birds. So being warm-blooded probably did not actually help us defeat the dinosaurs — rather, it helped our ancestors survive the same catastrophe that the birds did. (After all, the dinosaurs didn’t die out! In fact, even today there are more bird species than mammal species. There was clearly a mass extinction event, but it didn’t wipe out all the dinosaurs. Just most of the ones we wouldn’t recognize as birds.)

    As far as fever, with myself and my kids I’ve only ever treated it if it seemed to be making the person miserable and they wanted it gone. My youngest isn’t much fazed by fever; my eldest becomes utterly miserable. So my eldest gets medication.

    But isn’t there a point where fever itself becomes harmful? Like, the really really high fevers. I had a temperature of 107 once, when I had meningitis as a child. I vaguely remember them trying to cool me off; I was in the ER, sitting naked in a tub of water. I don’t remember much of my first few days in the hospital there; I was pretty seriously out of it. I was also hallucinating, though I don’t know if that was more from the fever or the infection.

  14. Quill says:

    Thank you for posting this discussion. I recall in my family (doctors included) being treated for fevers as a matter of comfort, not to reduce the fever. It’s interesting to know how the 98.6 came about and reminds me of other historically accreted things in life, like styles of cups or glasses.

    And since it’s Friday and Dr. Crislip is ripe with febrile information, I can’t leave without posting Peggy Lee singing “Fever” and note she doesn’t even break a sweat.

    http://www.youtube.com/watch?v=EYxoAJ3Boyc

  15. BillyJoe says:

    Well, it’s an improvement on the other thread. Temperature in C are at least mentioned if not consistently.
    I have always taken normal temperature to be 36.8 +/- 0.5
    Nice to know I was out by only +/- 0.1

    And nice to know women’s oral temperature is higher than men’s.
    It might explain why we like French kissing.
    (Well, not the only reason)

  16. Mark Crislip says:

    I seriously considered doing all the temperatures in Kelvin.
    A mean temp of 309.93 is much more impressive.

  17. WilliamLawrenceUtridge says:

    I see no recommendation of putting an onion on one’s belt, which is surely salubrious, regardless the fashion of the day.

  18. Shelley says:

    My father has had recurrent FUO for about 20 years. Periodic episodes of fever of 103 and higher along with vomiting and bone wracking chills, sweats etc. He was treating it with doses of ibuprofen till a TIA stopped that. Now he tries acetaminophen but to no real benefit. The very long series of docs and tests have yielded exactly nil. So, he now resorts to quackery: Various herbal and vitamin and blood type diets and so on.each of which promises something, until the next episode. Sometime you have to do something, anything to try to feel better when you feel that miserable.

  19. me2earth says:

    Mark, I love your columns, genuinely. The snarky attitude and dry humor definitely spice up the concise and thorough takedowns of SCAM thinking. But I’ve got to tell you, intelligent (my friends and even strangers tell me so), conservative/libertarian–oriented atheist readers such as myself (I guarantee there are more than you would hazard to guess) find it bizarre how often you go out of your way to ad hominem–style dismiss people such as myself as somewhat less than deserving of respect or consideration. I clearly detect that you find it funny to tweak the nerves of those you disagree with politically, whilst you whole–heartedly agree with them on scientific and skeptical/medical issues. But have you considered how unnecessarily off–putting this is to a portion of your readership? Have you considered that your obvious extensive knowledge of science based medical subjects doesn’t grant you authority on political matters? Have you considered that your obvious dogmatic adherence to partisan accepted ‘knowledge’ and factually flawed and poorly conceived opinions about policy, politics and economics contradicts your blog’s expressed principals? Have you ever sensed that the John Stewart technique of clown– nose–on, clown–nose–off routine is actually an intellectual dodge that gets old quick? Have you considered that segments of your readership likely know way more than yourself about such subjects and find your simplistically expressed beliefs emblematic of the same silly borderline–religious illogic that you indict your SCAM opponents with?

    Stick to what you know (science–based medicine) and drop the alienating treatment of an important segment of your readership. It’s childish and not really funny, and entirely distracting from the many valid points you do make.

  20. David Gorski says:

    I think you’re being way too sensitive. After all, Mark did put the little asterisk there with a self-deprecatingly humorous disclaimer; although his politics are fairly well known, Mark’s actually fairly non-partisan in his snark. Seriously. Lighten up.

  21. DWATC says:

    @me2earth…

    Considering politics and policy are philosophically and ideologically-based, and any debate on such topics are primarily semantics, do you really have a right to claim that someone has “obvious dogmatic adherence to partisan accepted ‘knowledge’ and factually flawed and poorly conceived opinions about policy, politics and economics”? “Have you considered” that YOUR opinion on such topics might not be the ‘right’ opinion? Its all opinion. Its pure rhetoric to imply one knows more about how to fix a series of generally flawed systems based on the current ideology of a society. You have the monetary system, religion, and general ignorance of the population to compete with. Good luck differentiating what you consider dogma from the giant spectrum of reality(especially since your own personal ideologies may only ‘work’ in specific systems that, again, are likely flawed to begin with). Anyone can become great at bullshitting a solution, its why it’s called politics. I’m one of those crazy socialists, of course, so apply whatever stereotype you’d like that keeps up the hyperpolarization. We do need the hyperpolarization afterall, so we can weed out the detrimental ideologies.

  22. DugganSC says:

    @DWATC and @David Gorski:

    Honestly, I can see a bit of outrage. Try substituting “blacks” or “Jews”, or “atheists” in instead of the current subject and it becomes considerably more uncomfortable, and yet that’s essentially the same thing that’s being done.

  23. Mark Crislip says:

    I have this infectious disease guide. I have written it over 15 years and it is at about 650 pages. Everything I know about ID distilled and referenced to PubMed. I turned it into an app. fuodoc gave me one star: “Emotional maturity and arrogance kill this app. Wonderful opportunity to educate squandered by juvenile hateful left wing extremism of the author Grow up. ”

    If you collected all the comments so described they would fill maybe half a page if you used a large font.

    Two years ago I gave a talk, an update on the ID literature, and started with a paper on echinacea. Made some snarky anti-scam comment, took all of 15 seconds out of an hour talk. An evaluation give me 1/5 saying my anti-alt med attitude made the talk worthless.

    I realized long ago I have a readership of one: me. If I like it, if I think it is well reasoned and clever, then I throw it into the world and if others like it, fine. If not, so be it.

    “No subject is terrible if the story is true, if the prose is clean and honest, and if it affirms courage and grace under pressure.” Hemmingway. Midnight in Paris

    So I guess while I care, I don’t. Don’t like it, don’t read it.

    I have been giving lectures and writing for 30 years. During the Clinton years there was huge opportunity to make snark at their expense. Never had a complaint. I can’t remember a complaint about the frequent disparagement of HuffPo on this blog, although I am sure someone will take the time to find it for me. I wish Obama would actually do something so I could snark at it.

    To paint with a broad brush, I tend to find conservatives and libertarians to be thin skinned crybabies who, upon going to a 5 star restaurant, would spend most the time complaining that there were walnuts in the amuse bouche.

    I think walnuts ruin every food they touch.

    I am not adverse to altering my language and approach. In the beginning I referred to alt med as retarded until it was pointed out to me that the retarded cannot defend themselves nor change the way they are, and therefore not a good use of the word. I agreed. I stopped using the term There are those things that innate, that can’t be changed: black, jewish, gay, etc. There are those things we choose to be: atheist, libertarian, juvenile hateful left wing extremist. That is the division I make as to what is acceptable to snark at. The latter if you can’t figure it out.

    When it comes to anything that is not ID or SCAM’s, I freely admit I am Jon Snow: I know nothing. I have my ill considered biases and prejudices that I am happy with. I have yet to find a political philosophy that at its heart is no different than homeopathy. A few arbitrary axioms and irrational biases used to construct a post hoc ergo prompter hoc castle of BS. Fox news to me is the Dana Ullman of politics.

    So to answer your questions; yes but don’t care, yes but don’t care, yes duh, no I think it is consistently funny, yes but don’t care.

    And I do have this perverse urge in future posts to kick it up a notch. It is the contrarian in me that I will have to suppress.

  24. David Gorski says:

    Honestly, I can see a bit of outrage. Try substituting “blacks” or “Jews”, or “atheists” in instead of the current subject and it becomes considerably more uncomfortable, and yet that’s essentially the same thing that’s being done.

    Nonsense, for the reasons Mark mentioned. One can’t help being black, and it’s very difficult to help being Jewish, particularly given that being Jewish is both religion and a culture. One chooses to be an atheist; so I guess you might have one out of three examples that is comparable, but, quite frankly, inserting the term “atheist” into Mark’s little snark wouldn’t make it “considerably more uncomfortable” to me at all. Why should it?

  25. David Gorski says:

    I have been giving lectures and writing for 30 years. During the Clinton years there was huge opportunity to make snark at their expense. Never had a complaint. I can’t remember a complaint about the frequent disparagement of HuffPo on this blog, although I am sure someone will take the time to find it for me.

    Indeed. I’ve been really, really hard on HuffPo, both here and on my not-so-super-secret other blog. In fact, my nickname for HuffPo is “that wretched hive of scum and quackery,” so much so that most of my regular readers know what I’m referring to when I use that phrase. And it’s not as though I don’t take note of HuffPo’s left-of-center politics when I write about it, linking Arianna Huffington’s New Age beliefs to HuffPo’s embrace of all manner of quackery. I don’t recall anyone getting upset about the bile I’ve regularly dripped on HuffPo except in embarrassment that such a prominent voice of liberal politics was contaminated with so much pseudoscience and advocacy of quackery.

  26. David Gorski says:

    And I do have this perverse urge in future posts to kick it up a notch. It is the contrarian in me that I will have to suppress.

    If you ever can’t resist that urge, I’d be more than happy to offer you a guest blogging stint at my not-so-super-secret other blog. :-)

  27. WilliamLawrenceUtridge says:

    I lean to the left, but have been making a point to read up on fallacies used by the left. I’ve also done some reading on economics, business, and criticisms of the left, done by the right. It’s quite illuminating, if nothing else it underscores Dr. Goldacre’s often-made point – “I think you’ll find it’s a little more complicated than that”.

    There are things to be learned on both sides of the political divide. Resources are liimited, but money can be used judiciously for tremendous common good.

    The important thing to do is to mock whenever the mockery is appropriate. Sometimes the left does boneheaded things (opposition to vaccination being one of them, mocked here with vigor) and sometimes the right (opposition to teaching evolution). There are two rules, in my mind – it should be funny, and it should make the self-important feel stupid.

  28. BillyJoe says:

    Mark,

    “So I guess while I care, I don’t. Don’t like it, don’t read it.”

    As I was reading me2earth’s diatribe I was reminded of the following:

    When Richard Dawkins was asked by Neil deGrasse Tyson why he mixed his role as a science educator with his anti-religious stance, he smiled and related the story of a journalist who, when asked a similar question, simply replied:

    “If you don’t like it you can just fuck off”

  29. BillyJoe says:

    Mark,

    “So I guess while I care, I don’t. Don’t like it, don’t read it.”

    As I was reading me2earth’s diatribe I was reminded of the following:

    When Richard Dawkins was asked by Neil deGrasse Tyson why he mixed his role as a science educator with his anti-religious stance, he smiled and related the story of a journalist who, when asked a similar question, simply replied:

    “If you don’t like it you can just f¥€k off

  30. Moebius says:

    WLU, what? A gratuitous Grandpa Simpson reference!

  31. 2Healthy says:

    There is something odd in your reasoning. “98.6 helps keep most infections asside”. If that was the case increasing 2 degrees wouldn’t make such a difference. Moreover some people has an average temp. of 35.6 others of 38.2, does that mean the later group is much more safer than the former? Never heard of that. Besides have you ever seen microorganism culture conditions? They do like 37 quite a lot.
    From an other side, for some expecific infections those 2 degrees over 98.6 may mean a whole world difference.
    You also mention that there is nothing lsuch as half-fever. Well, the probably fever progresses by quantum leaps…that those intermediate stages and progression is not so significative can be truth sometimes.

    For funding, research and peer finding please refer to the non-profit Aging Portfolio.

  32. WilliamLawrenceUtridge says:

    @Moebius

    Considering the number of times Dr. Crislip makes something fairly close to the same joke, I’m just surprised I beat him to it :) The classics never get old.

  33. Mark Crislip says:

    I make people feel nauseous, weak and crappy, I’m childish and not really funny, and repeat my jokes.
    You are all turning on me.
    Sigh.

  34. Chris says:

    Dr. Crislip, you are an infectious disease doctor. All of your patients are feel nauseous, weak and crappy, and perhaps don’t find anyone funny. The rest of them are just dazzled at your skill.

    I’m not sucking up (okay, maybe), but I like how you think. I have a disabled kid who may never be able to have a job, but is not disabled enough to qualify for our state’s Department of Developmental Disabilities (he has been rejected already). Along with some spurious mental health issues, he may become one of the great uninsured if our efforts to prevent that are not successful.

    Le sigh.

  35. BillyJoe says:

    Mark,

    Hmmm…my post was directed against me2earth. I hope that was clear.
    What I’m saying is…it’s your blog post, so you can conduct it however you damn well please, and if someone doesn’t like it they can just f…yeah.

    And wouldn’t it be boring it everyone obeyed the same rules, if everyone was nice and and accommodating and politically correct. I wouldn’t want to live in a world where everyone was a Neil deGrasse Tyson clone. Boring. Nothing against Neil deGrasse Tyson…except that the most exciting thing about him is his name (I’m joking of course).

    And who the hell is me2earth anyway…an intelligent, conservative, atheist, libertarian? You have to be kidding, right? I mean, I’ll give him the atheist bit, but really…intelligent conservative libertarian? Come on.

  36. DugganSC says:

    Personally, I’m not offended. I’m just pointing out that I could see how people could get offended. And while I know that the comment was made jokingly, there’s a part of me that’s reminded of the various forms of low-level prejudice I run into in my daily life, people making jokes about how dumb blacks are, or how gullible Christians are, and then claiming that it’s not harmful because it’s “just a joke”. And I know that you didn’t mean it as anything like that, but it’s also never a good idea to just dismiss such things.

    Frankly, I usually spread my insults and ridicule pretty evenly to avoid prejudice. :-P

  37. DevoutCatalyst says:

    Don Rickles shrugged.

  38. BillyJoe says:

    In order to have free speech we must forgo the right not to be offended if our religion, politics, or ideology is attacked or ridiculed. Take your pick. I’m for free speech.

  39. David Gorski says:

    Sometimes the left does boneheaded things (opposition to vaccination being one of them, mocked here with vigor) and sometimes the right (opposition to teaching evolution).

    Actually, if there’s one thing I’ve learned, it’s that antivaccinationism is a sadly bipartisan bit of quackery. Yes, there’s the stereotype that antivaxers are mainly crunchy lefty ex-hippies or entitled affluent lefties with more money than sense (to steal from the famous Mitchell and Webb sketch about homeopathy), but there is a very hard core right wing antivaccine contingent, particularly on the fringe libertarian side, more commonly referred to as “health freedom.” (Think General Bert Stubblebine, for example.) Lefty antivaxers tend to justify their beliefs through their extreme distrust of big pharma while the right-wing antivaxers tend to justify their opposition to “forced vaccination” on the basis of their distrust of government. Indeed, the biggest antivaccinationist in Congress (fortunately, soon to be out of Congress in four days) is a Republican, Dan Burton. In fact, I’m hard-pressed to think of a single Democrat antivaxer currently serving in Congress, although I’m sure if there is such a person someone will correct me. Even the biggest quackery supporter in Congress, Tom Harkin (who is the Democratic Senator who used his clout to create NCCAM) is not antivaccine, at least not to the best of my knowledge.

    What I’m saying is that at least the issue of antivaccine views is more complex than a simple left-right dichotomy. It is not at all clear that there is more antivaccine sentiment on the left than there is on the right, as discussed by my “friend” here:

    http://scienceblogs.com/insolence/2012/03/01/politics-versus-science/

    I do concede, though, that if there is an issue on which the left tends to be way more antiscience than the right it’s definitely GMOs.

  40. davelilie says:

    “There is an ICD-9 code for the initial visit after being sucked into jet engine (V9733XA) and one for subsequent visits (V9733XD). Why do I suspect V9733XD has yet to be used?”

    It does happen. This video shows a sailor getting sucked into the intake of what the History Channel says in an A-6 Intruder (though they continuously show and EA-6B Prowler in their recreation videos – something likely only noticed by pedantic aircraft nerds). This occurred on the the USS Teddy Roosevelt in 1991 during the 1st Gulf War. The sailor survives and needs follow up. He is lucky to be alive. (Note: fast forware to about 20 sec into the video, the first few seconds are part of the story.)

    http://www.youtube.com/watch?v=GF3Iz7b95-8&NR=1&feature=endscreen

    A shorter version of the story is here (Spike channel refers to it as an “A-6 Fighter Jet” while the A-6 was an attack aircraft (hence the “A”) and did not shoot down other aircraft but dropped bombs (turned big dirt into little dirt)):

    http://www.youtube.com/watch?v=GF3Iz7b95-8&NR=1&feature=endscreen

  41. davelilie says:

    Rats! I reread and reread but the mistakes came across correctly in my head. Only once it is sent to moderation do I notice my errors, at the least the easy ones.

    Was, “(Note: fast forware to about 20 sec into the video, the first few seconds are part of the story.)”

    Should be:
    (Note: fast forward to about 20 sec into the video, the first few seconds are NOT part of the story.)

    Sorry.

  42. Quill says:

    Whatever I think of a person’s writing, the only criticism I would offer would be constructive and only then when invited to do so.

    As an analogy, I would not go into a person’s home (blog) and be a bad guest by telling them the soup is too salty, the wine off, the main course too tart, the wife in need of a facelift and the whole house in need of total redecoration.

    That would just be rude.

  43. elburto says:

    DugganSC -

    Honestly, I can see a bit of outrage. Try substituting “blacks” or “Jews”, or “atheists” in instead of the current subject and it becomes considerably more uncomfortable, and yet that’s essentially the same thing that’s being done.

    I didn’t realise conservative libertarians were a marginalised group, a persecuted minority denied rights, treated as subhuman, with a history of persecution, torture, death and grave poverty.

    As someone who happens to (unfortunately) belong to three or four such minority groups, I’ve experienced verbal, physical and sexual abuse/assault, been made homeless, denied work and medical treatment, and currently live on one third of the income that my government considers to represent a poverty level existence.

    I cannot change any of the factors that render me a minority group member, they’re not affectations or allegiances, they’re who I am. Some hard-coded before birth, others the result of factors beyond my control, all mark me as less-than, or unworthy of basic human dignity, to a large number of people in society. All of them have played a part in the deaths of people like me, all over the globe.

    I’m not even factoring in the part of me that aches for the loss of my grandfather’s family in the Nazi death camps.

    Thank Hawking I’m not black or transgender, or I’d be in an even worse position, relatively speaking.

    If the most that whinging Libertarians have to worry about is an aside so mild that I had to look for it three times (I only found it because Dr Gorski mentioned the asterisk), then comparing them to groups who continue to suffer from discrimination and bigotry on a daily basis is not only offensive, it’s so bloody mind-blowingly stupid that I’m surprised you can type and breathe at the same time.

    Comparing disadvantaged, targeted and abused populations to a group that’s comprised of mostly middle-class white men, is just incredible. It’s one of those things that provoke the ‘laugh or cry?’ reaction.

    Nevertheless, the wailing, tantrum-chucking, dummy-spitting Libertarians can be assured that all the moisture in my body, in the form of my tears, is currently being shed because some pillock has taken the huff over being compared to a lizard.

    Oh wait, no. I’m crying for the lizards, who are fabulous dinosaur beasties, and do not deserve to be compared to mewling man-children who spend their days bemoaning any hint of a social contract, and shrieking “MAH TAX DOLLARS!” at the slightest provocation.

    But then, I’m one of those dirty European socialist types, who thinks taxes should be increased when there’s a public services deficit, so I’m clearly not to be trusted.

    *whistles ‘The Red Flag’*

    Dr Crislip – never change. All the best to you (and almost everyone else) for 2013.

  44. BillyJoe says:

    Ouch. I mean OUCH!
    But I do believe me2earth has gone to ground….helped along by Duggan.

  45. DugganSC says:

    @BillyJoe:
    *faint smile* Glad to help?

  46. UncleHoot says:

    I believe that it has been long recognized that exercise increases core body temperature. I’ve wondered if, perhaps, this is one of the (many) reasons why people who exercise are generally healthier than those who do not. In more recent years, we’ve seen hyperthermia used in cancer treatments as well. So, could it actually benefit us to occasionally raise our body temperatures into the 38-39 range for a few hours per week? This article makes me wonder a bit more…

  47. BillyJoe says:

    UncleHoot,

    You have generated an hypothesis.
    I trust you know what comes next.
    Your problem will be accounting for confounding variables.
    Good luck!

  48. Kultakutri says:

    Is it only me to think that some people take great pleasure in finding ways how to get offended?

  49. WilliamLawrenceUtridge says:

    I believe that it has been long recognized that exercise increases core body temperature. I’ve wondered if, perhaps, this is one of the (many) reasons why people who exercise are generally healthier than those who do not. In more recent years, we’ve seen hyperthermia used in cancer treatments as well. So, could it actually benefit us to occasionally raise our body temperatures into the 38-39 range for a few hours per week? This article makes me wonder a bit more…

    Exercise causes a large number of temperature changes throughout the body, particularly in this case there is no single “body temperature”. The temperature inside working muscles during high intensity, long-term exercise can reach 45C or higher. The limiting factor during exercise is actually the “battle” for blood between muscles and skin – the former to provide energy and eliminate wastes, the latter to cool the blood through sweat and radiation. Eventually too much blood perfuses the skin, the muscles run out of sugar and simply shut down. The physiological changes that occur with exercise are widespread and go far beyond just a rise in temperature (here is a starting point, though it does note that changes in temperature is often ignored in in vitro experiments :))

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