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Rapid Responses: Rapid Responses published:
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Reticulo-Endothelial-System-Hyperfunction Syndrome.
- Sergio Stagnaro (5 July 2002)
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A faster way to deal with ear infection
- wendy m mclean (8 July 2002)
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Caution
- Ray Friedman (16 July 2002)
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Predicting the need for antibiotics in children with AOM
- Federico Marchetti, Luca Ronfani, Sergio Conti Nibali, Giorgio Tamburlini (3 September 2002)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio N° 23/ 8 16037 Riva Trigoso (Genoa) Italy
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Sirs, In their article, P. Little et al. underscore distinctly today’s lack of knowledge, useful in bed-side identifying which children with acute otitis media (not to speak of adult with a large number of other diseases) at risk of poor outcome as well as assessing benefit from antibiotics in these children (1). It is well known that most children with otitis media will not benefit symptomatically from immediate use of antibiotics. Authors’ conclusion is: “Children with high temperature or vomiting were more likely to benefit from antibiotics, although it is still reasonable to wait 24-48 hours as many children will settle anyway”. Therefore, they write, in children with otitis media but without fever and vomiting antibiotic treatment has little benefit and a poor outcome is unlikely. In my opinion, however, doctors need now-a-days a “clinical” tool , easy and rapid to perform, reliable in bed-side recognizing patients, children or adults alike, with infectious process, batterial Gram pos., Gram neg. or virus in origin, which may be OR NOT, at least in intial stage, accompanied by fever, vomiting a.s.o. I don’t absolutely agree with those who say that we must “wait 24-48 hours as many children will settle anyway”. We have to ascertain, rapidly and clinically, the “real” cause of infectious process. Fortunately, thanks to Biophysical Semeiotics, we can now to do it. As a matter af fact, I described in a large number of previous papers (2,3,4) such as tool, termed Reticulo-Endothelial System Hyperfunction Syndrome (RESHS), that Pub-Med indexed for Medline. This very useful biophysical semeiotic syndrome corresponds to both erythrocyte sedimentation rate (ESR) and proteins electrophoresis, but is surely more sensitive and specific. This syndrome has to be ascertained most often in daily practice. In healthy, digital pressure of mean intensity, applied on medial line of sternal-body, iliac crests and cutaneous projection area of spleen, after 10 sec. exactly, provokes gastric aspecific reflex (besides caecum dilation and spleen decongestion): in the stomach both fundus and body dilate, while antral-pyloric region contracts, as allows to ascertain the auscultatory percussion of stomach. By contrast, in acute Gram pos.bacterial infections the latency time lowers to 6 sec. “complete” RESHS). Moreover, in case of viral disorders, e.g., flu, there is not “acute” synthesis of antibodys in the spleen and consequently only latency time of spleen-gastric reflex persists “normal”, i.e., 10 sec. (“incomplete” RESHS). Finally, in infectious diseases, caused by Gram-neg. bacteria, splenic antibody synthesis and other local defence reaction are present, but statistically reduced, in a clear-cut way (gastric aspecific reflex intensity is light = “intermediate” RESHS). (For further information: See my site HONCode, ID. N. 233736, http://digilander.libero.it/semeioticabiofisica and the Page, I weekly hold in www.Katamed.it). Sergio Stagnaro, Active Member NYAS. 1) Little P., Gould C. Moore M., et al. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002;325:22 ( 6 July ). 2) Stagnaro S., Auscultatory Percussion of Rheumatic Diseases. X European Congress of Rheumatology. Moscow. 26 June-July, Proceedings, pg 175,1983. 3) Stagnaro S., Sindrome percusso-ascoltatoria di Iperfunzione del Sistema Reticolo-IstiocitarioMin. Med. 74, 479,1983 [Pub-Med indexed for MEDLINE]. 4) Stagnaro-Neri M., Stagnaro S., Appendicite. Min. Med. 87, 183, 1996 (Pub-Med indexed for Medline. |
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wendy m mclean, retired home
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It has been known for many years that xylitol will reduce the incidence of ear infection. Xylitol chewing gum or sweets given to a child (or adult) with an ear infection will reduce the pain within 30 minutes. If the pain returns after 2 lots of xylitol the child is likely to need antibiotics. Greater use of products containing xylitol would save families days of misery. Products available in the UK include chewing gum, sweets, vitamin preparations and toothpaste suitable for children over 2. It is deplorable that many doctors still seem to be ignorant about the increasing volume of research on xylitol's anti-bacterial benefits. |
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Ray Friedman, Private Practice Sandton South Africa
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This is an excellent article and fits in well with a number of known factors. 1. the vast majority of acute otitis media (ACOM)attacks in "normal" children will subside spontaneously 2. Many antibiotic studies peddled by pharmaceutical companies make use of this phenomenon as the studies outcomes are so limited. BUT readers must excercise caution under the following problems. NOTE: This applies to common pathogens in the middle ear - not other sites A. At risk children do not respond in same manner - children in child care, under 2 years of age, multiple recurrent ACOM (not URTI), Geographical location of treatment, to name a few important ones Inappropriate usage of antibiotics does not just mean "to use or not to use". Most of the "damage" being done and more importantly costs generated are from the use of the wrong antibiotics and inadequate dosages of such antibiotics. This is of particular importance in the group identified in your study B. Abscence of adequate study endpoints and at least a month follow-up, fails to identify the biggest group of sequelae that we find in practice - costs of these are far in excess of a single treatment of otitis media. The dutch study quoted is in contrast to the rising incidence of mastoiditis seen in Holland with current treatment plans Thanks for the interesting study |
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Federico Marchetti, Clinical Paediatrician Institute of Child Health,IRCCS Burlo Garofolo, Via dell'Istria 65/1, 34100 Trieste, Italy, Luca Ronfani, Sergio Conti Nibali, Giorgio Tamburlini
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Sir. Little et al (1) report that children with acute otitis media (AOM) with temperature >37.5 °C or vomiting were more likely to benefit from immediate antibiotics, and suggest a shorter (24 to 48 hours) waiting period before using antibiotic in patients with either fever or vomiting. We have recently carried out a large observational prospective study aimed at evaluating feasibility and effectiveness in general practice of a case- management algorithm based on symptomatic treatment (paracetamol: 10-15 mg/kg dose) and on strict criteria (recurrent AOM, ear discharge and persistence of fever or earache after 48-72 hours) for antibiotic use. The study was carried out by a network of 169 paediatric practitioners and enrolled 1277 children aged 12 months to 14 years (2). Of 1099 children eligible for symptomatic treatment, 743 (68%) were successfully treated without antibiotics. We have also analysed our findings to identify which features predict poor outcome and as a consequence which children may benefit from antibiotic use. In our series, with respect to predictors suggested by Little et al., 581/1099 children (53%) had fever (>37.5°C) or vomiting. Out of these, 39% required antibiotic treatment at follow-up, versus 24% of those with neither sign present (RR:1,6; 95 % CI:1.33-1.93). Temperature >=38.3°C and a red bulging drum were shown to have good specificity and high positive predictive value for S. pneumoniae infection (3). In our series, 121/1099 children (11%) had both these signs. Out of 121 cases, 67 (55%) required antibiotic treatment, versus 29% of cases without the association of the above two signs (RR: 1.91; 95% CI: 1.58- 2.30). At multivariate analysis adjusted odds ratio for antibiotic use was 3.47 (95% CI: 2.19-5.50). Our findings, while confirming that most children with AOM will not benefit from antibiotics, show that temperature >=38.3°C and a red bulging drum are better predictors of poor outcome than fever or vomiting, are found in a much smaller proportion of children, and therefore should be preferred as criteria for identifying children for whom immediate antibiotic, or a shorter waiting time before antibiotic use, may be beneficial. 1. Little P, Gould C, Moore M, Warner G, Dunleavey J, Williamson I. Predictors of poor outcome and benefits from antibiotics in children with acute otitis media: pragmatic randomised trial. BMJ 2002; 325:22 2. Ronfani L, Conti Nibali S, Marchetti F, per il gruppo di lavoro OMA- ACP. Il trattamento sintomatico dell'otite media acuta in pediatria ambulatoriale. Medico e Bambino 2002; 21: 170-8 3. Rodriguez WJ, Schwartz RH. Streptococcus pneumoniae causes otitis media with higher fever and more readness of tympanic membranes than Haemophilus influenzae or Moraxella catharrhalis. Pediatr Infect Dis J 1999; 18: 942.44 Dr Federico Marchetti, (corresponding author) Clinical Paediatrician Institute of Child Health, IRCCS Burlo Garofolo, Trieste Via dell'Istria 65/1 34100 Trieste, Italy e mail: marchetti@burlo.trieste.it Dr Luca Ronfani, Researcher, Centro per la Salute del Bambino, Trieste Sergio Conti Nibali, General Paediatrician, Messina Dr. Giorgio Tamburlini Researcher, Institute of Child Health, IRCCS Burlo Garofolo, Trieste for the Italian Study Group on Acute Otitis Media |
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