Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Beyond traditional physical semeiotics: Biophysical Semeiotics.
- Sergio Stagnaro (6 December 2002)
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rhinitis or sinusitis?
- Henri Partouche (9 December 2002)
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Antibiotics for acute purulent rhinitis : effective?
- An I De Sutter, Marc De Meyere, Mieke van Driel, Thierry Christiaens, Jan De Maeseneer. (16 December 2002)
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Acute purulent rhinitis - what is the diagnosis?
- Peter J Robb, Epsom, Surrey, KT18 7EG (5 January 2003)
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Purulent Rhinitis - Diagnosis
- Ray L Friedman (21 February 2003)
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Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy
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Sirs, In my opinion, Bruce Arroll’s editorial is of paramount importance for all physicians, and particularly for those, who are working at the bed-side.(1) In fact, the treatment of mucopurulent rhinitis, a component of the common cold, as well as a consequence of a lot of other causes, must be necessarily different from case to case. However, in order to prescribe rationally antibiotics in such as disease, general practitioners would be able to recognize “clinically” the real nature of disease, e.g.., the presence of Gram- positive and/or Gram-negative bacteria, otherwise, as occurred in one study, no general practitioners said that they would give antibiotics for clear rhinitis but 72% would for purulent rhinitis (2). Thanks to the new physical semeiotics, i.e., Biophysical Semeiotics (See my site, HONCode 233736, http://digilander.libero.it/semeioticabiofisica, and the Page I hold weekly in italian site www.katamed.it, as well as www.piazzetta.sfera.it) doctors can nowadays easily and rapidly recognize the real nature – viral, bacterial (Gram-positive or Gram- negative), oncological, rheumatic, a.s.o.– by bed-side assessing, in qualitative and quantitative way,e.g., antibody production as well as bone marrow activity (3). I hope that this new physical semeiotics, in a future that has already begun, will help physicians all around the world in treating properly “also” inflammatory disorders, if the authors of the guideline resolve, finally and fortunately, to learn at first them-selves Biophysical Semeiotics, in the interest of patients, physicians and NHS, thanks to bmj.com, which kindly posts my weekly comments. 1) Arroll B. Antibiotics for acute purulent rhinitis Probably effective but not routinely recommended BMJ 2002;325:1311-1312 ( 7 December ) 2) Arroll B, Goodyear-Smith F. General practitioner management of upper respiratory tract infections: when are antibiotics prescribed? N Z Med J 2000; 113: 493-496[ISI][Medline]. 3) Stagnaro S., Sindrome percusso-ascoltatoria di Iperfunzione del Sistema
Reticolo-Istiocitario. Min. Med. 74, 479, 1983 (Pub-Med indexed for
Medline)
Competing interests: None declared |
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Henri Partouche, MD 88 avenue G Péri ST- OUEN 93400FRANCEOUEN
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It's seems, reading your paper, that the the duration of the patient's purulent nasal discharge of more than ten days is not compatible with the simple diagnosis of acute purulent rhinitis. The diagnostic of sinusitis is difficult and the duration of the nasal discharge is one of the component of the diagnostic. The cited studies had probably included patients with sinusitis and the results of antibiotics intervention are similar to those described by S D de Ferranti and coll.(BMJ 98 ; 317:632-7). The confusion in the terminology is one of the problems in primary care. Rhinitis? Sinusitis.? Prolonged nasal discharge? The question is of importance regarding the effect in the praticien's precribing attitude and the consequences on bactérial resistances and cost… Henri Partouche MD
Chargé d'enseignement, Département de médecine générale de la faculté, Necker-Enfants malades, 156, rue de Vaugirard 75015 Paris Competing interests: None declared |
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An I De Sutter, researcher Department of General Practice an Primary Health Care.1K3.De Pintelaan 185, 9000 Gent, Belgium., Marc De Meyere, Mieke van Driel, Thierry Christiaens, Jan De Maeseneer.
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At the moment guidelines on rhinitis advise against antibiotics because of their ineffectiveness. In their editorial, Arrol and Kenealy (1) propose to reconsider these guidelines since pooling the results of all trials shows that there is a small benefit from antibiotics on purulent rhinorrhea. In this editorial, our trial(2) is correctly cited as one of the trials showing a benefit from antibiotics on the duration of purulent rhinorrhea. In this trial at least half of the participants suffered from rhinosinusitis(confirmed by radiology) not just rhinitis. Besides the duration of purulent rhinorrhea, we reported also the duration of general illness and the duration of facial pain and we compared the severity change for 23 different symptoms such as quality of sleep, fatigue, concentration, time off work or school, etc.... . Yet, for none of these outcomes we found a significant benefit from amoxicillin - not even the need to blow the nose was significantly decreased. The only effect was that in the group treated with amoxicillin when blowing the nose the mucus was sooner non-purulent. Therefore, our conclusion was that antibiotics are not effective. We propose that in trials or meta-analyses on self-limiting diseases, patient-centered endpoints - such as impairment of well-being - are considered as measures of effectiveness. Upper respiratory tract infections make people feel ill. An effect on this feeling of illness is important for the patient, more than the colour of his rhinorrhea. However, at the moment there is no evidence that antibiotics have an effect on 'feeling ill'. To conclude : antibiotics may be effective to discolour purulent "rhinorrhea", but not to cure purulent "rhinitis". (1) Arroll B, Kenealy T. Antibiotics for purulent rhinitis. BMJ 2002; 325 : 1311-2. (2) De Sutter AI, De Meyere MJ, Christaens TC, Van Driel ML, Peersman W, De Maeseneer JM. Does amoxicillin improve outcomes in patients with purulent rhinorrhea? A pragmatic randomized double-blind controlled trial in family practice. J Fam Pract 2002; 51 : 319-323. Competing interests: None declared |
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Peter J Robb, consultant ENT surgeon Epsom General Hospital, Epsom, Surrey, KT18 7EG
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The Editor BMJ BMA House Tavistock Square LONDON WC1H 9JR 14th December 2002 EDITOR – The editorial by Arroll and Kenealy was a helpful and interesting summary of the role of systemic antibiotic treatment for the management of acute purulent rhinitis.1 The authors' define the condition as persisting for up to 10 –14 days before treatment may be indicated. Starting treatment at this time is, however, to be discouraged in the absence of a diagnosis. This is particularly true where the rhinitis is unilateral or bloodstained. Persisting unilateral purulent rhinitis in a child may represent a nasal foreign body requiring removal, and if the discharge is bilateral and recurrent, adnenoiditis may be the diagnosis and warrant consideration of adenoidectomy. In an adult, neoplasia is the diagnosis of exclusion if purulent rhinitis, persists, particularly if unilateral or bloodstained. The article fails to offer important axiomatic information to the non -specialist, who may be asked to offer an opinion on such a symptom relatively often. If purulent rhinitis persists for more than two weeks, the question must be, what is the diagnosis, not, are antibiotics appropriate? Yours sincerely Peter J Robb BSc (Hons) FRCS FRCSEd Honorary Secretary British Association for Paediatric Otorhinolaryngology 1 Arroll B, Kenealy T. Antibiotics for acute purulent rhinitis. BMJ 2002; 325:1311-12. (7 December) Competing interests: None declared |
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Ray L Friedman, Vice Chairman, Rhinitis Study Group, South Africa Sandton & Linksfield Park Cilinics South Africa
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Dear Sirs The response by Robb is referred to. I concur entirely with him More time spent on guidlines to diagnosis rather than prescribing is urgently needed. Rhinitis in particular, but upper respiratory tract disease literature is bedevilled with studies where start and end points of diagnosis are so vague and without any true validity that they are worthless in real practice. The most important facets of treating a purulent rhinitis, acute or chronic, still reside in a reasonable history and examination. As far as an examination is concerned, in the nose this appears to be relegated to a comment on the colour of the discharge and possibly a cursory examination of the vestibule. Even eosinophils in mucous cause "purulence" Thank You for this opportunity Competing interests: None declared |
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