Journals Watch - Cystic fibrosis and coeliac disease

Missed this week's journals? Dr Raj Thakkar brings you up to date with the latest research.

Cystic fibrosis: cough was lower in patients receiving azithromycin compared with controls (Photograph: SPL)
Cystic fibrosis: cough was lower in patients receiving azithromycin compared with controls (Photograph: SPL)

Azithromycin for pulmonary function in patients with cystic fibrosis
2010; 303 (17): 1707-15

It is crucial that we manage patients with cystic fibrosis effectively to minimise their pulmonary damage. For patients infected with Pseudomonas aeruginosa, azithromycin has been shown to be of benefit.

This RCT aimed to establish if azithromycin influenced LFTs and frequency of exacerbations in patients who are not infected with pseudomonas.

The trial involved 260 patients aged six to 18 years. Their FEV1 was at least 50 per cent predicted and all patients had been clear of pseudomonas infection for one year. Azithromycin was given three times per week for 168 days in the treatment arm.

The difference in change of FEV1 between treatment and placebo groups was 0.02L (95% CI -0.05 to 0.08). Patients receiving azithromycin had a relative risk reduction of 50 per cent. Cough was also lower in the treatment group. The number of hospital admissions was not significant between the groups.

The results are hard to interpret in terms of change in practice. Should azithromycin be included in future guidelines?

Diagnostic testing for coeliac disease
JAMA 2010; 303 (17): 1738-46

There is plenty of evidence to suggest coeliac disease is under diagnosed in the UK.

As GPs, it is important to reassure our patients who are well and to diagnose patients who have genuine pathology, making the most appropriate use of diagnostic tests.

This important meta-analysis looked at the performance of serological tests for coeliac disease in patients presenting with chronic abdominal symptoms.

Data from more than 6,000 patients was included. Sensitivity of IgA antiendomysial antibodies for a diagnosis of coeliac disease was 0.90 (CI 0.8 to 0.95) and specificity was 0.99 (CI 0.98 to 1.00).

Sensitivity and specificity for IgA antitissue transglutaminase antibodies were 0.89 (CI 0.82 to 0.94) and 0.98 (CI 0.95 to 0.99) respectively. Data for antigliadin antibodies were not impressive for sensitivity.

This study can help us manage patients who present with abdominal symptoms and understand the results of the tests we arrange.

Stents in coronary artery disease
N Engl J Med 2010; 362 (18): 1663-74

Patients often ask about their particular stents and it is satisfying to address their concern.

Drug eluting stents, such as those containing everolimus and paclitaxel, offer a reduced risk of restenosis.

This study looked at effectiveness of everolimus or paclitaxal eluting stents. Clinical endpoints, namely cardiac death, angina or MI in territory of lesion, were measured at one year. More than 3,687 patients were enrolled in the study.

Everolimus-eluting stents performed significantly better than paclitaxel at one year.

Rates of MI and stent thrombosis were both lower in the everolimus groups.

However, everolimus did not offer superiority in patients with diabetes.

Outpatient pulmonary rehabilitation following acute exacerbations of COPD
Thorax 2010; 65: 423-8

Evidence exists promoting the benefit of pulmonary rehabilitation in COPD patients. This study looked at whether pulmonary rehabilitation given to patients after discharge reduced the risk of readmission compared with usual care.

This three-month study involved 60 patients. Readmissions were found to be 33 per cent in the usual treatment arm compared with 7 per cent in the pulmonary rehabilitation group, with an odds ratio of 0.15 (CI 0.03 to 0.72).

This study reinforces how coordinated follow-up after discharge can reduce the chances of deterioration, improve patients' quality of life and reduce the burden on secondary care.

Diagnosis of serious bacterial infection in young febrile children
BMJ 2010; 340: c1594

Serious bacterial infection in febrile children can easily be missed. This Australian study looked at practice in the A&E setting.

The review included 15,781 children under five years who visited the emergency department between 2004 and 2006. A clinical evaluation model was compared with clinical judgment, and 543 children had a UTI, 533 had pneumonia and 64 had bacteraemia.

Only 66 per cent of children received antibiotics acutely for UTI, 69 per cent for pneumonia and 81 per cent for bacteraemia.

In addition, 20 per cent of children were found to receive antibiotics in the absence of bacterial infection. Therefore, doctors' diagnoses had a low sensitivity (10-50 per cent) but high specificity (90-100 per cent).

It would be interesting to see how GPs compare with emergency doctors.

Sigmoidoscopy screening in prevention of colorectal cancer
Lancet 2010; 375 (9726): 1624-33

This study assessed the effectiveness of a one-off flexible sigmoidoscope test as a screening tool for colorectal cancer. It assessed patients between 55 and 64 years. Patients were followed up for approximately 11.2 years.

The incidence of colorectal cancer was 23 per cent less in the test group compared with controls. Death from colorectal cancer was 31 per cent less in the test group.

Analysis showed that death from rectosigmoid cancers was reduced by 50 per cent in the test group.

The researchers found 191 people were required to be screened in order to prevent one cancer and 489 sigmoidoscopes were required to prevent one cancer-related death.

The data are impressive and suggest we should advocate screening.

  • Dr Thakkar is a GP in Wooburn Green, Buckinghamshire, and a member of our team of regular research reviewers
The Quick Study
  • Cystic fibrosis patients receiving azithromycin had a 50 per cent relative risk reduction in pulmonary exacerbations.
  • Coeliac disease is best diagnosed with IgA antitissue transglutaminase antibodies and IgA antiendomysial antibodies tests.
  • Everolimus-eluting stents were shown to perform significantly better than paclitaxel-eluting stents at one year.
  • COPD patients receiving post-discharge pulmonary rehabilitation were less likely to be readmitted to hospital.
  • Serious bacterial infection in young febrile children was under-diagnosed in an Australian emergency setting.
  • Colorectal cancer incidence was 23 per cent less in those who had sigmoidoscopy screening compared with those who did not.


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