Journals watch: Immunotherapy and trimethoprin resistance

Too busy to read all of the journals? Dr Jonathan Holliday selects some interesting research.

Sublingual immunotherapy improved the symptoms of rhinoconjunctivitis (Photo: DR P. MARAZZI/SCIENCE PHOTO LIBRARY)
Sublingual immunotherapy improved the symptoms of rhinoconjunctivitis (Photo: DR P. MARAZZI/SCIENCE PHOTO LIBRARY)

Sublingual immunotherapy for rhinoconjunctivitis and asthma

JAMA 2013; 309(12): 1278-88

Allergic rhinitis affects up to 40% of the population. In the US the Food and Drug Administration has not yet approved sublingual immunotherapy. This study looked at 63 RCTs that included 5,131 subjects. Eight out of 13 trials looking specifically at asthma reported greater than 40% improvement in symptoms.

Nine out of 36 trials showed greater than 40% improvement in the symptoms of rhinitis or rhinoconjunctivitis. A reduction in medication use for both asthma and allergies was widely seen.

Overall there was a moderate level of evidence to support the efficacy of sublingual immunotherapy.

Although heterogeneity prevented a full meta-analysis, the researchers graded the strength of evidence regarding associations of sublingual immunotherapy with improvement in symptom scores, need for medication and quality of life in patients with allergic asthma, rhinitis and conjunctivitis.

An accompanying editorial concluded the use of sublingual immunotherapy for allergic rhinitis and allergic conjunctivitis is not associated with safety concerns.

Trimethoprim resistance in childhood UTI

Br J Gen Pract 2013; 63: 185-6

This interesting paper demonstrates the association between repeat trimethoprim prescribing and resistance in children.

The study linked all cases of laboratory confirmed Escherichia coli UTI infections in children aged under 16 years in Tayside, Scotland, with trimethoprim prescriptions issued by community pharmacists between 2004 and 2009.

It showed an almost linear rise in trimethoprim resistance from 19% in 2004 to 33% in 2009.

The figures rose dramatically the more times an individual was treated with trimethoprim. The average resistance rate across the five years rose from 21% for a single E coli UTI treatment to 26% for two infections treated, to 32% for three infections and to 45% for four infections.

Follow the NICE guidelines for treating childhood UTI with regard to culture, and consider an alternative antibiotic in cases of childhood UTI if trimethoprim has been used in the preceding three months, or possibly longer.

Circulating tumour DNA and metastatic breast cancer

N Engl J Med 2013; 368: 1199-209

Management of metastatic breast cancer requires monitoring the tumour load to assess the patient's response to treatment.

Better biomarkers are always being sought. Currently, cancer antigen 15-3 (CA15-3) measurements and the presence of tumour cells are used.

However, circulating cell-free DNA carrying tumour-specific alterations has not been investigated or compared with other circulating biomarkers in breast cancer.

In this study, circulating tumour DNA was detected in 29 of the 30 women (97%) in whom somatic genomic alterations were identified. This compared with 21 of 27 women (78%) in whom CA15-3 was detected and 26 of 30 women (87%) in whom circulating tumour cells were detected.

Not only was the detection rate better, but circulating tumour DNA levels showed greater dynamic range and greater correlation with changes in tumour burden.

Bowel cancer screening and stage at diagnosis

Med J Aust 2013; 198(6): 327-30

This is a cohort comparison study of colorectal cancer (CRC) patient data from the National Bowel Cancer Screening Programme (NBCSP) in South Australia.

The main outcome measure was the stage of CRC at diagnosis, which is critical in determining probability of survival. Of 3,481 eligible patients, 221 had been invited to the NBCSP.

Evaluations of cancer screening using mortality as an endpoint take many years to complete and staging at presentation is therefore a reasonable surrogate marker for mortality.

Of eligible patients they compared three groups: invited, participants and screen positive. Membership of the invited group improved chances, while to be a participant improved chances further. Of those who screened positive, 40% were stage A, compared with 19% in other patients.

Looking at stage D, 2.6% of test positive patients were found to be stage D, compared with 12.4% in other patients.

Dr Holliday is a GP in Berkshire and a member of our team who regularly review the journals.

Reflect on this article and add notes to your CPD Organiser on MIMS Learning


These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

Audit trimethoprim prescribing in under 16-year-olds to assess numbers of courses given within a 12-month period. Correlate this with confirmed UTI. Discuss these findings and prescribing patterns at a practice clinical meeting.

Consider ways of increasing bowel cancer screening uptake in the practice, such as sending letters to all patients approaching their 60th birthday.

Involve the patient participation group in ways to increase the uptake of bowel cancer screening in your patient population.

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