Development and application of Adverse drug reactions reports QUality Algorithm (AQUA-12) score: a single-centre quality improvement initiative.

PURPOSE: To develop a reliable assessment tool to monitor the quality of adverse drug reaction (ADR) reports and evaluate its performance within a quaternary hospital setting. METHODS: Adverse drug reactions report QUality Algorithm (AQUA-12) was developed by a multidisciplinary team with the expertise in the management of ADRs. The design was based on data elements required to establish medication causality. Inter-rater reliability of AQUA-12 was evaluated over three rounds in two phases: development and prospective evaluation phases, by independent assessors both internal and external to the institutional ADR review processes. The characteristics and quality of ADR reports were subsequently assessed, and potential factors contributing to low-quality reports were identified. RESULTS: A total of 70 ADR reports were assessed, 20 in development and 50 in evaluation phases. The inter-rater reliability of AQUA-12 was found to be excellent in all three rounds (Cronbach's alpha of  ≥ 0.9, p < 0.001 for all). Approximately one in five reports concerned immediate hypersensitivity reactions while delayed hypersensitivity reactions constituted 60% of all reactions. AQUA-12 identified 18 (25.7%) reports as 'low-quality' with a score of  < 10. Identification of suspected medications (37.1%), description of index ADR (27.1%), and key events (ADR narrative, 35.7%) were the top data elements incomplete or missing from all reports. Univariable analyses identified the severity of the reaction as a factor associated with low quality of reports (p = 0.008). CONCLUSIONS: AQUA-12 is a practical and highly reliable assessment tool that can be utilised in hospital settings to regularly monitor the completeness of ADR reports to guide quality improvement initiatives.

Combination treatment with monoclonal antibodies: Secukinumab, benralizumab and dupilumab for the combined management of psoriasis and severe asthma.

Biological disease-modifying agents have increasingly become available for the effective treatment of both cutaneous and non-cutaneous inflammatory conditions. We report a case of a woman treated successfully for psoriasis and psoriatic arthritis with the IL-17 inhibitor secukinumab whilst simultaneously being treated for severe asthma and nasal polyps, initially with the IL-5 inhibitor benralizumab, followed by dupilumab, a monoclonal antibody that targets the IL-4 receptor alpha subunit which blocks signalling from both IL-4 and IL-13.

Medication-related anaphylaxis treated in hospital: Agents implicated, patient outcomes, and management lessons.

PURPOSE: On background of increasing medication-related anaphylaxis rates in Australia, our aim was to determine epidemiology, outcomes, adverse drug reaction (ADR) reporting rates, and accuracy of coding in patients treated for nonantimicrobial medication-related anaphylaxis in our hospital network. METHODS: From January 2010 to December 2015 patients treated in our hospital network for medication-related anaphylaxis were identified using International Classification of Diseases, 10th Edition diagnosis code T88.6. Cases were also extracted from the hospital ADR database. Medical records were reviewed to ensure consistent diagnosis and to extract clinical, documentation, and outcome data. RESULTS: Of 1110 patients coded as T88.6, 177 (15.9%) met the medication-related anaphylaxis definition. Eighty (40.8%) had anaphylaxis due to nonantimicrobial agents. Thirteen of these (16.3%) had a previous reaction to the same medication/group. In 51 (63.8%) patients, anaphylaxis occurred during inpatient stay, with 31 reactions occurring during surgery. Eighty-five medications were implicated, most commonly neuromuscular blocking agents (31, 36.5%) and nonsteroidal anti-inflammatory drugs. No trends were noted over the 6-year period, and there was no anaphylaxis-related mortality. Fifty-three (66.3%) patients were assessed in allergy clinics. One in 10 cases did not have the reaction documented in the discharge summary. Adverse drug reaction reports were received for 38 patients (47.5%). CONCLUSIONS: Although acute patient outcomes were excellent, gaps in practice were noted regarding ADR coding accuracy and reporting rates. One in 6 patients had a prior hypersensitivity reaction to a similar medication, so we recommend accurate documentation, ADR review with allergy follow-up, and patient held information to decrease re-exposure risk.

Phenotypic Distinctions Between Omega-5-Gliadin Allergy and Peanut Allergy: Clinical Profile, Reaction Rates and Triggers, and Quality of Life.

Background: Different phenotypes of food allergy may exist, exhibiting distinct clinical features, and driven by different pathogenic mechanisms. We compared omega-5-gliadin (O5G) allergy to peanut allergy, focusing on clinical features, reaction rates and triggers, and quality of life (QOL). Methods: We surveyed adults with O5G allergy and peanut allergy regarding their diagnosis, co-morbidities, allergic reactions, and QOL measured by the FAQLQ-AF. Results: We received responses from 43/80 (54%) individuals with O5G allergy and 43/130 (33%) with peanut allergy. Compared to peanut allergic individuals, those with O5G allergy were older at age of onset (37.2 vs 2.5 years, p < 0.001), had fewer additional atopic conditions (0.88 vs 2.93, p < 0.001) or food allergies (0.15 vs 1.86, p < 0.001), and more frequent reactions before diagnosis (1.085 vs 0.29 per month, p < 0.05) Reaction rates improved in both groups following diagnosis. Reactions to peanut were more often triggered by accidental exposure (84% vs 26%, p < 0.001) and being away from home (65% vs 28%, p < 0.001), while reactions to O5G were more often due to deliberate ingestion (30% vs 9%, p < 0.05) or unexpected exercise (35% vs 2%, p < 0.001). Overall QOL score was similar between groups (4.2 in O5G allergy, 4.7 in peanut allergy, p = 0.12), but worse among women and those with additional food allergies. Conclusion: Phenotypic differences between O5G and peanut allergy support the development of different clinical approaches and the possibility of targeting distinct pathogenic mechanisms for prevention and treatment. Quality of life was impaired to a similar degree between groups.

Strongyloides infection as a reversible cause of chronic urticaria.

Recurrent urticaria is a frequent presenting complaint in the Allergy Clinic, despite the fact that chronic urticaria is not an IgE-mediated (atopic) condition in most cases. We present four cases assessed over 5 years in our allergy service who were found to have evidence of strongyloidiasis and whose clinical features resolved with standard anti-helminth treatment.

Asthma mortality in Australia in the 21st century: a case series analysis.

OBJECTIVE: As previous asthma mortality studies were undertaken between 1986 and 1997, and treatments have evolved since that time, in order to direct future asthma interventions, we investigated the reasons for asthma deaths between 2005 and 2009. DESIGN: We undertook a case series analysis by searching the National Coroners' Information System using the most recent International Classification of Diseases-10 codes J45 and J46 and the keyword 'asthma' as the underlying cause of death. SETTING: Records for 283 cases aged 70 years and under were retrieved from each Australian state and territory. Coroner's findings, autopsy, toxicology and police reports were reviewed to determine: if the team agreed the death was due to asthma and whether the death was preventable or modifiable factors existed? Owing to the likelihood of comorbidities or alternative diagnoses contributing to deaths in those over 70 years of age, this group was excluded. RESULTS: Examination of available data in those aged under 70 years identified risk factors associated with asthma death. These included physical barriers (rural and remote location, institutionalised care), psychosocial issues (social disengagement, mental illness, living alone, being unemployed), smoking, drug and alcohol dependence, allergies, respiratory tract infections, inadequate treatment and delay in seeking help. CONCLUSIONS: Our study provides a current assessment of death from asthma across Australia. Further reductions in the rate of asthma deaths will require interventions targeted at the personal, practice and policy levels. Asthma-related health literacy needs to be improved especially among those with episodic asthma. Reforms are also needed to address inequity in healthcare delivery to 'reach the unreached'. Our study points to the dangers associated with smoking, drug and alcohol use and the consequences of delay in seeking care among those with asthma.