Atopic dermatitis in adults: An Australian management consensus.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) has significant negative impact on health-related quality of life, mood, sleep, work productivity and everyday activities. Research into the use of new drugs in the management of AD continues to develop, and international updates and recommendations have been published. However, questions remain in the Australian setting. This consensus aims to provide evidence-based insights and practical advice on the management of adult AD in Australia. METHODS: A panel (five dermatologists and one clinical immunologist) met to review the literature, critically examine clinical questions of relevance to Australian healthcare practitioners and develop a series of recommendation statements. A consensus panel, comprising the initial panel plus nine additional members, used a 2-round Delphi voting process to determine a set of final guidance statements. CONSENSUS: ≥75% agreement in the range 7-9. RESULTS: Round 1 voting comprised 66 guidance statements. Of these, consensus was reached on 26, which were retained, and five were removed. The remainder (35) were modified and one new guidance statement was added for inclusion in round 2 voting. After round 2, consensus was reached on 35, which were retained, and one was removed (considered redundant). The 61 guidance statements upon which consensus was reached were then used to support a series of core consensus recommendations and a management flow chart. CONCLUSIONS: Expert consensus recommendations providing practical guidance of clinical relevance to specialists and primary care physicians in Australia have been developed. Dissemination of this guidance and evaluation of its impact on patient outcomes remain to be undertaken.

Food avoidance and restriction in adults: a cross-sectional pilot study comparing patients from an immunology clinic to a general practice.

BACKGROUND: With the introduction of avoidant/restrictive food intake disorder (ARFID) in the Diagnostic and Statistical Manual - fifth edition, there is an increased need to understand the prevalence and pattern of food avoidance and restriction in adults. High rates of food allergy and intolerance in immunology clinic populations, and subsequent high rates of elimination diets, place these individuals at a greater risk of developing pathological eating behaviours. This descriptive cross sectional pilot study aims to provide preliminary data on the prevalence and nature of food avoidance and restriction in an adult population, and to explore the reasons for this behaviour. METHOD: A self-administered questionnaire was designed and distributed to adults presenting to an immunology clinic and a general practice over the course of 6 months to describe the prevalence and nature of avoidant and restrictive eating behaviours in this population. Pearson's chi square test was used to examine the strength of a potential link to a formal diagnosis of avoidant restrictive food intake disorder in these patients. RESULTS: A total of 102 completed questionnaires were used for data analysis. Food avoidance or restriction was detected in 81 respondents (79%), with rates not significantly higher in the immunology clinic group compared to the general practice group (p = .242). Food allergy and intolerance were the most common reasons for disturbed eating patterns. Life impact secondary to food avoidance and restriction was reported by 26% of respondents, with significantly higher rates observed in the immunology clinic cohort compared to the general practice (p = .011). CONCLUSIONS: Eating disturbances similar to those characteristic of ARFID are very common in adults. Food avoidance and restriction due to perceived food allergy and intolerance are significant reasons for such disordered eating patterns, particularly in an immunology clinic population. Further investigation is needed to determine if such eating behaviours are pathological and whether they qualify for a diagnosis of ARFID.

Salicylate elimination diets in children: is food restriction supported by the evidence?

A review of case notes from our Sydney-based paediatric allergy services, between 1 January 2003 and 31 December 2011, identified 74 children who had been prescribed diets that eliminated foods containing natural salicylates before attending our clinics. The most common indications for starting the diets were eczema (34/74) and behavioural disturbances (17/74) including attention deficit hyperactivity disorder (ADHD). We could find no peer-reviewed evidence to support the efficacy of salicylate elimination diets in managing these diseases. We do not prescribe these diets, and in a survey of European and North American food allergy experts, only 1/23 respondents used a similar diet for eczema, with none of the respondents using salicylate elimination to treat ADHD. A high proportion (31/66) of children suffered adverse outcomes, including nutritional deficiencies and food aversion, with four children developing eating disorders. We could find no published evidence to support the safety of these diets in children. While this uncontrolled study does not prove a causal relationship between salicylate elimination diets and harm, the frequency of adverse events appears high, and in the absence of evidence of safety or efficacy, we cannot recommend the use of these diets in children.

Poor efficacy of oral tacrolimus in the treatment of severe generalized atopic eczema in adults: a small retrospective case series.

We report a small, but novel case series of four adults with severe generalized atopic eczema (AE) not responsive to several other immunomodulatory therapies, who were treated with oral tacrolimus (5 mg twice-daily). Three of the four patients failed therapy with systemic tacrolimus, despite two of these showing an initial clinical response; the fourth patient remains on tacrolimus monotherapy with good control of skin disease. Although oral tacrolimus was well-tolerated in this small group of adults, the clinical efficacy in this series for severe AE was poor. Tacrolimus may yet have a role in less severe disease, but larger prospective studies are required to qualify its place as a treatment option in AE.

Reforming New South Wales public hospitals: an assessment of the Garling inquiry.

The final report of the Special Commission of Inquiry into Acute Care Services in NSW Public Hospitals was published on 27 November 2008. The report acknowledges the challenges facing the New South Wales health system, including increasing numbers of patients, rising treatment costs, workforce pressures, and the breakdown of working relations between clinicians and management. Many of Commissioner Garling's 139 recommendations formalise aspects of clinical care that should and could be happening now if the system were better managed, including better supervision and training of junior staff. Commissioner Garling recommends that change should be driven by clinicians "from the bottom up", but does not adequately describe how this should happen. Implementation of the report's recommendations that will require strong leadership and continuing consultation with clinicians and the community.

Chronic human herpes virus 8 infection successfully treated with valganciclovir.

BACKGROUND: : A 57 year old Italian female with a 3 year history of constituitional symptoms with non-HIV Kaposi sarcoma was referred to the immunology clinic. She was previously diagnosed with chronic human herpes virus 8 (HHV8) infection with positive HHV8 polymerase chain reaction in serum. OBJECTIVE: : Is valganciclovir effective in treating chronic human herpes virus 8 infection without Multicentric Castleman's Disease (MCD)? RESULTS: : She was started on valganciclovir, resulting in remission of her symptoms, improvement in inflammatory markers and clearing of detectable HHV8 viraemia CONCLUSION: : Valganciclovir is effective in treating symptomatic HHV8 infections without MCD.