Who's at risk of thunderstorm asthma? The ryegrass pollen trifecta and lessons learnt from the Melbourne thunderstorm epidemic.

The Melbourne thunderstorm asthma epidemic in November 2016 was unprecedented in scale and impact. We systematically reviewed our hospital's patients with thunderstorm asthma to identify key risk factors. Of 85 adult patients assessed, the majority (60%) had no prior diagnosis of asthma. However, allergic rhinitis during the grass pollen season was almost universal (99%), as were ryegrass pollen sensitization (100%) and exposure to the outdoor environment during the thunderstorm (94%). Airborne pollen levels on the thunderstorm day were extreme. We conclude that ryegrass pollen sensitization, clinical allergic rhinitis, and acute allergen exposure constitute a risk-factor 'trifecta' for thunderstorm asthma.

Gleason group concordance between biopsy and radical prostatectomy specimens: A cohort study from Prostate Cancer Outcome Registry - Victoria.

BACKGROUND: A new prostate cancer (PCa) prognostic grading system [Gleason groups (GGs)] has been proposed based on the contemporary Gleason scores (GSs), which has five simplified prognostic categories. The objective of this study was to evaluate the agreement between the GGs of prostate biopsy and radical prostatectomy specimens and to identify predictive factors for upgrading GGs. METHODS: A total of 5339 cases of RP notified to the Prostate Cancer Outcomes Registry, Victoria, Australia over 6 years (2009-2014) from 46 hospitals, were included. The upgrading was evaluated using the new PCa prognostic grading system, the International Society of Urologic Pathology grade groups, which has five prognostic categories. GG 1 is GS ≤ 6, GG 2 is GS 3 + 4 = 7, GG 3 is GS 4 + 3 = 7, GG 4 is GS 8, and GG 5 is GS 9 and 10. Predictors of upgrading were assessed using univariate and multivariate models. RESULTS: The GG of prostate biopsies and RP specimens were concordant in 54.5% of cases, while 31.1% were upgraded and 14.3% were downgraded. Longer time interval between biopsy and RP [44-99 days: odds ratio (OR) = 1.3, 95% confidence interval (CI) = 1.1-1.6; > 99 days: OR = 3.0, 95% CI = 2.4-3.8), and RP performed in a metropolitan hospital (biopsy in a regional hospital: OR = 2.2, 95% CI = 1.6-3.2, biopsy in a metropolitan hospital: OR = 1.7, 95% CI = 1.2-2.2) were significant predictors of GG upgrading. Patients who were diagnosed by transperineal biopsy compared to transrectal ultrasound (OR = 0.6, 95% CI = 0.5-0.8) and higher percentage of positive biopsy cassettes (25-62.5%: OR = 0.7, 95% CI = 0.6-0.8, > 62.5: OR = 0.6, 95% CI = 0.5-0.8) were significantly associated with less likelihood of upgrade. CONCLUSION: The lack of concordance among hospitals may be attributable to the specialist expertise of the pathologist. Expert review of specimens may help to overcome this discordance. Clinicians should consider clinical parameters and potential limitations of the GG at biopsy when making treatment decisions with regard to PCa.

Cronkhite-Canada syndrome: A rare disease presenting with dermatological and gastrointestinal manifestations.

We present a case of Cronkhite-Canada syndrome, which is a rare disease classically characterised by hyperpigmentation, alopecia and onychodystrophy associated with clinical gastrointestinal symptoms and hamartomatous gastrointestinal polyps. Management primarily involves immunosuppression and nutritional support, which led to remission in this case. The recognition of cutaneous features may lead to early diagnosis and reduce morbidity and mortality.

Should we keep changing the diagnostic criteria for Behçet's disease?

In medicine, clinical acumen is used to achieve diagnosis, guide management and prevent disease. While for some diseases, diagnosis is reached with the assistance of objective tests, many conditions rely upon the use of clinical diagnostic criteria; Behçet's disease is one such case. In order to remain clinically relevant, as knowledge of a condition changes over time so too must its diagnostic criteria. Preferably, when new criteria for a disease are conceptualised it is through sound methodology, followed by a confirmation of accuracy by way of systematic validation and response to treatment. The most recently proposed revised International Criteria for Behçet's Disease for the diagnosis of Behçet's disease have been systematically validated and should replace the use of the clinically inferior International Study Group criteria, while not displacing the role of clinical judgement. Effort should now be invested in acquiring better understanding of the pathogenesis of the disease in the hope of developing a more objective test.