Thunderstorm asthma in seasonal allergic rhinitis: The TAISAR study.

BACKGROUND: Asthma epidemics associated with thunderstorms have had catastrophic effects on individuals and emergency services. Seasonal allergic rhinitis (SAR) is present in the vast majority of people who develop thunderstorm asthma (TA), but there is little evidence regarding risk factors for TA among the SAR population. OBJECTIVE: We sought to identify risk factors for a history of TA and hospital presentation in a cohort of individuals with SAR. METHODS: This multicenter study recruited adults from Melbourne, Australia, with a past diagnosis of TA and/or self-reported SAR. Clinical information, spirometry results, white blood cell count, ryegrass pollen-specific (RGP-sp) IgE concentration, and fractional exhaled nitric oxide were measured to identify risk factors for a history of TA in individuals with SAR. RESULTS: From a total of 228 individuals with SAR, 35% (80 of 228) reported SAR only (the I-SAR group), 37% (84 of 228) reported TA symptoms but had not attended hospital for treatment (the O-TA group), and 28% (64 of 228) had presented to the hospital for TA (the H-TA group). All patients in the H-TA group reported a previous asthma diagnosis. Logistic regression analysis of factors associated with O-TA and H-TA indicated that lower FEV1 value and an Asthma Control Questionnaire score higher than 1.5 were associated with H-TA. Higher blood RGP-sp IgE concentration, eosinophil counts, and fractional exhaled nitric oxide level were significantly associated with both O-TA and H-TA. Receiver operating curve analysis showed an RGP-sp IgE concentration higher than 10.1 kU/L and a prebronchodilator FEV1 value of 90% or lower to be biomarkers of increased H-TA risk. CONCLUSION: Clinical tests can identify risk of a history of TA in individuals with SAR and thereby inform patient-specific treatment recommendations.

Collaboration between the coroner and emergency physicians: efforts to improve outcomes from aortic dissection.

The Coroners Prevention Unit at the Coroners Court of Victoria (CCV) is a multidisciplinary team that investigates deaths referred by the state's coroners, with a view to identifying prevention opportunities. The death of a woman from acute aortic dissection (AAD) after an emergency department attendance prompted the coroner to request a roundtable meeting with emergency physicians (EPs) from Melbourne. The round table was attended by 17 EPs from Melbourne hospitals, along with representatives from the CCV. The meeting identified important clinical, system and cultural features of AAD presentation and management that might be useful in improving case detection and management, and hence outcomes. A key recommendation was that EPs teach junior staff that AAD is the "subarachnoid haemorrhage of chest pain", to change the way patients with chest pain are assessed, with an emphasis on red flags for AAD being considered at the beginning of any discussion. This innovative collaboration between the CCV and EPs may serve as a model for future interactions between the CCV and the medical profession.