Stinging insect identification: Are the allergy specialists any better than their patients?

BACKGROUND: It has been reported that the general population is not skillful at identifying stinging insects with the exception of the honeybee. No information is available to evaluate allergy physicians' accuracy with stinging insect identification. OBJECTIVE: To measure the accuracy of allergists' ability to identify stinging insects and assess their common practices for evaluating individuals with suspected insect hypersensitivity. METHODS: A picture-based survey and a dried specimen insect box were constructed to determine allergists' and nonallergists' accuracy in identifying insects. Allergists attending the 2013 American College of Allergy, Asthma, and Immunology meeting were invited to participate in the study. Common practice approaches for evaluating individuals with stinging insect hypersensitivity were also investigated using a brief questionnaire. RESULTS: Allergy physicians are collectively better at insect identification than nonallergists. Overall, the mean (SD) number of correct responses for nonallergists was 5.4 (2.0) of a total of 10. This score was significantly lower than the score for allergists (6.1 [2.0]; P = .01) who participated in the study. Most allergists (78.5%) test for all stinging insects and use skin testing (69.5%) as the initial test of choice for evaluating individuals with insect hypersensitivity. CONCLUSION: Overall, allergists are more skilled at Hymenoptera identification. Most allergy specialists reported testing for all stinging insects when evaluating insect hypersensitivity, and skin testing was the preferred testing method in nearly 70% of allergists. These data support the practice parameter's recommendation to consider testing for all flying Hymenoptera insects during venom evaluation, which most of the participating allergists surveyed incorporate into their clinical practice.

The HIT study: Hymenoptera Identification Test--how accurate are people at identifying stinging insects?

BACKGROUND: Stinging insects in the order Hymenoptera include bees, wasps, yellow jackets, hornets, and ants. Hymenoptera sting injuries range from localized swelling to rarely death. Insect identification is helpful in the management of sting injuries. OBJECTIVE: To determine the accuracy of adults in identifying stinging insects and 2 insect nests. METHODS: This was a cross-sectional, multicenter study using a picture-based survey to evaluate an individual's success at identifying honeybees, wasps, bald-face hornets, and yellow jackets. Bald-face hornet and paper wasp nest identification also was assessed in this study. RESULTS: Six hundred forty participants completed the questionnaire. Overall, the mean number of correct responses was 3.2 (SD 1.3) of 6. Twenty participants (3.1%) correctly identified all 6 stinging insects and nests and only 10 (1.6%) were unable to identify any of the pictures correctly. The honeybee was the most accurately identified insect (91.3%) and the paper wasp was the least correctly identified insect (50.9%). For the 6 questions regarding whether the participant had been stung in the past by any of the insects (including an unidentified insect), 91% reported being stung by at least 1. Men were more successful at identify stinging insects correctly (P = .002), as were participants stung by at least 4 insects (P = .018). CONCLUSION: This study supports the general perception that adults are poor discriminators in distinguishing stinging insects and nests with the exception of the honeybee. Men and those participants who reported multiple stings to at least 4 insects were more accurate overall in insect identification.

Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized controlled trial.

OBJECTIVE: To examine the changes in performance on heart failure knowledge assessments administered before and after discharge education. METHODS: We conducted a randomized controlled trial comparing the effects of a 1-h, one-on-one teaching session with a nurse educator to the standard discharge process in patients with systolic heart failure. Patients completed a 30 point heart failure knowledge questionnaire (HFKQ) prior to and 3 months after the education intervention. RESULTS: Patients randomized to the nurse education intervention (n=113) demonstrated significantly higher total HFKQ score increases compared to patients receiving the standard discharge process (n=114) (median, IQR 1, 0 to 4 vs 0, -2 to 2, p=0.007). Patients experiencing death or rehospitalization in the subsequent 6 months were found to have significantly lower HFKQ scores (10, 7 to 12 vs 11, 8 to 13, p=0.002) compared to patients without a clinical event. CONCLUSION: Heart failure nurse education at the time of hospital discharge results in improved patient knowledge and reduced risk of readmission. PRACTICE IMPLICATIONS: Health care personnel should encourage education sessions for heart failure patients. Resources possibly need to be allocated for nurse led education sessions in heart failure patients as it improves outcomes and knowledge.

Six-minute walk distance predicts 30-day readmission in hospitalized heart failure patients.

BACKGROUND AND AIMS: Identification of patients with heart failure (HF) at high risk of hospital readmission is critical to refine processes for reducing readmission rates. We hypothesized that patients with higher 6-min walk (6MW) distance at the time of hospital discharge are at low risk for early readmission. METHODS: We prospectively enrolled 265 patients admitted with HF and left ventricular systolic dysfunction. 6MW testing was administered prior to discharge. Multivariate logistic regression analysis was performed to determine the relationship between 6MW distance and 30-day readmission, stratifying by ≤400 m and >400 m. RESULTS: Two hundred ten patients underwent 6MW testing prior to discharge. Patients with 6MW >400 m had a 30-day readmission rate of 15.9%, whereas patients with 6MW ≤400 m had a 30-day readmission rate of 30.3% (p = 0.016). Patients requiring readmission within 30 days had a median 6MW of 30 m, whereas patients not requiring readmission at 30 days walked 338 m (p = 0.012). 6MW distance predicted freedom from readmission at 30 days (OR: 0.435, 95% CI 0.21-0.9, p = 0.025). Other independent predictors of 30-day readmission included history of gout (0.117, 0.021-0.637, p = 0.013), use of angiotensin-converting enzyme inhibitor or accepted alternative (0.372, 0.169-0.820, p = 0.014) and blood urea nitrogen level (1.019, 1.003-1.035, p = 0.020). CONCLUSIONS: Low 6MW distance predicts early hospital readmission in patients with HF. Programs seeking to produce systems that are effective in reducing early hospital readmission may desire to incorporate 6MW testing during HF hospital care.

Brugada syndrome in an active duty Air Force senior pilot.

INTRODUCTION: Brugada syndrome describes a subgroup of patients at risk for polymorphic ventricular tachycardia, ventricular fibrillation, and sudden cardiac death and is likely underdiagnosed among aviators. CASE REPORT: A 40-year-old male pilot presented to the clinic for his physical. He denied any symptoms on initial questioning. Subsequent electrocardiogram (ECG) revealed premature ventricular couplets with ST-segment elevation in V1 and V2 of the precordial leads with T-wave abnormalities. DISCUSSION: Special care must be taken if ECG demonstrates a Brugada pattern-especially in patients with a history of syncope or a family history of sudden death. Recent studies have confirmed a significant risk reduction in symptomatic patients with type 1 Brugada to as low as 0.8% to 3% with an implantable cardioverter defibrillator. CONCLUSION: Symptomatic patients displaying type 1 Brugada ECG (spontaneous or after sodium channel blockade) should receive an implantable cardioverter defibrillator and must be permanently disqualified. The Aeromedical Consultation Service should review all cases of Brugada syndrome and render a return to fly for asymptomatic nondiagnostic Brugada types.

The impact of patient-specific quality-of-care report cards on guideline adherence in heart failure.

BACKGROUND: It is unknown if physician education through heart failure (HF) patient-specific quality-of-care report cards (HFRC) impacts outpatient HF guideline adherence. METHODS: A prospective pre-post design study was performed to test the hypothesis that a one-time, patient-specific HFRC delivered to physicians after HF patient (ejection fraction < or = 40%) discharge would lead to improved HF guideline adherence compared with control practitioners. Patients were contacted at 1, 3, and 6 months after discharge to assess medication usage and intolerances. Six month quality score (QS) was the primary end point, calculated as the sum of adherence to 4 medication performance measures (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, aldosterone inhibitors, and warfarin for atrial fibrillation). RESULTS: The mean QS at discharge was 3.10 +/- 0.78 in controls (n = 189) and 3.25 +/- 0.79 in the HFRC group (n = 76, P = .11). Controlling for discharge QS, the HFRC resulted in a significantly improved QS at 3 months (beta = .11, P = .023) but not at the 6-month primary end point (beta = .084, P = .14). Controlling for baseline medication use, patients of practitioners receiving the HFRC were 32.5 (P = .019) and 8.5 (P = .030) times more likely to receive, or have a documented contraindication to, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker at 3 and 6 months, respectively. There were no significant differences in indicated beta-blocker, aldosterone inhibitor, or warfarin prescriptions at any follow-up. CONCLUSIONS: Although one-time patient-specific report cards result in short-term statistically significant improvements in outpatient evidence-based HF care, the gain does not translate into sustained improvements in quality of care.

Brain natriuretic peptide predicts serious cardiac allograft rejection independent of hemodynamic measurements.

BACKGROUND: Serum brain natriuretic peptide (BNP) has been reported to be elevated in heart transplant recipients with both cellular and vascular rejection. Whether BNP can be used to help predict the severity of rejection is not well established. METHODS: We analyzed serial BNP measurements obtained during endomyocardial biopsy procedures in consecutive heart transplant patients occurring >45 days after transplantation. To eliminate potential confounding from prior rejection episodes, we included only observations in which the previous biopsy grade was 0 or 1A. Multivariable linear regression was performed examining the outcome of increasing seriousness of rejection, defined as grade 0 < 1A < 2 < 1B < 3A < vascular rejection. A univariable logistic regression model was performed using log-transformed BNP as a predictor of vascular rejection. RESULTS: There were 77 patients, with 161 separate observations. Median time between transplantation and first assessment was 6.0 months (interquartile range, 2.1, 31.6). Using multivariable linear regression, 3 factors were significantly associated with biopsy score: pulmonary capillary wedge pressure (p < 0.0001), BNP (p = 0.003), and heart rate (p = 0.01). Even after other significant univariable predictors (including pulmonary capillary wedge pressure) were forced into the model, BNP remained a significant predictor of biopsy score (p = 0.02). Log BNP was a significant univariable predictor of vascular rejection, with an odds ratio of 12.55 (per 1 unit increase, 95% confidence interval 3.43-45.84; p = 0.0001) and a model c-statistic of 0.91. CONCLUSIONS: BNP predicts new episodes of serious cardiac allograft rejection, particularly vascular rejection, independent of hemodynamic measurements, and may be a useful part of rejection surveillance.

Discharge education improves clinical outcomes in patients with chronic heart failure.

BACKGROUND: Although interventions combining patient education and postdischarge management have demonstrated benefits in patients with chronic heart failure, the benefit attributable to patient education alone is not known. We hypothesized that a patient discharge education program would improve clinical outcomes in patients with chronic heart failure. METHODS AND RESULTS: We conducted a randomized, controlled trial of 223 systolic heart failure patients and compared the effects of a 1-hour, one-on-one teaching session with a nurse educator to the standard discharge process. Subjects were contacted by telephone at 30, 90, and 180 days to collect information about clinical events, symptoms, and self-care practices. The primary end point of the study was the total number of days hospitalized or dead in the 180-day follow-up period. Subjects randomized to receive the teaching session (n=107) had fewer days hospitalized or dead in the follow-up period (0 and 10 days, median and 75th percentiles) than did controls (n=116, 4 and 19 days; P=0.009). Patients receiving the education intervention had a lower risk of rehospitalization or death (relative risk, 0.65; 95% confidence interval, 0.45 to 0.93; P=0.018). Costs of care, including the cost of the intervention, were lower in patients receiving the education intervention than in control subjects by 2823 dollars per patient (P=0.035). CONCLUSIONS: The addition of a 1-hour, nurse educator-delivered teaching session at the time of hospital discharge resulted in improved clinical outcomes, increased self-care measure adherence, and reduced cost of care in patients with systolic heart failure.