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.

Aspirin therapy in aspirin-exacerbated respiratory disease: a risk-benefit analysis for the practicing allergist.

This study was designed to investigate the risks associated with aspirin (ASA) therapy that is used in high doses for the treatment of ASA-exacerbated respiratory disease (AERD) and to review therapeutic strategies for the prevention of nonsteroidal anti-inflammatory drug (NSAID)-induced side effects. A PubMed search was performed using the key words "aspirin" and "adverse effects." Additional citations were generated by surveying the reference lists of the pulled articles. More than 120 articles were reviewed and references were selected based on their relevance to the subject matter. Prevalence rates of ASA hypersensitivity in the general population have been reported to be 0.6-2.5%. Asthmatic patients have higher rates of ASA hypersensitivity. The allergy/immunology specialty is unique in the use of prolonged high-dose ASA therapy for the treatment of AERD. ASA use is associated with an increased risk for the development of serious gastrointestinal (GI) events including GI bleeding, ulcers, and perforation. Established risk factors for GI ulcer development include advanced age, history of ulcer or GI bleed, concomitant use of corticosteroids or anticoagulants, high-dose ASA/NSAID therapy, and possibly concomitant Helicobacter pylori infection. Effective strategies to prevent GI complications include initiation of a proton pump inhibitor (PPI), misoprostol, or double dose H(2)-receptor antagonists (H(2)RAs) at the start of ASA therapy. Allergist/immunologists are involved in treatment decisions regarding high-dose ASA use in AERD. The primary risk of using ASA therapy is the development of GI complications. Cotherapy with a PPI, misoprostol, or double dose H(2)RAs can reduce GI complications associated with high-dose ASA therapy.

The TEN study: time epinephrine needs to reach muscle.

BACKGROUND: An epinephrine autoinjector (EAI) is designed to deliver epinephrine into the vastus lateralis muscle. Several studies have demonstrated both patient and physician difficulties in correctly using EAIs, specifically premature removal of the device from the thigh. OBJECTIVE: To evaluate the correlation between duration of injection with an EAI and amount of epinephrine absorbed into muscle tissue. METHODS: Twenty-one EAI devices (0.3 mL) were used to determine the amount of epinephrine injected into marbleized beef during 7 time periods. A digital scale was used to record preinjection and postinjection weights of EAIs and beef. The weight difference between the preinjection and postinjection periods of the EAIs was used to calculate the total amount of epinephrine released and available for absorption into the marbleized beef. The difference between the preinjection and postinjection beef weight was used to determine the amount of epinephrine absorbed into the meat. RESULTS: The correlation with duration of injection for both the amount of epinephrine absorbed and released was 0.321 (P = .48). At all intervals, 95.9% or more of epinephrine was absorbed into the marbleized beef. The correlation with duration of injection and percent of epinephrine absorbed was 0.464 (P = .29). There were no time periods that were significantly different from the percentage of epinephrine absorbed by the marbleized beef at 10 seconds (analysis of variance P = .16). CONCLUSION: No linear relationship between time and amount of epinephrine injected or absorbed into muscle tissue was demonstrated. These data suggest that holding the device in place for 1 second is as effective as 10 seconds.

Recurrent diarrhea in a 26-year-old man.

This is a case report of a 26-year-old healthy man with chronic diarrhea for 2 years. He was initially believed to have irritable bowel syndrome by his primary care physician after all stool studies yielded negative results. His symptoms persisted, which prompted a referral to a gastroenterology specialist. The patient's esophagogastroduodenoscopy revealed variable villous blunting and a paucity of CD 138 plasma cells, which helped reveal the final diagnosis. This cases illustrates a unique presentation of a common primary immunodeficiency that allergy/immunology specialists, along with primary care specialists, will likely encounter.

The efficacy of pediatric advanced life support training in emergency medical service providers.

Pediatric advanced life support (PALS) teaches skills unique to pediatric resuscitation. The purpose of this study was to assess the effect of PALS training among emergency medical service (EMS) providers in out-of-hospital trauma and medical resuscitations. A physician panel evaluated all EMS run sheets of pediatric traumas and medical resuscitations brought to a tertiary children's hospital/regional trauma center over a 3-year period. In 183 responses, EMS personnel were the sole providers of medical stabilization. Evaluation included the ability to secure an airway, establish vascular access, shock recognition, and appropriate cardiac rhythm assessment and resuscitation. The panel was blinded to the PALS training status of the responding EMS squad until completion of the review. Pediatric advanced life support-trained EMS personnel responded to 36% of the resuscitations reviewed. A significant difference in successful intubations was noted in PALS-trained squads compared with squads with no PALS training (85% vs 48%; P < 0.001). A significant difference was also noted in the ability to obtain vascular access in shock/arrest cases (100% vs 70%; P < 0.001). Similarly, PALS-trained squads were more successful in intraosseous line placement than non-PALS-trained squads (100% vs 55%; P < 0.01). However, despite better procedural skills, there was no difference in mortality rates between the groups (37% PALS vs 32% non-PALS). We conclude that PALS training improves procedural skills among EMS personnel and should be strongly considered as part of EMS training.

Serratia marcescens causing cervical necrotizing oropharyngitis.

Necrotizing fasciitis is a rare, life-threatening infection. We report a case of necrotizing oropharyngitis caused by Serratia marcescens in a previously immunocompetent 6-year-old male. This necrotizing infection led to a near-total defect of the oropharynx. The wound was managed with daily wound debridement of the patient's oropharynx with 3% hydrogen peroxide, carotid artery coverage with Kaltostat, and pharyngeal packing with iodoform ribbon gauze. Our patient's resultant nasopharyngeal and hypopharyngeal stenoses present challenges for restoration of form and function for voicing and deglutition. We present our experience of managing this child's hypopharyngeal stenosis with a minimally invasive double-balloon dilatation technique.