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.

Comparison of pain during skin-prick testing, immunizations, and phlebotomy.

BACKGROUND: Allergy skin prick testing is a medical procedure that is very useful for assessing a patient's sensitization to specific allergens. Some patients are worried about pain associated with prick skin testing. OBJECTIVE: To compare pain among different age groups, to look at pain during skin prick testing in younger children, and to compare the pain during skin prick testing to procedures including routine immunizations and phlebotomy. METHODS: A survey was provided to patients undergoing allergy skin testing, immunizations or phlebotomy at the Wilford Hall Medical Center. RESULTS: There were 197 patients and 26 parents of patients aged 3-8 years who completed surveys during allergy skin testing. The average anticipated (pre procedure) pain score was 4.3 for the patients aged 3-8 years, 4.6 for the patients aged 9-17 years and 3.2 for the patients older than 17 years. The average actual pain score of the patients during skin testing was 3.1 for the patients aged 3-8 years, 2.2 for the patients aged 9-17 years and 1.4 for the patients older than 17 years. For the parents of patients aged 3-8 years, the average anticipated average pain score was 3.0 and the average actual pain score was 1.7. CONCLUSIONS: The actual pain experienced from skin prick testing is perceived to be much less than the anticipated pain. Patients and referring physicians should not have a fear of pain from allergy skin prick testing.

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.

Can equal access to care eliminate racial disparities in pediatric asthma outcomes?

A survey was given to the parents of 80 children with asthma between the ages of 3 and 18 years at the Pediatric Pulmonology Clinics of three military treatment facilities to evaluate asthma management and outcomes for different racial groups. Results demonstrated that management practices for the three groups were similar and that there were no significant differences in emergency department visits, prescription of oral steroids, or in the number of hospitalizations across the three groups. These findings suggest that equal access to care may allow children of different racial backgrounds to receive similar asthma care and achieve similar outcomes.

Medical students' perceptions of medical education research and their roles as participants.

PURPOSE: To better understand whether medical students perceive medical education research as important to their medical training and whether published opinions about why medical students participate in research are accurate. METHOD: In 2003-04, 896 first- through fourth-year medical students at Kansas City University of Medicine and Biosciences College of Osteopathic Medicine were asked to complete an online eight-item questionnaire by responding Yes or No to each question. Responses were tallied by year of medical training and converted into numbers and percentages. Chi-square analysis was used to compare response rates among first- through fourth-year students and responses between preclinical and clinical students. RESULTS: A total of 524 students (58.5%) completed the questionnaire. A total of 488 (93%) medical students believed medical education research should be conducted to improve their medical training, 477 (91%) did not feel coerced to participate in studies because of faculty members' positions of authority, and 398 (76%) did not believe they would receive better grades, recommendations, and/or other favors. Four hundred sixty-eight (89%) students were not concerned with their confidentiality as study participants, while 326 (62%) wanted special protections. Response rates by year of medical school were not significantly different (p > .05). Responses of preclinical and clinical students for six of the eight questions were significantly different (p < .05). CONCLUSIONS: Medical school decisionmakers should recognize that students value medical education research. Published opinions about why medical students participate in studies are incongruent with medical students' views. Full review of medical education studies by Institutional Review Boards may be unnecessary and inappropriate.

Health Professions Scholarship Program: are the armed forces getting quality osteopathic physicians?

To compare the medical knowledge and reasoning of osteopathic medical students in the Health Professions Scholarship Program (HPSP) with corresponding civilian students, we analyzed their performance on the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) levels 1 and 2. The results from this study showed no significant difference between that HPSP medical students (COMLEX-USA level 1, N = 37; COMLEX-USA level 2, N = 34) and civilian students (COMLEX-USA level 1, N = 507; COMLEX-USA level 2, N = 492) on COMLEX-USA level 1 (p = 0.24) and COMLEX-USA level 2 (p = 0.50). Moreover, no significant difference was observed between Air Force (COMLEX-USA level 1, N = 8; COMLEX-USA level 2, N = 6), Army (COMLEX-USA level 1, N = 13; COMLEX-USA level 2, N = 13), and Navy (COMLEX-USA level 1, N = 16; COMLEX-USA level 2, N = 15) HPSP students for COMLEX-USA level 1 (p = 0.42) and COMLEX-USA level 2 (p = 0.75). Therefore, we conclude that, upon graduation from medical school, the medical knowledge and reasoning of HPSP osteopathic graduates as determined by COMLEX-USA are equivalent to those of their civilian counterparts.

Local production of IgE in the respiratory mucosa and the concept of entopy: does allergy exist in nonallergic rhinitis?

OBJECTIVE: To review research regarding locally produced IgE and its impact on patients with chronic rhinitis. DATA SOURCES: PubMed search with the following keywords: entopy, local IgE, nonallergic rhinitis, idiopathic rhinitis, vasomotor rhinitis, and allergic rhinitis. STUDY SELECTION: Articles were selected based on their relevance to entopy and locally produced IgE and its clinical effect and relationship to idiopathic rhinitis (IR). RESULTS: Local IgE has been found in a variety of tissues, including nasal and bronchial mucosa. IgE is produced in these local tissues and not simply the product of migration to the tissue from regional lymphoid tissue or blood. Local IgE has been identified in most of both atopic and nonatopic asthmatic patients and allergic rhinitis patients. Up to 40% of patients with IR and a positive nasal provocation test result have evidence of locally produced IgE, which has been coined entopy. Although patients with allergic rhinitis and IR show similar inflammatory patterns with increased activated mast cells, eosinophils, and T-cell subsets in some studies, other studies on IR patients are conflicting with regard to both inflammation and allergen-specific nasal provocation test results. CONCLUSION: The concept of local allergy in IR patients is both intriguing and controversial. Studies have reported conflicting results, and currently there is no single best test to evaluate for entopy. It is known that there are a large number of IR patients for whom current treatment regimens are suboptimal. Therefore, further research elucidating the mechanisms of IR and the concept of localized IgE are needed to optimally diagnose this condition and treat this group of patients.

Systemic reaction rates to field stings among imported fire ant-sensitive patients receiving >3 years of immunotherapy versus <3 years of immunotherapy.

As imported fire ants (IFAs) expand their range, hypersensitivity reactions to their stings are becoming a significant cause of morbidity and mortality in the United States. Currently, IFAs whole body extract (WBE) immunotherapy is the mainstay of treatment for IFA hypersensitivity but the optimal duration of treatment is unknown. A questionnaire was administered to patients diagnosed with IFA venom hypersensitivity based on history and the presence of IFA venom-specific IgE who had been offered immunotherapy. The patients were grouped into those who received > or =3 years of immunotherapy and those who received <3 years of immunotherapy. Forty of the 272 patients initially identified were successfully contacted (14%) with 6 patients being excluded. Of these patients, 19 reported having received <3 years of IFA immunotherapy (reduced course) and 15 stated they had been given >3 years of immunotherapy (complete course). Subsequent field stings were reported by 18 (95%) of the reduced course groups and 14 (93%) of the complete course group with 1 person from each group (6 and 7%, respectively) experiencing a systemic reaction. There were no significant differences between the two groups in the number of patients with subsequent field stings or systemic reactions after subsequent IFA stings. Less than 3 years of IFA immunotherapy may offer long-term protection against IFA hypersensitivity reactions although additional studies with more subjects and controls are necessary before definitive conclusions may be made.

Effects of an alternate dissection schedule on gross anatomy laboratory practical performance.

The current medical curricula reform that is taking place in many medical schools throughout the world has resulted in less time for gross anatomy laboratory instruction. In response, anatomists are using a variety of approaches (e.g., peer teaching, prosections, plastinated anatomical models, etc.) to adapt to these changes. To accommodate recent curricular reform at the University of Health Sciences College of Osteopathic Medicine, an alternating dissection schedule was implemented. The purpose of this study is to examine the effects of the alternating schedule on gross anatomy laboratory practical performance. Using a Mann-Whitney Rank Sum test, back and upper limb (back-upper limb), and lower extremity laboratory practical performance for students who dissected in every laboratory (EL group; n = 227) is compared to students who dissected in every other laboratory (EOL group; n = 254). For the back-upper limb part of the anatomy laboratory practical, the mean percentage scores for the EL and EOL groups were 74.5% and 68.1%, respectively (P < 0.001). The mean percentage scores for the EL and EOL groups on the lower limb portion of the anatomy lab practical were 75.9% and 75.6%, respectively (P = 0.994). These data suggest that the use of an alternating dissection schedule had an equivocal effect on the students' gross anatomy laboratory practical performance for these two sections. The reasons for these conflicting results may have been related to regional complexity or volume of information, and the sequence in which the regions were taught.

Effects of four supplemental instruction programs on students' learning of gross anatomy.

Many researchers have reported that supplemental instruction programs improve medical students' performance in various basic sciences. This study was conducted to evaluate the summative effects of four supplemental instruction programs (i.e., second-year medical student teaching assistant program; directed study program; weekly instructor laboratory reviews; and a web-based anatomy program) on medical students' gross anatomy laboratory practical performance. First-year medical students from the graduating class of 2006 (n = 223) received the four supplemental instruction programs (Experimental Group). The Control Group consisted of first-year medical students from the graduating class of 2005 (n = 254) who did not receive the four supplemental learning methods. Mann-Whitney rank sum tests were used to compare the two groups' median percentages for the back-upper limb (B-UL) and the lower limb (LL) parts of a gross anatomy laboratory practical. The Experimental Group's median percentages for both the B-UL (77.78%) and LL (83.33%) were significantly greater than that of the Control Group (B-UL = 69.00%; LL = 81.00%; P < 0.05). Results from a post-hoc student survey showed that more students both rated and ranked the weekly instructor laboratory reviews as extremely useful and most beneficial, respectively. A greater number of students rated and ranked the web-based anatomy program as not useful and least beneficial, respectively. The results from this study suggest that the four supplemental instruction programs improved students' learning of gross anatomy as measured by laboratory practical performance. In addition, students most valued the additional time in the gross anatomy laboratory with the instructors.

The relationship between premedical coursework in gross anatomy and histology and medical school performance in gross anatomy and histology.

Many premedical students enroll in courses whose content will be encountered again during their medical education. Presumably, students believe this practice will lead to improved academic performance in corresponding medical school courses. Therefore, this study was undertaken to determine whether a premedical gross anatomy and/or histology course resulted in increased performance in corresponding medical school courses. A second aim of the study was to examine whether the type of premedical gross anatomy and/or histology course differentially affected medical school performance. A survey that assessed premedical gross anatomy and histology coursework was administered to 440 first-year medical students. The results from this survey showed that students with premedical gross anatomy (n = 236) and/or histology (n = 109) earned significantly more points in the corresponding medical school course than students without the premedical coursework (P < 0.05). Analysis of premedical course types revealed that students who took a gross anatomy course with prosected specimens (n = 35) earned significantly more points that those students without premedical gross anatomy coursework (P < 0.05). The results from this study suggest: 1) premedical gross anatomy and/or histology coursework improves academic performance in corresponding medical school courses, and 2) a premedical gross anatomy course with prosected specimens, a specific type of undergraduate course, significantly improves academic performance in medical gross anatomy.