- Email: [email protected]
Bee stings
THE LANCET
Bee stings SIR—Epistemology classically recognises that researchers doing an experiment can inadvertently (and sometimes inevitably) alter the very event that they strive, however scrupulously, to observe and describe. In this case what they actually observe is no longer the natural event subjected to observation but the result of their interaction with it (think of “white-coat hypertension”). This notion also applies to experiments with bee stings. Notoriously—provided anaphylaxis does not occur—local reactions lose intensity after repeated stings (tachyphylaxis) or reiterated inoculation of honey bee venom (desensitisation). Accordingly, the object of Visscher and colleagues’ (Aug 3, p 301)1 observations (weals after bee stings) were inevitably being modified (desensitisation) while the experiment (repeated stings) was being done: thus what they actually observed and described must have been bee stings in desensitised persons (what bee keepers become). Indeed the author-volunteer received “preliminary” stings (of unspecified number), ten intracutaneous injections of increasing venom doses, and 50 “study” stings. In view of the natural history of “wild” stings of honey bees (ie, oedema, erythema, pain, allodynia, and hyperalgesia, which can cover a third of the volar aspect of the forearm for over 36 h), would not this be a formidable Herculean deed without the assistance of desensitisation? Visscher and colleagues’ conclusions therefore strictly apply only to stings in desensitised persons. Furthermore, since the dose-response relation established is applicable only to weal size in the first 10 min—a measure not necessarily correlated with intensity of pain—their advice to rapidly remove stings may remain devoid of tangible implications to victims of wild bee stings whose main concern is pain. Incidentally it is ancestral knowledge among local apiculturists that the sooner you remove a sting—never mind how—the better. However, they neither “pinch” them nor “scrape” them off with an object. I see them slap or squeeze away the offending bee with the palm of the hand. Bruno Simini 55050 Gattaiola, Lucca, Italy
1
Visscher PK, Vetter RS, Carmazine S. Removing bee stings. Lancet 1996; 348: 301–02.
Author’s reply SIR—As Simini correctly notes, repeated bee stings usually lead to desensitisation. Both myself and Vetter are beekeepers and receive frequent stings all year round, so we have reactions to bee stings that are low and stable (ie, no longer reducing during the course of these experiments). We admit that if we had local reactions as severe as those described by Simini, we would not have been inclined to achieve an adequate experimental sample size! Our conclusions do not relate to the specific extent of reaction to be expected in a particular patient, but rather the amount of venom received. My forearm can thus be viewed as an analytical instrument, with the hypodermic injections providing calibration of the instrument’s output (weal size) in response to varying inputs (quantities of venom). We have no reason to believe that low sensitivity of the individual affects the kinetics of venom injection by the bee sting. So, this bioassay should provide general conclusions about venom dose, even though not general for weal size. For most patients pain is the primary concern. However, bee stings are life threatening to some, and for these systemic allergic reactions to venom, which are dose-dependent, the
900
quantity of venom received is significant beyond the pain it causes. Furthermore, initial pain is correlated with venom dose (a fact I can vouch for from the calibration series). Local reactions in patients without systemic reactions can often be even more severe than described by Simini, are also dose-dependent, and can be extremely uncomfortable. We are well aware that most beekeepers remove stings in whatever way is convenient. Indeed, it was this experience that initially made us sceptical of the conventional advice advising against methods that might compress the venom sac (which would include slapping or squeezing with the palm of the hand). As we showed, beekeepers’ practice is sound: do not let concerns over the method of removal cause delay, just remove the sting as rapidly as possible. It will hurt less, it will swell less, and it will be less likely to kill you. P Kirk Visscher Department of Entomology, University of California Riverside, Riverside, CA 92521, USA
SIR—The article by Visscher and colleagues1 has great clinical relevance in the management of individuals with bee venom anaphylaxis. In the past decade I have seen two patients who have had only widespread urticarial rash when stung on the arm and the upper chest and the sting was promptly scraped off with the fingernails. However, bronchial constriction in one and hypotension in the other occurred when they were stung in the middle of the back and could not scrape the sting off in the manner they had been advised. Thus for fear of squeezing more venom into the skin they did not attempt any removal of the sting. Had both people tried to remove the sting without “concern for the method”—eg, rubbing their back against a wall—then it is possible that the more severe reactions may have been averted. Amolak S Bansal Lions Human Immunology Laboratory, Princess Alex andra Hospital, Brisbane, Australia 4102
1
Visscher PK, Vetter RS, Camazine S. Removing bee strings. Lancet 1996; 348: 301–02.
Changes in breast cancer incidence among Norwegian women under 50 SIR—We report an increase in incidence of breast cancer in women under 50 years during the past decade. For this age group the incidence rates were stable from 1953 (the first year of registration in the Norwegian Cancer Registry) to 1982. Between 1983 and 1993 the rates increased by 50%. The annual increases were estimated to be 4·0%, 1·1%, 0·5%, and 0·3% for the age groups 0–49, 50–59, 60–69, 70–79, respectively (figure). The corresponding increases in mortality rates were 5·0%, – 0·9%, 0·9%, and 0·5%. The stage distribution at time of diagnosis shows that in 1970–73, 51% of all cases under 50 years of age were localised, compared with 54% in 1986–89 and 54% in 1990–93. Among the young women diagnosed in the localised stage, the 5-year relative survival was 90·5% for those diagnosed in 1970·73 and 91·1% in 1986–89. For older age groups the survival rates between 1970–73 and 1986–89 improved from 85·0% to 90·3% for the age group 50–59 and from 86·3% to 90·7% and 79·9% to 87·7% for the next 10-year age groups. Neither the stage distribution nor the survival rate indicate that there have been any substantial changes in diagnostic intensity, procedures, or criteria for malignancy. The
Vol 348 • September 28, 1996
Bee stings SIR—Epistemology classically recognises that researchers doing an experiment can inadvertently (and sometimes inevitably) alter the very event that they strive, however scrupulously, to observe and describe. In this case what they actually observe is no longer the natural event subjected to observation but the result of their interaction with it (think of “white-coat hypertension”). This notion also applies to experiments with bee stings. Notoriously—provided anaphylaxis does not occur—local reactions lose intensity after repeated stings (tachyphylaxis) or reiterated inoculation of honey bee venom (desensitisation). Accordingly, the object of Visscher and colleagues’ (Aug 3, p 301)1 observations (weals after bee stings) were inevitably being modified (desensitisation) while the experiment (repeated stings) was being done: thus what they actually observed and described must have been bee stings in desensitised persons (what bee keepers become). Indeed the author-volunteer received “preliminary” stings (of unspecified number), ten intracutaneous injections of increasing venom doses, and 50 “study” stings. In view of the natural history of “wild” stings of honey bees (ie, oedema, erythema, pain, allodynia, and hyperalgesia, which can cover a third of the volar aspect of the forearm for over 36 h), would not this be a formidable Herculean deed without the assistance of desensitisation? Visscher and colleagues’ conclusions therefore strictly apply only to stings in desensitised persons. Furthermore, since the dose-response relation established is applicable only to weal size in the first 10 min—a measure not necessarily correlated with intensity of pain—their advice to rapidly remove stings may remain devoid of tangible implications to victims of wild bee stings whose main concern is pain. Incidentally it is ancestral knowledge among local apiculturists that the sooner you remove a sting—never mind how—the better. However, they neither “pinch” them nor “scrape” them off with an object. I see them slap or squeeze away the offending bee with the palm of the hand. Bruno Simini 55050 Gattaiola, Lucca, Italy
1
Visscher PK, Vetter RS, Carmazine S. Removing bee stings. Lancet 1996; 348: 301–02.
Author’s reply SIR—As Simini correctly notes, repeated bee stings usually lead to desensitisation. Both myself and Vetter are beekeepers and receive frequent stings all year round, so we have reactions to bee stings that are low and stable (ie, no longer reducing during the course of these experiments). We admit that if we had local reactions as severe as those described by Simini, we would not have been inclined to achieve an adequate experimental sample size! Our conclusions do not relate to the specific extent of reaction to be expected in a particular patient, but rather the amount of venom received. My forearm can thus be viewed as an analytical instrument, with the hypodermic injections providing calibration of the instrument’s output (weal size) in response to varying inputs (quantities of venom). We have no reason to believe that low sensitivity of the individual affects the kinetics of venom injection by the bee sting. So, this bioassay should provide general conclusions about venom dose, even though not general for weal size. For most patients pain is the primary concern. However, bee stings are life threatening to some, and for these systemic allergic reactions to venom, which are dose-dependent, the
900
quantity of venom received is significant beyond the pain it causes. Furthermore, initial pain is correlated with venom dose (a fact I can vouch for from the calibration series). Local reactions in patients without systemic reactions can often be even more severe than described by Simini, are also dose-dependent, and can be extremely uncomfortable. We are well aware that most beekeepers remove stings in whatever way is convenient. Indeed, it was this experience that initially made us sceptical of the conventional advice advising against methods that might compress the venom sac (which would include slapping or squeezing with the palm of the hand). As we showed, beekeepers’ practice is sound: do not let concerns over the method of removal cause delay, just remove the sting as rapidly as possible. It will hurt less, it will swell less, and it will be less likely to kill you. P Kirk Visscher Department of Entomology, University of California Riverside, Riverside, CA 92521, USA
SIR—The article by Visscher and colleagues1 has great clinical relevance in the management of individuals with bee venom anaphylaxis. In the past decade I have seen two patients who have had only widespread urticarial rash when stung on the arm and the upper chest and the sting was promptly scraped off with the fingernails. However, bronchial constriction in one and hypotension in the other occurred when they were stung in the middle of the back and could not scrape the sting off in the manner they had been advised. Thus for fear of squeezing more venom into the skin they did not attempt any removal of the sting. Had both people tried to remove the sting without “concern for the method”—eg, rubbing their back against a wall—then it is possible that the more severe reactions may have been averted. Amolak S Bansal Lions Human Immunology Laboratory, Princess Alex andra Hospital, Brisbane, Australia 4102
1
Visscher PK, Vetter RS, Camazine S. Removing bee strings. Lancet 1996; 348: 301–02.
Changes in breast cancer incidence among Norwegian women under 50 SIR—We report an increase in incidence of breast cancer in women under 50 years during the past decade. For this age group the incidence rates were stable from 1953 (the first year of registration in the Norwegian Cancer Registry) to 1982. Between 1983 and 1993 the rates increased by 50%. The annual increases were estimated to be 4·0%, 1·1%, 0·5%, and 0·3% for the age groups 0–49, 50–59, 60–69, 70–79, respectively (figure). The corresponding increases in mortality rates were 5·0%, – 0·9%, 0·9%, and 0·5%. The stage distribution at time of diagnosis shows that in 1970–73, 51% of all cases under 50 years of age were localised, compared with 54% in 1986–89 and 54% in 1990–93. Among the young women diagnosed in the localised stage, the 5-year relative survival was 90·5% for those diagnosed in 1970·73 and 91·1% in 1986–89. For older age groups the survival rates between 1970–73 and 1986–89 improved from 85·0% to 90·3% for the age group 50–59 and from 86·3% to 90·7% and 79·9% to 87·7% for the next 10-year age groups. Neither the stage distribution nor the survival rate indicate that there have been any substantial changes in diagnostic intensity, procedures, or criteria for malignancy. The
Vol 348 • September 28, 1996