SARS-CoV-2 Antibody Longitudinal Profile of Immune Globulin Preparations.

INTRODUCTION: Intravenous immunoglobulin (IVIG) preparations, used for the treatment of antibody deficiencies, provide a glimpse of the general population's antibody profile as each preparation is generated from a pool of thousands of donors. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus responsible for the coronavirus disease 2019 (Covid-19) pandemic, and a vaccine for the prevention of Covid-19 was authorized for emergency use in December 2020. We completed a longitudinal analysis of SARS-CoV-2 antibody levels in commercial IVIG preparations. MATERIALS AND METHODS: We collected IVIG samples from our infusion clinic. IVIG product lot number, product name, and manufacturer information were recorded, with the date of preparation verified from the manufacturer. SARS-CoV-2 antibody titers as well as total immunoglobulin levels were measured using commercially available assays. The study received Institutional Review Board approval. RESULTS: We found no SARS-CoV-2 antibodies in preparations generated on or before January 2020. Overall, SARS-CoV-2 antibody levels in IVIG preparations tended to increase with progressing preparation date. We observed a dramatic and continual rise of SARS-CoV-2 antibody levels in IVIG preparations made in the beginning after January 2021, coinciding with the peak in incidence of confirmed cases and availability of Covid-19 vaccines in the United States. CONCLUSION: SARS-CoV-2 antibody levels in IVIG mirror case prevalence, and vaccination resulted in a far more rapid rate of rise in antibody levels. IVIG preparations or serum repositories can provide an accessible way to model a population's evolving novel pathogen exposure, immunity, and vaccine response.

The Impact of Deployment on the Practice of the Military Internist: A Needs Assessment for Post-Deployment Refresher Training.

INTRODUCTION: U.S. Army internists serve in a variety of provider roles during deployment, many of which vary from the traditional responsibilities of a general internist or internal medicine subspecialist. There is significant interest in defining specific clinical and procedural skills in which Army internists may require refresher training after deployment, but information to quantify and clarify these needs is lacking. MATERIALS AND METHODS: An online, anonymous survey was created to assess Army internists' experience and comfort level with specialty-specific problems and procedures before and after deployment. This survey was distributed via the Army Central Simulation Committee to all U.S. Army internists eligible for deployment. The survey was available online from January 11, 2012, to March 9, 2012. RESULTS: Ninety-seven of all 115 (84%) U.S. Army internists eligible for deployment responded. The reported comfort level with core clinical problems in general internal medicine before and after deployment did not change, with the exception of decreased comfort with the performance of advanced cardiac life support (87% versus 76% comfortable, p = 0.035), evaluation and management of anemia (92% versus 83% comfortable, p = 0.039), and comfort with preoperative risk stratification and mitigation (81% versus 65% comfortable, p = 0.017). Providers' reported comfort level performing core internal medicine procedures decreased, including significant decreases with lumbar puncture (p < 0.001), arterial line placement (p = 0.02), ultrasound-guided central line placement (p = 0.01), ultrasound-guided thoracentesis (p = 0.004), and arthrocentesis (p = 0.01). Despite a reported deceased comfort with certain core clinical problems and procedural skills, only 10 of 68 (13%) respondents reported being offered refresher skills training following deployment. CONCLUSION: Although Army internists' comfort with core general internal medicine clinical problems remains largely unaffected by deployment, confidence in core internal medicine procedures suffers because of limited opportunities to practice these skills in the deployed setting. Skills training and assessment in procedures required for individual provider practice should be a primary focus of reintegration after deployment.

Allergen stabilities and compatibilities in immunotherapy mixtures that contain cat, dog, dust mite, and cockroach extracts.

BACKGROUND: Indoor allergen mixtures that contain cat, dog, dust mite, and cockroach extracts are commonly used in allergy clinics for subcutaneous immunotherapy, but product-specific stabilities and mixing compatibilities in these complex patient formulas have not been determined. OBJECTIVES: To assess the recoveries of cat, dog epithelia, dog dander, dust mite Dermatophagoides farinae, and cockroach mix allergen activities in 5 component mixtures and 1:10 (vol/vol) dilutions stored for up to 12 months. METHODS: Concentrated stock mixtures, 10-fold dilutions of these mixtures in human serum albumin-saline diluent, and analogous single-extract controls were analyzed for major allergen concentrations (cat Fel d 1, dog dander Can f 1) and multiallergen IgE-binding potencies (dog epithelia, D farinae, cockroach mix) after storage for 3, 6, 9, and 12 months at 2°C to 8°C. RESULTS: The selected immunoassays were specific for individual target extracts in the 5-component mixtures and exhibited analytical sensitivities sufficient for evaluation of both the concentrated and diluted indoor allergen formulas. All control samples except diluted cockroach extract had near-complete stabilities during refrigerated storage. Mixtures that contained cat, dog epithelia, dog dander, and D farinae extracts exhibited favorable mixing compatibilities in 1:1 (vol/vol) concentrates (47.5% glycerin) and 1:10 (vol/vol) dilutions (4.75% glycerin), relative to corresponding control sample reactivities. Cockroach allergens in both 1:1 (vol/vol) and 1:10 (vol/vol) concentrations were stabilized significantly by mixing with the other 4 indoor allergen extracts. CONCLUSION: Extracts in mixtures that contained 5 common sources of indoor allergens possess favorable stabilities and mixing compatibilities and support the practice of combining these products in the same patient treatment formulations for subcutaneous immunotherapy.

Cross-reactivity and masqueraders in seafood reactions.

Confounding variables play a significant role in many adverse seafood reactions and a clear understanding of these factors is important in properly characterizing reactions associated with potential masqueraders and mimics. Although the medical literature is replete with reviews of seafood hypersensitivity and reports of cross-reactive and newly characterized allergens, there has not been a recent effort to provide an updated overview of the several processes that may lead clinicians to draw incorrect conclusions in evaluating reported reactions to seafood. Ranging from seafood intoxications to other nonallergic or complex seafood reactions, these events can easily be misconstrued as representing a seafood IgE-mediated allergy. Among these are the more familiar topics of cross-reactivity and scombroid intoxication, and those with a still evolving understanding such as ciguatera fish poisoning and Anisakis reactions. This article seeks to provide an accessible but comprehensive summary of the relevant information surrounding these confounders in assessing adverse reactions to seafood. Such knowledge may be instrumental in unraveling complex or otherwise unclear presentations and aid clinicians in accurately evaluating and managing patients with reported seafood reactions.

Atrophic rhinitis.

A case of atrophic rhinitis complicated by nasal septum perforation is presented, followed by a discussion of the clinical characteristics, pathophysiology, diagnosis, and management of this disease process. Clinical pearls and pitfalls are emphasized for the use of the practicing allergist and fellow in-training. The diagnosis of atrophic rhinitis is guided by a careful clinical history and evaluation to exclude other possible etiologies for the patient's symptoms and physical findings. Because atrophic rhinitis is a poorly understood process, it is surrounded by considerable contention in the literature and its management is not well defined. Atrophic rhinitis often carries significant morbidity and is best addressed by a multidisciplinary approach.