Understanding immune responses to native antigens in response to natural infections can lead to improved approaches to vaccination. This study sought to characterize the humoral immune response to anthrax toxin components, capsule and spore antigens in individuals (n = 46) from the Kayseri and Malatya regions of Turkey who had recovered from mild or severe forms of cutaneous anthrax infection, compared to regional healthy controls (n = 20). IgG antibodies to each toxin component, the poly-γ-D-glutamic acid capsule, the Bacillus collagen-like protein of anthracis (BclA) spore antigen, and the spore carbohydrate anthrose, were detected in the cases, with anthrax toxin neutralization and responses to Protective Antigen (PA) and Lethal Factor (LF) being higher following severe forms of the disease. Significant correlative relationships among responses to PA, LF, Edema Factor (EF) and capsule were observed among the cases. Though some regional control sera exhibited binding to a subset of the tested antigens, these samples did not neutralize anthrax toxins and lacked correlative relationships among antigen binding specificities observed in the cases. Comparison of serum binding to overlapping decapeptides covering the entire length of PA, LF and EF proteins in 26 cases compared to 8 regional controls revealed that anthrax toxin-neutralizing antibody responses elicited following natural cutaneous anthrax infection are directed to conformational epitopes. These studies support the concept of vaccination approaches that preserve conformational epitopes.

Introduction: Our goal was to characterize further variability in how providers both define a difficult intubation and apply a difficult tracheal intubation alert. Materiala and Methods: We developed a survey describing 26 different intubation scenarios encompassing a range of clinical complexity and equipment. Scenarios included multiple factors hypothesized to impact a provider’s definition of a difficult intubation and the threshold for a difficult intubation alert. Provider responses were then assessed for variability and agreement. The survey was distributed at 2 academic medical centers, 1 in Portland, ME (1 teaching hospital, 600 beds) and 1 in Philadelphia, PA (2 teaching hospitals, 1180 total beds). Electronic surveys were sent to anesthesia and emergency medicine providers (total N=617). Providers were asked to grade the difficulty of the scenario presented and whether they would activate the difficult intubation alert in the electronic health record. Responses were pooled and summarized as a frequency (%) and analyzed by provider type and institution. Results: Providers lacked agreement about scenarios that were very difficult or when an alert should be used. This variability was similar among provider types and institutions. Providers assessed scenarios as being more difficult and were more likely to apply an alert when videolaryngoscopy was not available. Conclusions: Substantial variability was demonstrated in providers’ definition of a difficult intubation and the threshold to activate a difficult intubation alert. This variability is consistent with related findings by other groups and represents a latent patient safety threat. The availability alone of videolaryngoscopy influences a provider’s definition of a difficult intubation, resulting in the grading of a scenario as less difficult. The associated risks may be mitigated by the delineation of specific criteria for difficult intubation designation and alert activation at the hospital or health system level.

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