The Art of Dosing for Subcutaneous Immunotherapy in North America

Subcutaneous immunotherapy (SCIT) is a long-established treatment option for allergic rhinoconjunctivitis. Proper dosing of the allergens is critical for the efficacy and safety of SCIT. Of the hundreds of liquid allergen extracts in the United States, effective and well-tolerated SCIT dosing has only been established for a small number. Thus, SCIT dosing remains largely empiric and continues to be, by necessity, an art. To highlight the complexity of SCIT dosing, this review summarizes the historical and current landscape of U.S. allergen extracts, differences among U.S. and European allergen extracts, allergen selection for SCIT, considerations for compounding of allergen extract mixtures, and recommended dosing. As of 2021, 18 standardized allergen extracts are available in the United States; all other extracts remain unstandardized without characterization of allergen content or potency. U.S. allergen extracts differ from European extracts in formulation and potency characterization. There is no standardized methodology for SCIT allergen selection, and interpretation of allergen sensitization is not straightforward. Compounding of SCIT mixtures requires consideration of potential dilution effects, allergen cross-reactivity, proteolytic activity, and additives. Probable effective dose ranges for SCIT are recommended in U.S. allergy immunotherapy practice parameters, although there are few studies using U.S. extracts supporting these doses as therapeutic. In contrast, optimized doses of sublingual immunotherapy tablets have been confirmed in North American phase 3 trials. The SCIT dosing for each patient remains an art that requires clinical experience and consideration of polysensitization, tolerability, compounding of allergen extract mixtures, and the range of recommended doses within the context of extract potency variability.

Gases in ice cores

Air trapped in glacial ice offers a means of reconstructing variations in the concentrations of atmospheric gases over time scales ranging from anthropogenic (last 200 yr) to glacial/interglacial (hundreds of thousands of years). In this paper, we review the glaciological processes by which air is trapped in the ice and discuss processes that fractionate gases in ice cores relative to the contemporaneous atmosphere. We then summarize concentration-time records for CO2 and CH4 over the last 200 yr. Finally, we summarize concentration-time records for CO2 and CH4 during the last two glacial-interglacial cycles, and their relation to records of global climate change.

Rapid Variations in Atmospheric Methane Concentration During the Past 110,000 Years

A methane record from the GISP2 ice core reveals that millennial-scale variations in atmospheric methane concentration characterized much of the past 110,00 years. As previously observed in a shorter record from central Greenland, abrupt concentration shifts of about 50 to 300 parts per billion by volume were coeval with most of the interstadial warming events (better known as Dansgaard-Oeschger events) recorded in the GISP2 ice core throughout the last glacial period. The magnitude of the rapid concentration shifts varied on a longer time scale in a manner consistent with variations in Northern Hemisphere summer insolation, which suggests that insolation may have modulated the effects of interstadial climate change on the terrestrial biosphere.

Climate Records Covering the Last Deglaciation

The oxygen-18/oxygen-16 ratio of molecular oxygen trapped in ice cores provides a time-stratigraphic marker for transferring the absolute chronology for the Greenland Ice Sheet Project (GISP) II ice core to the Vostok and Byrd ice cores in Antarctica. Comparison of the climate records from these cores suggests that, near the beginning of the last deglaciation, warming in Antarctica began approximately 3000 years before the onset of the warm Bølling period in Greenland. Atmospheric carbon dioxide and methane concentrations began to rise 2000 to 3000 years before the warming began in Greenland and must have contributed to deglaciation and warming of temperate and boreal regions in the Northern Hemisphere.

Gravitational Separation of Gases and Isotopes in Polar Ice Caps

Atmospheric gases trapped in polar ice at the firn to ice transition layer are enriched in heavy isotopes (nitrogen-15 and oxygen-18) and in heavy gases (O(2)/N(2) and Ar/N(2) ratios) relative to the free atmosphere. The maximum enrichments observed follow patterns predicted for gravitational equilibrium at the base of the firn layer, as calculated from the depth to the transition layer and the temperature in the firn. Gas ratios exhibit both positive and negative enrichments relative to air: the negative enrichments of heavy gases are consistent with observed artifacts of vacuum stripping of gases from fractured ice and with the relative values of molecular diameters that govern capillary transport. These two models for isotopic and elemental fractionation provide a basis for understanding the initial enrichments of carbon-13 and oxygen-18 in trapped CO(2), CH(4), and O(2) in ice cores, which must be known in order to decipher ancient atmospheric isotopic ratios.