Summary Background Single nucleotide polymorphisms in the vitamin K epoxide reductase (VKOR) gene have been successfully used for warfarin dosage prediction. However, warfarin resistance studies of naturally occurring VKOR mutants do not correlate with their clinical phenotype. This discrepancy presumably arises because the in vitro VKOR activity assay is performed under artificial conditions using the non-physiological reductant dithiothreitol. Objectives The aim of this study is to establish an in vivo VKOR activity assay in mammalian cells(HEK293) where VKOR functions in its native milieu without interference from endogenous enzymes. Methods Endogenous VKOR activity in HEK293 cells was knocked out by transcription activator-like effector nucleases (TALENs)-mediated genome editing. Results and Conclusions Knockout of VKOR in HEK293 cells significantly decreased vitamin K-dependent carboxylation with vitamin K epoxide(KO) as substrate. However, the paralog of VKOR, VKORC1L1, also exhibits substantial ability to convert KO to vitamin K for carboxylation. Using both VKOR and VKORC1L1 knockout cells, we examined the enzymatic activity and warfarin resistance of ten naturally occurring VKOR mutants that were reported previously to have no activity in an in vitro assay. All ten mutants are fully active, five have increased warfarin resistance with the order being W59R>L128R≈W59L>N77S≈S52L. Except for the L128R mutant, this order is consistent with the clinical anticoagulant dosages. The other five VKOR mutants do not change VKOR’s warfarin sensitivity, suggesting that factors other than VKOR play important roles. In addition, we confirmed that the conserved loop cysteines in VKOR are not required for active site regeneration after each cycle of oxidation.

Background In the 5 years that have passed since the publication of the 2018 International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis (ICAR‐Allergic Rhinitis 2018), the literature has expanded substantially. The ICAR‐Allergic Rhinitis 2023 update presents 144 individual topics on allergic rhinitis (AR), expanded by over 40 topics from the 2018 document. Originally presented topics from 2018 have also been reviewed and updated. The executive summary highlights key evidence‐based findings and recommendation from the full document. Methods ICAR‐Allergic Rhinitis 2023 employed established evidence‐based review with recommendation (EBRR) methodology to individually evaluate each topic. Stepwise iterative peer review and consensus was performed for each topic. The final document was then collated and includes the results of this work. Results ICAR‐Allergic Rhinitis 2023 includes 10 major content areas and 144 individual topics related to AR. For a substantial proportion of topics included, an aggregate grade of evidence is presented, which is determined by collating the levels of evidence for each available study identified in the literature. For topics in which a diagnostic or therapeutic intervention is considered, a recommendation summary is presented, which considers the aggregate grade of evidence, benefit, harm, and cost. Conclusion The ICAR‐Allergic Rhinitis 2023 update provides a comprehensive evaluation of AR and the currently available evidence. It is this evidence that contributes to our current knowledge base and recommendations for patient evaluation and treatment.

Objectives: We aimed to assess the role of spirometry measures and Dyspnea Index (DI) in response to treatment of subglottic stenosis (SGS) and ability to predict need for surgery. We also assessed correlations between spirometry measures, DI, and physical SGS parameters. Methods: Thirty-seven adult female SGS patients were prospectively enrolled. Spirometry data and DI were obtained at serial clinic visits; physical SGS parameters were obtained intraoperatively. PIFR, PEFR, EDI, FEV1/FVC, and DI were compared preoperatively to postoperatively for patients who underwent operative intervention. Spirometry data, DI, and physical SGS parameters were analyzed for correlations, and receiver operating characteristic (ROC) curves were created for spirometry measures and DI to determine optimal cutoffs for recommending surgery. Results: Means of all measured spirometry measures changed significantly from preoperative to postoperative visits (P < .05). Mean DIs changed significantly between preoperative (27.5, n = 13, SD = 8.6) and postoperative visits (8.6, n = 13, SD = 5.5, P < 5 × 10-5). All Pearson correlations were negligible to moderate. The area under the curve (AUC) for peak inspiratory flow rate (PIFR) was 0.903 (95% CI, 0.832-0.974) with cutoff at 2.10 L/s; the AUC for DI was 0.874 (95% CI, 0.791-0.956) with cutoff between 22-25; the AUC for peak expiratory flow rate (PEFR) was 0.806 (95% CI, 0.702-0.910) with cutoff at 2.5 L/s; all other ROC curves were less than good. Conclusion: PIFR, PEFR, EDI, FEV1/FVC, and DIs significantly improve after treatment for SGS. No strong correlations exist between spirometry measures, DI, and physical SGS parameters. PIFR was the most sensitive and specific for predicting timing of operative intervention in our cohort.

Objectives: To determine whether subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) better improves patient outcomes and quality of life for adults with allergic rhinitis or rhinoconjunctivitis (AR/C) with or without mild to moderate asthma.Methods: Systematic review methodology was based on the Cochrane Collaboration handbook and Preferred Reporting Items for Systematic Reviews and Meta-analyses. Four databases (PubMed, Cochrane Library, EMBASE, and Web of Science) were queried from inception to July 30, 2020. Two independent reviewers screened potentially relevant studies and assessed risk of bias. Outcomes of interest were symptom score (SS), medication score (MS), combined symptom medication score (CSMS), and Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ). Meta-analyses with an adjusted indirect comparison were conducted in RevMan 5.4.1.Results: Seven SCIT versus SLIT randomized controlled trials (RCTs) demonstrated no significant differences for any outcomes, but insufficient data precluded direct meta-analysis. For the adjusted indirect comparison, 46 RCTs over 39 studies were included for SCIT versus placebo (n = 13) and SLIT versus placebo (n = 33). Statistically significant results favoring SCIT were found for SS (standardized mean difference [SMD] = 0.40; 95% confidence interval [CI] = 0.31-0.49), MS (SMD = 0.26; 95% CI = 0.14-0.39), CSMS (SMD = 0.42; 95% CI = 0.17-0.67), and RQLQ (MD = 0.24; 95% CI = 0.04-0.44). Statistically significant results favoring SLIT were found for SS (SMD = 0.42; 95% CI = 0.32-0.53), MS (SMD = 0.40; 95% CI = 0.28-0.53), CSMS (SMD = 0.37; 95% CI = 0.29-0.45), and RQLQ (MD = 0.32; 95% CI = 0.20-0.43). No significant differences were found between SCIT and SLIT for SS (SMD = À0.02; 95% CI = À0.15 to 0.11), MS (SMD = À0.14; 95% CI = À0.31 to 0.03), CSMS (SMD = 0.05; 95% CI = À0.21 to 0.31), or RQLQ (MD = À0.08; 95% CI = À0.31 to 0.15).Conclusion: SCIT and SLIT are comparably effective treatments for adults with AR/C. More RCTs analyzing SCIT versus SLIT are needed to directly compare the two.