High-dose pollen intralymphatic immunotherapy: Two RDBPC trials question the benefit of dose increase.

BACKGROUND: The same dosing schedule, 1000 SQ-U times three, with one-month intervals, have been evaluated in most trials of intralymphatic immunotherapy (ILIT) for the treatment of allergic rhinitis (AR). The present studies evaluated if a dose escalation in ILIT can enhance the clinical and immunological effects, without compromising safety. METHODS: Two randomized double-blind placebo-controlled trials of ILIT for grass pollen-induced AR were performed. The first included 29 patients that had recently ended 3 years of SCIT and the second contained 39 not previously vaccinated patients. An up-dosage of 1000-3000-10,000 (5000 + 5000 with 30 minutes apart) SQ-U with 1 month in between was evaluated. RESULTS: Doses up to 10,000 SQ-U were safe after recent SCIT. The combined symptom-medication scores (CSMS) were reduced by 31% and the grass-specific IgG4 levels in blood were doubled. In ILIT de novo, the two first patients that received active treatment developed serious adverse reactions at 5000 SQ-U. A modified up-dosing schedule; 1000-3000-3000 SQ-U appeared to be safe but failed to improve the CSMS. Flow cytometry analyses showed increased activation of lymph node-derived dendritic but not T cells. Quality of life and nasal provocation response did not improve in any study. CONCLUSION: Intralymphatic immunotherapy in high doses after SCIT appears to further reduce grass pollen-induced seasonal symptoms and may be considered as an add-on treatment for patients that do not reach full symptom control after SCIT. Up-dosing schedules de novo with three monthly injections that exceeds 3000 SQ-U should be avoided.

Parental poverty and occupation as risk factors for pediatric sleep-disordered breathing.

OBJECTIVES/BACKGROUND: Previous studies have found associations between pediatric sleep-disordered breathing (SDB) and socioeconomic status (SES), as well as a neighborhood-related disadvantage. This study analyzes the association among familial SES, parental occupation, and SDB in Swedish offspring. METHODS: A nationwide dataset was constructed by linking Swedish census data to hospital discharge register data on all first hospitalizations of children and adolescents aged 0-18 years during the study period 1997-2007. The outcome was SDB, defined as diagnostic codes for obstructive sleep apnea (OSA), adenotonsillar hypertrophy, or tonsillar hypertrophy. Familial SES was defined as family income and maternal education. The odds ratio (OR) was calculated with a 95% confidence interval (CI). RESULTS: 34,933 of three million children had a first hospital diagnosis of SDB. The OR was significantly increased in offspring in families with a low income (1.79) and maternal education (1.21). Significantly increased ORs were found in 14 of 38 maternal (37%) and 13 of 48 paternal (27%) occupations, and six of them involved both parents: drivers, welders, and workers in mechanics and iron metalware, chemical processing, and manufacture of food and glass. A significantly decreased OR was found in 12 (25%) of the paternal occupations, e.g., scientists, physicians, teachers, artists, administrators, and farmers, as well as in maternal occupations, such as artists and farmers, with offspring aged 0-6 years. CONCLUSION: This study indicates that low familial SES and parental occupations associated with a low educational level increased, whereas academic parental occupations and farmers decreased the risk of SDB in offspring.

Familial risk of sleep-disordered breathing.

OBJECTIVE: To estimate the incidence of hospitalization for paediatric obstructive sleep apnoea syndrome (OSAS) or sleep-disordered breathing (SDB) caused by adenotonsillar or tonsillar hypertrophy without infection in children with a parent affected by OSAS. PATIENTS AND METHODS: Using the MigMed database at Lund University, hospital data on all children aged 0-18 years in Sweden between 1997 and 2007 (total of 3 million individuals) were used to identify all first hospital admissions for OSAS or either adenotonsillar or tonsillar hypertrophy. Next, individuals were categorized as either having or not having a parent affected by OSAS. Standardized incidence ratios (SIRs) with 95% confidence intervals (CIs) were estimated for boys and girls with a parent affected by OSAS. Children with OSAS or adenotonsillar or tonsillar hypertrophy without a parent affected by OSAS acted as the reference group (SIR=1). RESULTS: After accounting for socio-economic status, age, and geographic region, the SIRs of OSAS in boys and girls with a parent affected by OSAS were 3.09 (95% CI 1.83-4.90) and 4.46 (95% CI 2.68-6.98), respectively. The SIRs of adenotonsillar or tonsillar hypertrophy in boys and girls with a parent affected by OSAS were 1.82 (95% CI 1.54-2.14) and 1.56 (95% CI 1.30-1.87), respectively. CONCLUSION: This study indicates familial clustering of sleep-disordered breathing, which is important information for clinicians.

Pharyngeal disturbances in OSAS patients before and 1 year after UPPP.

CONCLUSIONS: The results indicate that conservative uvulopalatopharyngoplasty with tonsillectomy (UPPP) did not change the degree of pharyngeal disturbances in patients with obstructive sleep apnea syndrome (OSAS). OBJECTIVES: To investigate if the symptom scores of pharyngeal disturbances in OSAS patients were changed 1 year after UPPP, by using a questionnaire pre- and postoperatively, and to compare with healthy non-snoring controls. METHODS: Fifty men and eight women, median age 46 years (range 25-75), median body mass index (BMI) 28 kg/m2 (20-38), and median preoperative oxygen desaturation index 16 (7-100) were included as they had all failed non-surgical treatment and wanted pharyngeal surgery. The questionnaire consisted of 10 questions with 4 degrees of disturbances; the maximum score was 30 and was evaluated before and 1 year after surgery. Fifteen age-, gender- and BMI-matched controls responded to the same questionnaire. RESULTS: Responses to the questionnaire were provided pre- and postoperatively by 47 of 58 patients (81%). Their median score was unchanged from 5 (range 0-17) to 5 (0-19), compared with controls 1 (0-3). Analyses of separate questions showed a significant decrease in the score for 'globus sensation' and 'swelling' postoperatively.

Uvulopalatopharyngoplasty in 158 OSAS patients failing non-surgical treatment.

CONCLUSIONS: Uvulopalatopharyngoplasty (UPPP) in patients with obstructive sleep apnoea syndrome (OSAS) who had failed treatment with continuous positive airway pressure (CPAP) and mandibular retaining device (MRD) was effective and safe. The satisfaction rate was high. We recommend UPPP in selected OSAS patients, especially younger patients. OBJECTIVES: To evaluate the efficacy and complication rate of UPPP. PATIENTS AND METHODS: This was a non-randomized prospective study of 139 men and 19 women, median age 45 years (range 20-75), median body mass index (BMI) 29 (range 20-48), who underwent UPPP. One year follow-up comprised ambulant sleep apnoea recordings and questionnaires with the Epworth Sleepiness Scale (ESS). RESULTS: In all, 76% of the patients underwent sleep recordings preoperatively and postoperatively. The oxygen desaturation index (ODI(4)) decreased from median 23 (range 6-100) to 8 (range 0-60), p<0.001. Criteria of success (>50% reduction and ODI<20), was 64%. The ESS value decreased from median 12 (range 0-21) to 6 (0-22), p<0.001. In all, 88% of the patients were satisfied. Four of 158 patients (2.5%) had serious postoperative complications. There was neither sequel of complications nor mortality.