Does DISE increase the success rate of surgery for obstructive sleep apnea in children? A systematic review of DISE directed treatment of children with OSAS.

OBJECTIVE: A systematic review of the evidence on the success of Drug-Induced Sleep Endoscopy (DISE) directed surgery in children with obstructive sleep apnea (OSA) defined as cure rate. DATA SOURCES: The PRISMA guidelines were followed and three databases (PubMed, Embase and Cochrane Library) were searched for studies on DISE directed surgery in children. ENDPOINTS: Pre- and post-surgical change in polysomnography (PSG); change in surgical target; side effects. REVIEW METHODS: Study quality was assessed using the modified Delphi technique quality appraisal tool for case series. Risk of bias was assessed using the Cochrane Collaboration's tool for assessing risk of bias. RESULTS: A total of 1805 studies were found. The most important reasons for exclusion were as follows: none-DISE studies, reports on adults, conflation of results on syndromic and healthy patients, no relevant outcome measurements. Five studies with a total of 376 patients (range: 26-126) were included. The surgeons changed the planned strategy in 50.4 % of patients according to the DISE findings. Comparison of pre- and post-surgical sleep monitoring revealed an average decrease in apnea-hypopnea index (AHI) of 11.1 and a treatment success (AHI < 5) and cure (AHI < 2) of 78 % and 53 %, respectively. The quality of the included studies was moderate especially due to small populations, designs without randomization or control groups, lack of analysis of drop outs, short follow-up, and considerable level of bias. CONCLUSION: DISE directed surgery has been shown to change the surgical approach when treating children with OSA. If this can be transferred into a better outcome compared to standard surgical treatment is unknown, due to the current poor level of evidence. To decide whether or not DISE should be included in the treatment of children with OSA, we suggest further data, preferably an RCT, to increase the level of evidence.

Neocortical Development in Brain of Young Children-A Stereological Study.

The early postnatal development of neuron and glia numbers is poorly documented in human brain. Therefore we estimated using design-based stereological methods the regional volumes of neocortex and the numbers of neocortical neurons and glial cells for 10 children (4 girls and 6 boys), ranging from neonate to 3 years of age. The 10 infants had a mean of 20.7 × 109 neocortical neurons (range 18.0-24.8 × 109) estimated with a coefficient of variation (CV) = 0.11; this range is similar to adult neuron numbers. The glia populations were 10.5 × 109 oligodendrocytes (range 5.0-16.0 × 109; CV = 0.40); 5.3 × 109 astrocytes (range 2.7-8.3 × 109, CV = 0.39); and 0.32 × 109 microglia (range 0.15-0.43 × 109, CV = 0.31). Thus, the estimated mean composite number of neocortical neuron and glial cells was 36.8 × 109 (range 26.8-48.3 × 109, CV = 0.21), of which approximately one-half were glial cells. There was a significant linear increase in oligodendrocyte and astrocyte numbers during the first 3 years of life, but no change in the total number of neurons. This is in line with our expectation that the total number of neocortical neurons is already determined in mid-fetal life.

Development of the Cell Population in the Brain White Matter of Young Children.

While brain gray matter is primarily associated with sensorimotor processing and cognition, white matter modulates the distribution of action potentials, coordinates communication between different brain regions, and acts as a relay for input/output signals. Previous studies have described morphological changes in gray and white matter during childhood and adolescence, which are consistent with cellular genesis and maturation, but corresponding events in infants are poorly documented. In the present study, we estimated the total number of cells (neurons, oligodendrocytes, astrocytes, and microglia) in the cerebral white matter of 9 infants aged 0-33 months, using design-based stereological methods to obtain quantitative data about brain development. There were linear increases with age in the numbers of oligodendrocytes (7-28 billion) and astrocytes (1.5-6.7 billion) during the first 3 years of life, thus attaining two-thirds of the corresponding numbers in adults. The numbers of neurons (0.7 billion) and microglia (0.2 billion) in the white matter did not increase during the first 3 years of life, but showed large biological variation.