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.

The effect of renal denervation on arterial stiffness, central blood pressure and heart rate variability in treatment resistant essential hypertension: a substudy of a randomized sham-controlled double-blinded trial (the ReSET trial).

OBJECTIVES: To investigate, whether renal denervation (RDN) improves arterial stiffness, central blood pressure (C-BP) and heart rate variability (HRV) in patients with treatment resistant hypertension. METHODS: ReSET was a randomized, sham-controlled, double-blinded trial (NCT01459900). RDN was performed by a single experienced operator using the Medtronic unipolar Symplicity FlexTM catheter. C-BP, carotid-femoral pulse wave velocity (PWV), and HRV were obtained at baseline and after six months with the SphygmoCor®-device. RESULTS: Fifty-three patients (77% of the ReSET-cohort) were included in this substudy. The groups were similar at baseline (SHAM/RDN): n = 27/n = 26; 78/65% males; age 59 ± 9/54 ± 8 years (mean ± SD); systolic brachial BP 158 ± 18/154 ± 17 mmHg; systolic 24-hour ambulatory BP 153 ± 14/151 ± 13 mmHg. Changes in PWV (0.1 ± 1.9 (SHAM) vs. -0.6 ± 1.3 (RDN) m/s), systolic C-BP (-2 ± 17 (SHAM) vs. -8 ± 16 (RDN) mmHg), diastolic C-BP (-2 ± 9 (SHAM) vs. -5 ± 9 (RDN) mmHg), and augmentation index (0.7 ± 7.0 (SHAM) vs. 1.0 ± 7.4 (RDN) %) were not significantly different after six months. Changes in HRV-parameters were also not significantly different. Baseline HRV or PWV did not predict BP-response after RDN. CONCLUSIONS: In a sham-controlled setting, there were no significant effects of RDN on arterial stiffness, C-BP and HRV. Thus, the idea of BP-independent effects of RDN on large arteries and cardiac autonomic activity is not supported.

Comparison of clinical practice of tonsil surgery from quality register data from Sweden and Norway and one clinic in Denmark.

OBJECTIVES: To compare the application of indications, demographics, surgical and haemostatic techniques in tonsil surgery in three countries. DESIGN: Non-randomised, prospective, observational cohort. SETTING: All patients registered in the National Tonsil Surgery Quality Registers in Sweden, Norway and West Jutland, Denmark. PARTICIPANTS: Data were retrieved from 2017 to 2019; registered surgeries: Sweden: 20 833; Norway: 10 294 and West Jutland, Denmark: 505. RESULTS: Tonsil surgery for obstruction was twice as common in Sweden (62.2%) compared with Norway (31%) and Denmark (27.7%). Recurrent tonsillitis was registered twice as frequently in Norway (35.7%) and Denmark (39%) compared with Sweden (16.7%). Chronic tonsillitis was registered more frequently in Norway (29.8%) than in Sweden (13.8%) and Denmark (12.7%). Day surgery (>76%) was comparable. The higher frequency of obstruction in Sweden affected age and gender distributions: Sweden (7 years, 50.4% boys), Norway (17 y, 42.1%) and Denmark (19 y, 38.4%). For obstructive disorders, tonsillotomy with adenoidectomy was used in a majority of Swedish children (72%), whereas tonsillectomy with or without adenoidectomy dominated in Norway (53.5%) and Denmark (57.9%). Cold steel was the technique of choice for tonsillectomy in all three countries. For tonsillotomy, hot dissection techniques dominated in all countries. Disparities were observed with regard to haemostatic techniques. Bipolar diathermy was commonly used in all countries. Monopolar diathermy was practically only used in Sweden. Infiltration with epinephrine in the tonsillar bed was registered in Sweden and Norway but not at all in Denmark. Combined cold surgical and cold haemostatic techniques were more commonly used in Sweden (22.7%) than in Norway (10.4%) and Denmark (6.2%). CONCLUSIONS: This study demonstrates disparities among the Nordic countries in tonsil surgery in terms of indications plus surgical and haemostatic techniques. Increased coverage and further monitoring of outcomes is needed to identify best practices and ideal guidelines for improved care.

Feasibility of conducting type III home sleep apnoea test in children.

OBJECTIVES: To test the feasibility of conducting unattended paediatric type III HSAT and to identify issues for improvements to optimize signal quality. MATERIAL AND METHODS: Parents were instructed in setting up the unattended HSAT and reported their experiences. Signal quality and causes of signal failure of recordings were assessed. RESULTS: Forty children were included. Mean age was 5.2 years. Predefined success criteria were met in 53% of recordings. Main causes of signal failure were nasal cannula, pulse-oximetry and battery failure. Sensor fixation techniques were developed and implemented during the study and hence signal quality improved. Seventeen (94%) parents reported HSAT to be either easy or medium hard to use.Conclusions and significance: Unattended paediatric type III HSAT can be conducted at home with acceptable signal quality. Signal quality improved considerably using simple sensor fixation techniques.

The first experiences of implementation of the Swedish tonsil register in Denmark.

Background: Tonsil surgery is a daily procedure at Ear, Nose and Throat (ENT) departments as well as ENT practices. Despite national tonsil guidelines in Denmark, no national survey has been introduced.Objectives: To display the process of implementing a Danish version of the Swedish tonsil register including a presentation and validation of the first year's results.Methods: The Swedish tonsil register was translated into Danish. Minor modifications were executed and the register was implemented at the ENT department, Region Hospital West Jutland, Denmark. All patients undergoing surgery due to benign tonsil and/or adenoid diseases were eligible. Written informed consent was obtained. Indication for surgery, comorbidity, surgical and haemostasis techniques, and complications were registered by the surgeon.Results: Several obstacles were encountered due to legal procedures, daily work, IT organisation, and discontinuous information. 58% of eligible patients were registered. The incidence of post-tonsillectomy haemorrhage requiring secondary surgery was 6.4%. The potential underlying risk factors were easily retrieved from the register.Conclusions and significance: The Danish version of the national Swedish tonsil database is a useful, easily accessible, and informative tool for monitoring and validation of tonsil/adenoid surgery. We recommend a nationwide register with a central steering committee.

Hospital-based versus community-based shared care cardiac rehabilitation after acute coronary syndrome: protocol for a randomized clinical trial.

INTRODUCTION: Participation in cardiac rehabilitation (CR) is poor although CR reduces morbidity and mortality. One way in which attendance may potentially be improved is by involving municipal health-care centres (MHCC) and the patient's general practitioner (GP) to a larger degree in a model of shared care cardiac rehabilitation (SC-CR). Our study tests the feasibility of SC-CR and compares the attendance and effects of SC-CR with the individually tailored hospital-based CR (H-CR) programme. MATERIAL AND METHODS: After admission for acute coronary syndrome (ACS) patients are randomized to phase II CR which is conducted either as SC-CR or H-CR. During SC-CR the patient is seen once in-hospital after which the GP takes over. MHCC supports the GP by offering educational intervention regarding smoking cessation, exercise, nutrition and mental health. A total of 208 persons hospitalised due to acute coronary syndrome are to be randomized before hospital discharge. CONCLUSION: The study aims to examine whether the organisation of SC-CR is feasible and provides the expected benefits. FUNDING: The trial is funded by Region Central Denmark. TRIAL REGISTRATION: Clinical Trials ID: NTC 01522001.