Dennis Rosen

Background:Increased periodic limb movements of sleep (PLMS), >5/hour, present in 1.2-7.7% of healthy children, are associated with hypertension, attention deficit, and hyperactivity. This study so...

Introduction Children with Down syndrome (DS) have a high incidence of obstructive sleep apnea (OSA) that is often associated with hypoventilation. Little is known, however, about the prevalence of sleep-associated hypoventilation independent of OSA in these children. Methods Retrospective chart review of all children with DS under 18 years of age undergoing polysomnography at a tertiary care paediatric hospital during a 2-year period. Exclusion criteria were as follow: those requiring oxygen or positive-pressure ventilation; with tracheostomy, baseline hypoxia, unrepaired cyanotic heart disease, pulmonary hypertension, and cerebral palsy; or OSA with >5 obstructions/hour. Results 86 children met inclusion criteria. 68 (79%) had ETCO₂values >50 mm Hg during sleep. 37 (43%) ranged 50–55 mm Hg, and 12 (14%) met American Academy of Sleep Medicine criteria for hypoventilation of ETCO₂ >50 mm Hg for >25% of total sleep time (TST). Average pulse-oximetry saturation (SpO₂) values during sleep were 97.8% (SD ±1; range: 95.1–99.9). Average percentage of TST with SpO₂ >92% was 99.89%. Conclusion Mildly elevated ETCO₂ in the absence of OSA is common in children with DS. This may reflect underlying differences in autonomic control of ventilation in these children and may be considered a normal variant not necessitating intervention other than close monitoring for pulmonary hypertension.

Jessica and Fred Leavitt's book, Improving Medical Outcomes, is an ambitious and far-reaching effort to suggest ways of delivering better health outcomes in a wide variety of areas. Its focus is mostly on lower-level grassroots interventions—those that can be implemented by individual physicians and patients. It does not, for the most part, examine ways in which fundamentally redesigning the health care system as a whole, or some of the frameworks such as health networks or hospitals in which medical care is provided in this country, might lead to added value on a much larger scale.

The shooting of President James Garfield 4 months after his inauguration on July 2, 1881, was a grievous blow to a nation still recovering from the Civil War and the trauma of President Lincoln's assassination only 16 years earlier. Garfield was struck by 2 bullets fired at close range as he was preparing to board a train for Williams College, one injuring his right arm, the other piercing his right flank and coming to rest behind his pancreas. He died 11 weeks later of complications from his injuries.

Murray & Nadel's Textbook of Respiratory Medicine attempts to cover the natural course of disease progression across the life span and embodies the collective knowledge of hundreds of leaders in the field—knowledge of pediatric and adult practice that is in turn based on the work of additional thousands. Now in its fifth edition, comprising 95 chapters and 2400 pages replete with charts, diagrams, tables, illustrations, and photographs, the book provides a truly encyclopedic overview of pulmonary medicine. The information is presented in a user-friendly and easy-to-read format, and each of the chapters concludes with a summary of key points for easy reference.

Obstructive sleep apnea (OSA) is very common in children with Down syndrome and other craniofacial abnormalities and causes significant deleterious physical, developmental, and behavioral outcomes. OSA in these individuals is generally more difficult to treat than in other children, because of increased postoperative complications and lower success rates for adenotonsillectomy, the mainstay of treatment for otherwise healthy children with OSA. There is a growing number of treatment options for these children, which can provide an alternative to continuous positive airway pressure or tracheostomy. Through the use of dynamic cine MRI studies, the level of obstruction can be identified and treatment made more focused. Screening for OSA in this population should be increased, and utilization made of the recent advances in imaging and surgical technique to treat it.