MECHANICAL VENTILATION REQUIRING cannulation of the trachea is an integral part of the therapy provided to patients in the surgical critical care setting. In the 1950s and early 1960s, airway management consisted of a short period of translaryngeal intubation quickly converted to tracheostomy. In the late 1960s and 1970s the time of translaryngeal intubation before tracheostomy gradually increased with the development of improved endotracheal tube design and construction. This concept became the standard of care in critical care units,'-6 irrespective of the type of patient cared for. In the late 1970s and early 1980s Dane and King; El Naggar et a1.,8 and Stauffer et al.9 compared translaryngeal intubation with tracheostomy in critically ill patients. Outcome analyses centered solely on the complications of tracheostomy and risk of tracheal stenosis. These studies have frequently been cited to demonstrate the dangers of tracheostomy and the high incidence of morbidity and death as a result of the procedure and supported prolonged translaryngeal intubation to avoid tracheostomy until absolutely necessary. In several well-performed prospective studies,"-12 the controversy concerning perioperative morbidity and death and timing of tracheostomy after translaryngeal intubation were addressed. These reports demonstrated that morbidity and mortality rates of tracheostomy were low and translaryngeal intubation of less than 7 days was associated with a risk of transient laryngeal injury of less than 10%. Tracheostomy after 7 days of translaryngeal intubation had a significant incidence of irreversible laryngeal and tracheal stenosis. On the other hand, in a prospective,

To evaluate the morphological and neurological findings in sacral spine injuries, a retrospective study was conducted of all patients admitted to Erie County Medical Center over a 2-year period with the diagnosis of pelvic or sacral injury. Of these 253 patients, 44 were found to have sacral fractures and form the basis of this study. The type of fracture, neurological deficit, treatment, and outcome in these patients were analyzed. The patient population consisted of 25 males and 19 females, with a mean age of 34 years (range 15 to 80 years). The fractures were classified by the degree of involvement of the foramina and central canal. Fractures through the ala sacralis only (Zone I, 25 cases) or involving the foramina but not the central canal (Zone II, seven cases) were less likely to cause nerve injury (24% and 29%, respectively). Fractures involving the central canal (Zone III), both vertical (five cases) and transverse (seven cases), were more likely to cause neurological injury (60% and 57%, respectively). Neurological deficits in Zone I and II injuries were usually unilateral lumbar and sacral radiculopathies. Zone III deficits were usually bilateral and severe; bowel and/or bladder incontinence was present in six of the 12 patients in this group. Deficits generally improved with time; however, operative reduction and internal fixation may have been useful, particularly in patients with unilateral root symptoms. The treatment options are discussed, and previously published series of sacral fractures are reviewed. The authors conclude that the classification of sacral fractures described is useful in predicting the incidence and severity of neurological deficit.

Study Objectives: Although unattended ambulatory polysomnography (PSG) is frequently performed in adults, few studies have been performed in children. The objective of this study was to evaluate the feasibility of comprehensive, ambulatory PSG, including electroencephalography, in school-aged children in the home environment. Methods: A total of 201 children, born premature with birth weights of 500-1,250 grams, currently aged 5-12 years and living in Canada and Australia, underwent unattended ambulatory PSG. Results: PSG was initially technically satisfactory in 183 (91%) cases. Fourteen studies were satisfactory when repeated, resulting in an overall satisfactory rate of 197 (98%). Artifactfree signals were obtained for ≥ 75% of recording time in more than 92% of subjects, with the exception of nasal pressure, which was satisfactory for ≥ 75% of recording time in only 67% of subjects. However, thermistry signals were satisfactory for ≥ 75% of recording time in 92% of subjects, and some measure of airfl ow was present for ≥ 75% of recording time in 96% of subjects. Children slept very well, with a long total sleep time (534 ± 73 [mean ± SD] minutes), high sleep effi ciency (92% ± 5%), and low arousal index (9 ± 3/h). Parents and children reported a high rate of satisfaction with the study. Conclusions: This large, international study has shown that comprehensive, unattended, ambulatory PSG is feasible, technically adequate and well-tolerated in school-aged children when performed under research conditions. Further studies regarding the cost effi cacy of this approach, and generalizability of the fi ndings to a clinical population, are warranted. Keywords: polysomnography, sleep study, ambulatory, home, child Citation: Marcus CL, Traylor J, Biggs SN, Roberts RS, Nixon GM, Narang I, Bhattacharjee R, Davey MJ, Horne RS, Cheshire M, Gibbons KJ, Dix J, Asztalos E, Doyle LW, Opie GF, D'ilario J, Costantini L, Bradford R, Schmidt B. Feasibility of comprehensive, unattended ambulatory polysomnography in school-aged children. J Clin Sleep Med 2014;10(8):913-918.