J Trauma Acute Care Surg Volume 75, Number 5
Letters to the Editor
Strasbourg Federation of Translational Medicine (FMTS) Institute of Physiology Strasbourg, France
Denis Chemla, MD, PhD Department of Physiology University of Paris-Sud Biceˆtre Hospital Le Kremlin-Biceˆtre, France
Loren0o Xavier, MD Division of Anesthesiology and Resuscitation University Hospitals of Strasbourg Department of Anesthesiology and Surgical Resuscitation Hoˆpital de Hautepierre Strasbourg, France
Ngai Liu, MD, PhD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France Research Outcomes Consortium Cleveland, Ohio
Thierry Chazot, MD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France
Jacques Marescaux, MD, PhD University Hospitals of Strasbourg New Civil Hospital Department of General and Endocrine Surgery IRCAD (Research Institute against Digestive Cancer) EITS (European Institute of Telesurgery) University of Strasbourg Strasbourg, France
Marc Fischler, MD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France
Pierre Diemunsch, MD, PhD Division of Anesthesiology and Resuscitation University Hospitals of Strasbourg; IRCAD/EITS Strasbourg Federation of Translational Medicine Institute of Physiology University of Strasbourg Strasbourg, France
Jacques Duranteau, MD, PhD Department of Anesthesiology and Resuscitation University of Paris-Sud Biceˆtre Hospital Le Kremlin-Biceˆtre, France
REFERENCES 1. Pottecher J, Chemla D, Xavier L, Liu N, Chazot T, Marescaux J, Fischler M, Diemunsch P, Duranteau J. The pulse pressure/heart rate ratio as a marker of stroke volume changes during hemorrhagic shock and resuscitation in
922
anesthetized swine. J Trauma Acute Care Surg. 2013;74(6):1438Y1445. 2. Devlin JJ, Kircher SJ, Littlejohn LF. Swine models of hemorrhagic shock: to splenectomize or not to splenectomize, that is the question. J Trauma. 2009;67(4):895Y896. 3. Wade CE, Hannon JP. Confounding factors in the hemorrhage of conscious swine: a retrospective study of physical restraint, splenectomy, and hyperthermia. Circ Shock. 1988;24(3):175Y182. 4. Stewart IB, McKenzie DC. The human spleen during physiological stress. Sports Med. 2002; 32(6):361Y369. 5. Tiniakov R, Scrogin KE. The spleen is required for 5-HT1A receptor agonist-mediated increases in mean circulatory filling pressure during hemorrhagic shock in the rat. Am J Physiol Regul Integr Comp Physiol. 2009;296(5): R1392YR1401.
Reducing pediatric firearm injury must start with stronger gun regulations To the Editor: hank you Lee et al. for shedding light on the association between statewide firearm regulations and pediatric morbidity. In a time when so many states are reexamining their gun laws, research of this kind is invaluable. The authors conclude that ‘‘pediatric firearm injury is a complex problem with many diverse causes that go beyond gun control laws.’’ However, their research helps support the notion that stronger gun regulations are a critical starting point in reducing child gun death. The study characterizes gun assault patients as primarily black male teens from poor urban neighborhoods. These young people often live in environments that are saturated with illegally trafficked guns. Before landing in the hands of a teenager, the guns may be sold by a corrupt or negligent gun dealer, bought by a ‘‘straw purchaser’’ who buys the gun for someone who would not pass a background check, bought without a background check at a gun show or online, or trafficked from states with lax laws into states with stronger gun laws. Physicians working in gun safety advocacy often focus on regulations that concern the gun owner and the homeVthat is, the end point of a gun’s travels. Effective advocacy would also address the so-called iron pipeline of gun trafficking that floods our patients’ neighborhoods with illegal guns. This would surely lead to a reduction in pediatric gun death.
T
*The author declares no conflicts of interest.
Nancy Dodson, MD, MPH Boston Children’s Hospital Boston, MA
‘‘Firing’’ the stapler in emergency general surgery patients: Not so fast! To the Editor: e read with great interest the article by Farrah et al.1 entitled ‘‘Stapled versus hand-sewn anastomoses in emergency general surgery: A retrospective review of outcomes in a unique patient population.’’ The authors concluded that stapled (ST) technique was an independent risk factor for anastomotic failure compared with hand-sewn (HS) technique in emergency general surgery (EGS) patients. While we congratulate the authors for investigating this important topic, we are concerned that the findings are marred by confounding and that the conclusion overreaches what the data allow. It seems that the multivariate logistic regression analysis (LRA) performed in this study included only three variables (technique, age, and admission albumin). Given this, it is likely that the reported effect size of technique (ST vs. HS) is influenced by confounding variables and may be overinflated or underappreciated as a result. In bivariate analysis, multiple other variables demonstrated a statistically significant effect on anastomotic failure and should have been included in the LRA. These variables included intraoperative hypothermia, steroid use, and whether the anastomosis was performed at the first operation. The concern the authors raise for overfitting is unwarranted given the small sample size and because a predictive model was not being developed. These known associations may account for some or even all of the magnitude of the effect noted in the technique variable in the LRA. For example, if the stapled anastomoses that failed were all in hypothermic patients, the effect attributed to stapling technique may truly be caused by hypothermia. While we recognize that all possible associations cannot be feasibly collected and included in an analysis of this type, we disagree that the three variables used adequately allowed for a valid multivariate model. The article states that the EGS service was staffed by seven different general surgeons, and this may represent the single largest variable driving differences in the decision to perform an HS versus an ST anastomosis. Much of the confounding in question may be captured by controlling for physician within a new statistical model. There is likely a select group of surgeons, possibly more experienced, who preferentially perform the HS technique. Outcome differences may be related to which surgeon did the operation.
W
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Letters to the Editor
Strasbourg Federation of Translational Medicine (FMTS) Institute of Physiology Strasbourg, France
Denis Chemla, MD, PhD Department of Physiology University of Paris-Sud Biceˆtre Hospital Le Kremlin-Biceˆtre, France
Loren0o Xavier, MD Division of Anesthesiology and Resuscitation University Hospitals of Strasbourg Department of Anesthesiology and Surgical Resuscitation Hoˆpital de Hautepierre Strasbourg, France
Ngai Liu, MD, PhD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France Research Outcomes Consortium Cleveland, Ohio
Thierry Chazot, MD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France
Jacques Marescaux, MD, PhD University Hospitals of Strasbourg New Civil Hospital Department of General and Endocrine Surgery IRCAD (Research Institute against Digestive Cancer) EITS (European Institute of Telesurgery) University of Strasbourg Strasbourg, France
Marc Fischler, MD Hoˆpital Foch Department of Anesthesiology Suresnes, France Faculty of Medicine Paris Descartes University V Paris, France
Pierre Diemunsch, MD, PhD Division of Anesthesiology and Resuscitation University Hospitals of Strasbourg; IRCAD/EITS Strasbourg Federation of Translational Medicine Institute of Physiology University of Strasbourg Strasbourg, France
Jacques Duranteau, MD, PhD Department of Anesthesiology and Resuscitation University of Paris-Sud Biceˆtre Hospital Le Kremlin-Biceˆtre, France
REFERENCES 1. Pottecher J, Chemla D, Xavier L, Liu N, Chazot T, Marescaux J, Fischler M, Diemunsch P, Duranteau J. The pulse pressure/heart rate ratio as a marker of stroke volume changes during hemorrhagic shock and resuscitation in
922
anesthetized swine. J Trauma Acute Care Surg. 2013;74(6):1438Y1445. 2. Devlin JJ, Kircher SJ, Littlejohn LF. Swine models of hemorrhagic shock: to splenectomize or not to splenectomize, that is the question. J Trauma. 2009;67(4):895Y896. 3. Wade CE, Hannon JP. Confounding factors in the hemorrhage of conscious swine: a retrospective study of physical restraint, splenectomy, and hyperthermia. Circ Shock. 1988;24(3):175Y182. 4. Stewart IB, McKenzie DC. The human spleen during physiological stress. Sports Med. 2002; 32(6):361Y369. 5. Tiniakov R, Scrogin KE. The spleen is required for 5-HT1A receptor agonist-mediated increases in mean circulatory filling pressure during hemorrhagic shock in the rat. Am J Physiol Regul Integr Comp Physiol. 2009;296(5): R1392YR1401.
Reducing pediatric firearm injury must start with stronger gun regulations To the Editor: hank you Lee et al. for shedding light on the association between statewide firearm regulations and pediatric morbidity. In a time when so many states are reexamining their gun laws, research of this kind is invaluable. The authors conclude that ‘‘pediatric firearm injury is a complex problem with many diverse causes that go beyond gun control laws.’’ However, their research helps support the notion that stronger gun regulations are a critical starting point in reducing child gun death. The study characterizes gun assault patients as primarily black male teens from poor urban neighborhoods. These young people often live in environments that are saturated with illegally trafficked guns. Before landing in the hands of a teenager, the guns may be sold by a corrupt or negligent gun dealer, bought by a ‘‘straw purchaser’’ who buys the gun for someone who would not pass a background check, bought without a background check at a gun show or online, or trafficked from states with lax laws into states with stronger gun laws. Physicians working in gun safety advocacy often focus on regulations that concern the gun owner and the homeVthat is, the end point of a gun’s travels. Effective advocacy would also address the so-called iron pipeline of gun trafficking that floods our patients’ neighborhoods with illegal guns. This would surely lead to a reduction in pediatric gun death.
T
*The author declares no conflicts of interest.
Nancy Dodson, MD, MPH Boston Children’s Hospital Boston, MA
‘‘Firing’’ the stapler in emergency general surgery patients: Not so fast! To the Editor: e read with great interest the article by Farrah et al.1 entitled ‘‘Stapled versus hand-sewn anastomoses in emergency general surgery: A retrospective review of outcomes in a unique patient population.’’ The authors concluded that stapled (ST) technique was an independent risk factor for anastomotic failure compared with hand-sewn (HS) technique in emergency general surgery (EGS) patients. While we congratulate the authors for investigating this important topic, we are concerned that the findings are marred by confounding and that the conclusion overreaches what the data allow. It seems that the multivariate logistic regression analysis (LRA) performed in this study included only three variables (technique, age, and admission albumin). Given this, it is likely that the reported effect size of technique (ST vs. HS) is influenced by confounding variables and may be overinflated or underappreciated as a result. In bivariate analysis, multiple other variables demonstrated a statistically significant effect on anastomotic failure and should have been included in the LRA. These variables included intraoperative hypothermia, steroid use, and whether the anastomosis was performed at the first operation. The concern the authors raise for overfitting is unwarranted given the small sample size and because a predictive model was not being developed. These known associations may account for some or even all of the magnitude of the effect noted in the technique variable in the LRA. For example, if the stapled anastomoses that failed were all in hypothermic patients, the effect attributed to stapling technique may truly be caused by hypothermia. While we recognize that all possible associations cannot be feasibly collected and included in an analysis of this type, we disagree that the three variables used adequately allowed for a valid multivariate model. The article states that the EGS service was staffed by seven different general surgeons, and this may represent the single largest variable driving differences in the decision to perform an HS versus an ST anastomosis. Much of the confounding in question may be captured by controlling for physician within a new statistical model. There is likely a select group of surgeons, possibly more experienced, who preferentially perform the HS technique. Outcome differences may be related to which surgeon did the operation.
W
* 2013 Lippincott Williams & Wilkins
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
