Seyed Mohsen Mousavi

Appropriate Management of Flail Chest Needs Proper Injury Classification

As for the secondary source we used for ABScertification status, we note that, as described in the Methods section,1, verification of certification by the ABS and the 23 other member boards of the American Board of Medical Specialties was determined from the American Board of Medical Specialties’ records used for our study purposes with the permission of the American Board of Medical Specialties. We agree that self-reported practice specialty data might not be accurate. We note that we reported findings comparing ABS-certified graduates with non board-certified graduates from regression models both with and without practice activity category of Surgery as a selection criterion. We direct interested readers to Table 2,1, showing reults of these 2 regression models; in both models, gradutes who were women, under-represented minorities, gradated in more recent years, initially failed US Medical icensing Examination Step l, and initially failed US Medcal Licensing Examination Step 2 Clinical Knowledge, ere all more likely to be non board-certified compared ith ABS-certified. We noted among our study limitations that “not all US raduates in 1997 2002 who entered categorical surgery poitions in 1997 2002 were necessarily included in our study ample, and our findings might not extend to those other US raduates in 1997 2002 who entered categorical general surery positions but were not included in our study sample.” We also noted that “our study sample included only graduates of US Liaison Committee on Medical Education accredited medical schools, so our results cannot be generalized to graduates of other (eg, osteopathic or international) medical schools.” We fully agree with their comments reiterating hese points that we made in our article. Finally, Drs Lewis and Malangoni remarked that “The iscrepancy noted by Andriole and Jeffe is a reflection of he change in career preference during the early years of esidency, not of difficulty in achieving certification after raining is completed.” The extent to which this statement ight be true for graduates in our study cohort remains an nanswered empirical question. We would welcome the pportunity to collaborate with the ABS to address this esearch question, among other questions of interest, about S medical school graduates’ surgery career paths and the iversity of the emerging surgery workforce.

Epidemiology of Cervical Spine Fractures

Background Epidemiology of cervical spine fractures (CSfx) in trauma patients of general population is not yet exclusively known. Objectives The purpose of this study was to evaluate the epidemiology of CSfx in trauma patients. Patients and Methods Data from trauma patients admitted in the emergency room (ER) of Shiraz Shahid Rajaei hospital during the 3.5 years period from September 22, 2009 to March 21, 2013, were gathered. All trauma patients with CSfx and/or spinal cord injuries were included in the study. The time of the trauma, mechanism of trauma, injury position, and incidence of cervical spine fractures in the patients were recorded. Results A total of 469 patients met the inclusion criteria. The mean age of the patients was 34.7 years old, with a minimum age of 16 years old and a maximum age of 89 years old. Young adults were most frequently affected. Out of 469 cases, 368 patients (78.47%) were male and 101 (21.53%) were female. We had a total of 17 SCI cases among our patients (3.62%), out of which 5 (29.41%) were deceased. The total number of deaths in our study was 29 (6.18%); 5 (17.24%) with SCI and 24 (82.76%) without SCI. Conclusions This study demonstrated that most victims of CSfx in our region are 16 to 40 years of age. A male predominance was observed, and motor vehicle collisions were the most frequent trauma mechanism leading to cervical spine injury (mostly due to car rollover accidents), with falls as the second most frequent. The rate of SCI in our study was 3.62% of all cases and the mortality rate was 6.18%.

Flail chest: are common definition and management protocols still useful?

We eagerly read and appreciate your weighty journal’s hint on the subject flail chest in the April 2010 issue [1]. We wish to respectfully comment on this subject, since we strongly suppose that some of our observations and experience of flail chest in our centre, with a heavy workload to contend with, [2] may be of great interest and useful in this field. Flail chest is a problem whose definition, diagnosis and management has changed over the years [3]. We suppose that the classic definition of flail chest has been sufficiently mentioned in previous studies and textbooks, and is known to the audience [1, 3]. Diagnosis is presumed to be based on observing the floating segment on the patient’s chest wall. Also, detecting specific types of rib fracture in a plain chest radiograph would confirm the diagnosis [1]. Also, as a result of our observations, we suggest that another diagnostic sign could be the tenderness in two separate but parallel lines on the patient’s chest wall, which may or may not develop to the paradoxical movement sign later. But practically, based on our observations, the ‘floating segment’ in the chest wall is seen much less frequently than expected. Even if present, the patient may develop this sign later in the hospital course. This delay in, or even the absence of, this sign seems to depend on the sites of fracture and isolated segment as well as power of muscle bulk over the region to support those fractured ribs. Secondly, flail chest diagnosis by chest X-ray sometimes encounters difficulties, especially when one of the fracture lines is located in the anteromedial part of the chest wall in the costochondral junction. In these cases, a chest CT scan may help the diagnosis [4, 5]. Using a CT scan also could help in the diagnosis of lung contusion and in excluding the rupture of the great vessels [1]. Also, in these cases, we can depend more on the physical examination. Moreover, as routine in Advanced Trauma Life Support (ATLS) protocols, diagnosis and management of flail chest is always discussed in the primary survey [6]. But based on the clinical practice, and also by a review of papers and references, it is implied that even if flail chest is diagnosed in primary survey either by physical examination or, later on, with the plain chest radiograph, no quick intervention will be done for its management and patient would rather be completely sedated, or be given analgesics, and admitted to the intensive care unit (ICU) or somewhere else for precise monitoring or perhaps be put on mandatory mechanical ventilation, as suggested by our observations. These patients, if merely having non-integrity of the chest wall and no other acute conditions, such as pneumothorax or haemothorax, often will not need any emergency intervention or even mechanical ventilation for hours. Also, chest tube insertion is considered only in those with pneumothorax or haemothorax. All in all, we believe that the management of flail chest should be considered in the secondary survey and the physician’s attention would better be diverted merely towards those conditions threatening the patient’s life in the primary survey. Finally, confining the definition of flail chest only to those cases with multiple rib fractures in two points may be noncomprehensive, since we have observed repetitiously that multiple broken ribs are present in one point but along a straight line, causing the patient to have non-integrity of the chest wall as well as respiratory failure. We would like to suggest using the phrase ‘non-integrated chest wall’ instead of flail chest for all cases in which insufficiency of the chest wall function leads to respiratory failure.