Dear "Trauma Surgery & Acute Care Open,"
I have perused the article titled "Beta blockers in traumatic brain injury: a systematic review and meta-analysis" with great enthusiasm (Hart et al., 2023). The study's findings present a promising foundation for future research endeavors, shedding light on the effects of beta blockers in the context of traumatic brain injury (TBI). The inclusion of a substantial sample size, totaling 13,244 individuals, bolsters the study's credibility. Nevertheless, it is essential to acknowledge the study's notable limitations, some of which could be addressed with relative ease. Therefore, I urge the authors to carefully consider the following remarks.
The meta-analysis employed by Hart et al. involved the use of ratios, such as odds ratio and risk ratio, to explore the relationship between interventions and outcomes. However, this method introduces certain biases that undermine the reliability of the findings due to loss of information that could have been used in other methodologies. For instance, the study fails to disclose crucial details regarding the drugs utilized in each study, their respective dosages, and the timing of administration. To compound this issue, these crucial pieces of information are neither provided in a table nor utilized in the meta-analysis. Consequently, the study leaves readers with unexplored sources of heterogeneity, which could have been addressed through subgro...
Dear "Trauma Surgery & Acute Care Open,"
I have perused the article titled "Beta blockers in traumatic brain injury: a systematic review and meta-analysis" with great enthusiasm (Hart et al., 2023). The study's findings present a promising foundation for future research endeavors, shedding light on the effects of beta blockers in the context of traumatic brain injury (TBI). The inclusion of a substantial sample size, totaling 13,244 individuals, bolsters the study's credibility. Nevertheless, it is essential to acknowledge the study's notable limitations, some of which could be addressed with relative ease. Therefore, I urge the authors to carefully consider the following remarks.
The meta-analysis employed by Hart et al. involved the use of ratios, such as odds ratio and risk ratio, to explore the relationship between interventions and outcomes. However, this method introduces certain biases that undermine the reliability of the findings due to loss of information that could have been used in other methodologies. For instance, the study fails to disclose crucial details regarding the drugs utilized in each study, their respective dosages, and the timing of administration. To compound this issue, these crucial pieces of information are neither provided in a table nor utilized in the meta-analysis. Consequently, the study leaves readers with unexplored sources of heterogeneity, which could have been addressed through subgroup analyses and regression modeling based on the unique characteristics of each individual study. This poses limitations on our ability to determine the optimal drug, dosage, and duration of therapy associated with the outcomes of interest.
In addition to the aforementioned concerns, there remain other potential moderators that were left uninvestigated in relation to their influence on the outcomes. For instance, a meta-regression modeling of the relationship between mean age and the male-to-all ratio and its impact on outcomes was not conducted. Such examinations of moderators are often essential in the context of most meta-analyses.
Lastly, I propose the publication of an erratum encompassing the aforementioned methodologies, a more comprehensive explanation of the study's limitations, and a discussion on how these limitations should be considered when interpreting the findings. However, it is crucial to underscore the undeniable value of this review, as it provides valuable insights for future research endeavors and clinical applications.
Reference:
Hart S, Lannon M, Chen A, et al. Beta blockers in traumatic brain injury: a systematic review and meta-analysis. Trauma Surgery & Acute Care Open. 2023;8:e001051. doi: 10.1136/tsaco-
In their review of surveillance methods for alcohol withdrawal syndrome (AWS) in the surgical ICU, the authors state that both the CIWA-Ar and BAWS scales “are not validated in critically ill, medically complex, or postoperative patients.” They correctly point out that one of the limitations of the CIWA-Ar is that most items require the patient to answer questions. They recommend the mMINDS tool because it “does not require the patient to answer questions.”
First, I would like to point out that the BAWS has been studied in critically ill patients – we published a report on 279 admissions to intensive care units at two hospitals where the BAWS was used to guide treatment (1). Second, while both the BAWS and mMINDS rely more on observation that patient report, both include assessment of orientation and hallucinations (plus delusions with mMINDS), which requires a patient to answer questions.
1. Rastegar DA, Jarrell AS, Chen ES. Implementation of an alcohol withdrawal protocol using the 5-item Brief Alcohol Withdrawal Scale for treatment of severe withdrawal in Intensive Care Units. J Intens Care Med 2021;36:1361-65.
To the Editor
I recently have read with great interest the article written by Kregel et la. entitled “Dysphagia is associated with worse clinical outcomes in geriatric trauma patients” which was published online in December 5, 2022 (1). Dysphagia is an important medical manifestation that has been reported to be associated with increased morbidity and mortality and decreased quality of life in hospitalized patients (2, 3); in this retrospective study, the authors assessed the relationship between having dysphagia and clinical outcomes of traumatic geriatric patients admitted to a trauma center. In this study, it was reported that dysphagia was associated with increased odds of having an unplanned admission to intensive care unit, a non-home discharge and increased length of stay. However, this study worked on a rather novel area and showed that screening for dysphagia could be beneficial in patients with traumatic injuries, there are some points that may endanger the validity of the findings and worth mentioning.
The most important concern that could be raised from this study is that dysphagia screening was only conducted in 5 % of the study population, of those 4 % has dysphagia. In other words, in this study, dysphagia screening was not performed for 95 % of them and in analyses, patients with dysphagia were compared with patients who were screened for dysphagia and had not the condition and those who were not screened for dysphagia. Therefore, the findings a...
To the Editor
I recently have read with great interest the article written by Kregel et la. entitled “Dysphagia is associated with worse clinical outcomes in geriatric trauma patients” which was published online in December 5, 2022 (1). Dysphagia is an important medical manifestation that has been reported to be associated with increased morbidity and mortality and decreased quality of life in hospitalized patients (2, 3); in this retrospective study, the authors assessed the relationship between having dysphagia and clinical outcomes of traumatic geriatric patients admitted to a trauma center. In this study, it was reported that dysphagia was associated with increased odds of having an unplanned admission to intensive care unit, a non-home discharge and increased length of stay. However, this study worked on a rather novel area and showed that screening for dysphagia could be beneficial in patients with traumatic injuries, there are some points that may endanger the validity of the findings and worth mentioning.
The most important concern that could be raised from this study is that dysphagia screening was only conducted in 5 % of the study population, of those 4 % has dysphagia. In other words, in this study, dysphagia screening was not performed for 95 % of them and in analyses, patients with dysphagia were compared with patients who were screened for dysphagia and had not the condition and those who were not screened for dysphagia. Therefore, the findings and aim of the study could be subjected to bias. The authors are suggested to conduct another set of analyses and assess the primary and secondary outcomes between those 4 % and one % with dysphagia and definitely without dysphagia, respectively.
Furthermore, the authors attempted to assess the association of having dysphagia with clinical outcomes including in-hospital mortality, intensive care unit admission and several other morbidities. However, they did not consider several key factors that are associated with these outcomes in traumatic patients and might play as confounders and therefore, did not include in them when conducting the statistical analyses, i.e., the multivariable model. In a systematic review and meta-analysis, Sammy et al. assessed factors that affect mortality in older traumatic patients (4). In this study, it was demonstrated that pre-existing conditions, medications, those with more unstable hemodynamic status, etc had higher rate of mortality. Besides, the site of injury is an important predictor of the outcome in these patients. However, the authors did not consider these variables and it could endanger the credibility of the results (5).
Acknowledgement: None.
Conflict of Interest statement: I declare no conflict of interests.
Funding: None.
References
1. Kregel HR, Attia M, Pedroza C, Meyer DE, Wandling MW, Dodwad S-JM, et al. Dysphagia is associated with worse clinical outcomes in geriatric trauma patients. 2022;7(1):e001043.
2. Bosch G, Comas M, Domingo L, Guillen-Sola A, Duarte E, Castells X, et al. Dysphagia in hospitalized patients: Prevalence, related factors and impact on aspiration pneumonia and mortality. European journal of clinical investigation. 2022:e13930.
3. Vesey S. Dysphagia and quality of life. British journal of community nursing. 2013;Suppl:S14, s6, s8-9.
4. Sammy I, Lecky F, Sutton A, Leaviss J, O'Cathain A. Factors affecting mortality in older trauma patients-A systematic review and meta-analysis. Injury. 2016;47(6):1170-83.
5. Yadollahi M. A study of mortality risk factors among trauma referrals to trauma center, Shiraz, Iran, 2017. Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2019;22(4):212-8.
To the editor;
I have recently studied the article written by Dr. Daniel Dante Yeh et al. published in “Trauma Surgery & Acute Care Open” (1). The study presents a protocol, developed to compare liberal versus restrictive strategies for antibiotic therapy in patients with complicated and uncomplicated appendicitis. Undeniably, the authors have contemplated the study, potential sources of bias, and statistical procedures, which promise brilliant results.
Intending to improve the methodological quality of this study, I decided to share my humble ideas. The authors have defined exclusion and inclusion criteria precisely, however, other factors may appear as confounders. For example, I believe that it is noteworthy to clear the authors’ decision on enrollment of patients who are allergic to computed tomography (CT) contrast media, renal insufficient, and suspicious of tumors on CT scan. Also, the protocol did not state whether the treating surgeon is part of the core study team.
Although, it is commonly considered that the randomization design in clinical trials should make groups and results comparable in an unbiased assessment of the outcomes, factors that were formerly recognized in the literature that could be associated with poor response or adherence to the treatment should foretaste in the quantitative analysis of the study; these factors could include basic laboratory findings, patients’ socioeconomic status (2), etc. The definition of the type of...
To the editor;
I have recently studied the article written by Dr. Daniel Dante Yeh et al. published in “Trauma Surgery & Acute Care Open” (1). The study presents a protocol, developed to compare liberal versus restrictive strategies for antibiotic therapy in patients with complicated and uncomplicated appendicitis. Undeniably, the authors have contemplated the study, potential sources of bias, and statistical procedures, which promise brilliant results.
Intending to improve the methodological quality of this study, I decided to share my humble ideas. The authors have defined exclusion and inclusion criteria precisely, however, other factors may appear as confounders. For example, I believe that it is noteworthy to clear the authors’ decision on enrollment of patients who are allergic to computed tomography (CT) contrast media, renal insufficient, and suspicious of tumors on CT scan. Also, the protocol did not state whether the treating surgeon is part of the core study team.
Although, it is commonly considered that the randomization design in clinical trials should make groups and results comparable in an unbiased assessment of the outcomes, factors that were formerly recognized in the literature that could be associated with poor response or adherence to the treatment should foretaste in the quantitative analysis of the study; these factors could include basic laboratory findings, patients’ socioeconomic status (2), etc. The definition of the type of appendicitis is an operative diagnosis (3). This may raise a potential source of bias by allocating the patients into complicated or uncomplicated groups at the surgeons’ discretion. I recommend authors employ well-defined criteria to address the bias.
Recall bias is a systematic error caused by inaccuracy in reporting past experiences, which can influence the patients’ response regarding health data (4, 5). The primary endpoint in the protocol is described as contacting the participants by telephone, 30 days after surgery, to ask about the endpoints. This exposes the study to recall bias, as the recall period may differ by age, socioeconomic level, and literacy. The recall may systematically be biased, thus, an alternative method with less subjective approaches such as short interview intervals is recommended.
"References"
1. Yeh DD, Hatton GE, Pedroza C, Pust G, Mantero A, Namias N, et al. Complex And Simple Appendicitis: REstrictive or Liberal postoperative Antibiotic eXposure (CASA RELAX) using Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR): study protocol for a randomized controlled trial. Trauma Surgery & Acute Care Open. 2022;7(1):e000931.
2. Mallah N, Orsini N, Figueiras A, Takkouche B. Income level and antibiotic misuse: a systematic review and dose–response meta-analysis. The European Journal of Health Economics. 2022;23(6):1015-35.
3. Mariage M, Sabbagh C, Grelpois G, Prevot F, Darmon I, Regimbeau JM. Surgeon's Definition of Complicated Appendicitis: A Prospective Video Survey Study. Euroasian journal of hepato-gastroenterology. 2019;9(1):1-4.
4. Coughlin SS. Recall bias in epidemiologic studies. Journal of clinical epidemiology. 1990;43(1):87-91.
5. Neugebauer R, Ng S. Differential recall as a source of bias in epidemiologic research. Journal of clinical epidemiology. 1990;43(12):1337-41.
We read with great interest “Plate of ribs: single institution’s matched comparison of patients managed operatively and non-operatively for rib fractures” by Griffard et al (1). As chest injuries are one of the most prevalent injuries encountered in trauma care, the importance of evidence for or against treatments cannot be overlooked. The authors review their institution’s recent experience with surgical stabilization of rib fractures (SSRF) and draw comparisons to other patients with chest injuries cared for by their group. We found several methodological concerns (including propensity matching, injury phenotype heterogeneity, and selection bias) that arise from their design that may significantly affect their analysis and conclusions.
To start, the authors reference three prior studies that use patient-matching to study operative vs. non-operative treatments of fractures. The authors indicate that they made a similar matched comparison; however, there was significant heterogeneity in the methods of the referenced studies. The first study used a 1:4 match of age, GCS, other surgeries, mechanical ventilation, pressors and transfusion requirement, but introduced selection bias by excluding tens of thousands of patients cared for at hospitals that did not use SSRF (2). The next study used a 1:1 match, excluding significant traumatic brain injury (TBI), spinal, and pelvic injuries or other injuries AIS =5, to match age, sex and thoracic AIS (3). This resulted i...
We read with great interest “Plate of ribs: single institution’s matched comparison of patients managed operatively and non-operatively for rib fractures” by Griffard et al (1). As chest injuries are one of the most prevalent injuries encountered in trauma care, the importance of evidence for or against treatments cannot be overlooked. The authors review their institution’s recent experience with surgical stabilization of rib fractures (SSRF) and draw comparisons to other patients with chest injuries cared for by their group. We found several methodological concerns (including propensity matching, injury phenotype heterogeneity, and selection bias) that arise from their design that may significantly affect their analysis and conclusions.
To start, the authors reference three prior studies that use patient-matching to study operative vs. non-operative treatments of fractures. The authors indicate that they made a similar matched comparison; however, there was significant heterogeneity in the methods of the referenced studies. The first study used a 1:4 match of age, GCS, other surgeries, mechanical ventilation, pressors and transfusion requirement, but introduced selection bias by excluding tens of thousands of patients cared for at hospitals that did not use SSRF (2). The next study used a 1:1 match, excluding significant traumatic brain injury (TBI), spinal, and pelvic injuries or other injuries AIS =5, to match age, sex and thoracic AIS (3). This resulted in a very small sample size of only 10 patients matched to the SSRF group. The final study used a very robust 1:4 propensity score match for 19 characteristics, some of which had 13 variables, and many of which were continuous variables (4). Unsurprisingly, their match was so stringent that at least 5 characteristics in the “matched” group were still significantly different to a p < 0.01 level. By contrast in the authors study, only age and number of rib fractures (in groupings) were matched, albeit at a 1:4 ratio. Matching helps to create a pseudo-randomized population, helping to control for confounding pre-intervention variables that would affect down-stream outcomes. Presumably this indicates that the authors hoped the quantity of additional patients “matched” would outweigh potential confounding information. As propensity score matching is not described in the methods, a more rigorous match may give markedly different results.
Second, after matching patients for the above criteria, the operative group was found to have significantly more flail segments, displaced rib fractures, and fewer bilateral rib fractures. Essentially, the two groups have different injury phenotypes. As many prior analyses have confirmed, segmental fractures, degree of displacement, and bilaterality play a significant role in respiratory physiology, analgesia needs, and translate into worse outcomes. A standardized definition of rib displacement has only recently been clarified in updated taxonomy (5), which suggests that the radiographic definition for displacement employed over this study timeline did not standardize rib fracture cortical overlap, and is therefore heterogenous.
Third, the authors report that all patients were screened for SSRF according to current guidelines. This suggests that the 4150 patients who were treated non-operatively (including the 148 matched patients) were deemed not operative candidates. It is hard to draw meaningful conclusions from comparing patients presumably with contraindications to SSRF (no fracture instability, no pulmonary derangements, other higher priority injuries, significant TBI, infection, hemodynamic instability, etc.) to those undergoing operative management. Could the groups have been matched by other chest injury specific means, such as Rib Score? Could the non-operative group be reviewed to determine if they met any criteria for fixation?
When taken in this context, the author’s findings of “no differences” and conclusions that “SSRF may not be as beneficial as current literature suggests” is potentially misleading. At best, the authors present a case-series of SSRF use in severe chest wall injuries with outcomes congruent with prior literature. At worst, the methodological concerns and selection bias creates an apples-to-oranges comparison that does not support the conclusions drawn. We appreciate the hard work and thoughtful process evaluation by the authors and look forward to further experience with SSRF to help guide and improve patient care.
Christopher Janowak, MD, FACS
Michael Goodman, MD, FACS
Division of Trauma
Section of General Surgery, Department of Surgery
University of Cincinnati, Cincinnati, OH, USA
1. Griffard J, Daley B, Campbell M, et al. Plate of ribs : single institution ’ s matched comparison of patients managed operatively and non- operatively for rib fractures. Trauma Surg Acute Care Open. 2020;5:1-5. doi:10.1136/tsaco-2020-000519
2. Wada T, Yasunaga H, Inokuchi R, et al. Effectiveness of surgical rib fixation on prolonged mechanical ventilation in patients with traumatic rib fractures: A propensity score-matched analysis. J Crit Care. 2015;30(6):1227-1231. doi:10.1016/j.jcrc.2015.07.027
3. Uchida K, Nishimura T, Takesada H, et al. Evaluation of efficacy and indications of surgical fixation for multiple rib fractures: a propensity-score matched analysis. Eur J Trauma Emerg Surg. 2017;43(4):541-547. doi:10.1007/s00068-016-0687-0
4. Shibahashi K, Sugiyama K, Okura Y, Hamabe Y. Effect of surgical rib fixation for rib fracture on mortality. J Trauma Acute Care Surg. 2019;87(3):599-605. doi:10.1097/ta.0000000000002358
5. Edwards JG, Clarke P, Pieracci FM, et al. Taxonomy of multiple rib fractures: Results of the chest wall injury society international consensus survey. J Trauma Acute Care Surg. 2020;88(2):E40-E45. doi:10.1097/TA.0000000000002282
This is my experience as Director of a Medical ICU in a major city Public General/Trauma Hospital in the State of Texas USA in the mid-1980's
The State had passed a mandatory motorcycle helmet law that had taken effect on Jan. 1 At the end of Jan, the NICU Director called as asked if I would accept some ventilated patients in transfer since his unit was full. I went to the ICU to evaluate them..
The NICU had 10 beds and 8 were filled with ventilated quadriplegic patients, All 8 had been riding motorcycles WITH helmets. After discussion, the NICU Director's hypothesis was that motorcycle riders that were previously killed in accidents from head trauma were now surviving their head trauma due to wearing helmets and were now suffering neck fractures. We had no idea how prevalent this NICU's experience was. Later, t State of Texas subsequently rescinded the law and the number of quadriplegics deceased.
My question to the authors is: Were there more quadriplegics from wearing helmets in your data?
Dear "Trauma Surgery & Acute Care Open,"
Show MoreI have perused the article titled "Beta blockers in traumatic brain injury: a systematic review and meta-analysis" with great enthusiasm (Hart et al., 2023). The study's findings present a promising foundation for future research endeavors, shedding light on the effects of beta blockers in the context of traumatic brain injury (TBI). The inclusion of a substantial sample size, totaling 13,244 individuals, bolsters the study's credibility. Nevertheless, it is essential to acknowledge the study's notable limitations, some of which could be addressed with relative ease. Therefore, I urge the authors to carefully consider the following remarks.
The meta-analysis employed by Hart et al. involved the use of ratios, such as odds ratio and risk ratio, to explore the relationship between interventions and outcomes. However, this method introduces certain biases that undermine the reliability of the findings due to loss of information that could have been used in other methodologies. For instance, the study fails to disclose crucial details regarding the drugs utilized in each study, their respective dosages, and the timing of administration. To compound this issue, these crucial pieces of information are neither provided in a table nor utilized in the meta-analysis. Consequently, the study leaves readers with unexplored sources of heterogeneity, which could have been addressed through subgro...
In their review of surveillance methods for alcohol withdrawal syndrome (AWS) in the surgical ICU, the authors state that both the CIWA-Ar and BAWS scales “are not validated in critically ill, medically complex, or postoperative patients.” They correctly point out that one of the limitations of the CIWA-Ar is that most items require the patient to answer questions. They recommend the mMINDS tool because it “does not require the patient to answer questions.”
First, I would like to point out that the BAWS has been studied in critically ill patients – we published a report on 279 admissions to intensive care units at two hospitals where the BAWS was used to guide treatment (1). Second, while both the BAWS and mMINDS rely more on observation that patient report, both include assessment of orientation and hallucinations (plus delusions with mMINDS), which requires a patient to answer questions.
1. Rastegar DA, Jarrell AS, Chen ES. Implementation of an alcohol withdrawal protocol using the 5-item Brief Alcohol Withdrawal Scale for treatment of severe withdrawal in Intensive Care Units. J Intens Care Med 2021;36:1361-65.
To the Editor
Show MoreI recently have read with great interest the article written by Kregel et la. entitled “Dysphagia is associated with worse clinical outcomes in geriatric trauma patients” which was published online in December 5, 2022 (1). Dysphagia is an important medical manifestation that has been reported to be associated with increased morbidity and mortality and decreased quality of life in hospitalized patients (2, 3); in this retrospective study, the authors assessed the relationship between having dysphagia and clinical outcomes of traumatic geriatric patients admitted to a trauma center. In this study, it was reported that dysphagia was associated with increased odds of having an unplanned admission to intensive care unit, a non-home discharge and increased length of stay. However, this study worked on a rather novel area and showed that screening for dysphagia could be beneficial in patients with traumatic injuries, there are some points that may endanger the validity of the findings and worth mentioning.
The most important concern that could be raised from this study is that dysphagia screening was only conducted in 5 % of the study population, of those 4 % has dysphagia. In other words, in this study, dysphagia screening was not performed for 95 % of them and in analyses, patients with dysphagia were compared with patients who were screened for dysphagia and had not the condition and those who were not screened for dysphagia. Therefore, the findings a...
To the editor;
Show MoreI have recently studied the article written by Dr. Daniel Dante Yeh et al. published in “Trauma Surgery & Acute Care Open” (1). The study presents a protocol, developed to compare liberal versus restrictive strategies for antibiotic therapy in patients with complicated and uncomplicated appendicitis. Undeniably, the authors have contemplated the study, potential sources of bias, and statistical procedures, which promise brilliant results.
Intending to improve the methodological quality of this study, I decided to share my humble ideas. The authors have defined exclusion and inclusion criteria precisely, however, other factors may appear as confounders. For example, I believe that it is noteworthy to clear the authors’ decision on enrollment of patients who are allergic to computed tomography (CT) contrast media, renal insufficient, and suspicious of tumors on CT scan. Also, the protocol did not state whether the treating surgeon is part of the core study team.
Although, it is commonly considered that the randomization design in clinical trials should make groups and results comparable in an unbiased assessment of the outcomes, factors that were formerly recognized in the literature that could be associated with poor response or adherence to the treatment should foretaste in the quantitative analysis of the study; these factors could include basic laboratory findings, patients’ socioeconomic status (2), etc. The definition of the type of...
We read with great interest “Plate of ribs: single institution’s matched comparison of patients managed operatively and non-operatively for rib fractures” by Griffard et al (1). As chest injuries are one of the most prevalent injuries encountered in trauma care, the importance of evidence for or against treatments cannot be overlooked. The authors review their institution’s recent experience with surgical stabilization of rib fractures (SSRF) and draw comparisons to other patients with chest injuries cared for by their group. We found several methodological concerns (including propensity matching, injury phenotype heterogeneity, and selection bias) that arise from their design that may significantly affect their analysis and conclusions.
To start, the authors reference three prior studies that use patient-matching to study operative vs. non-operative treatments of fractures. The authors indicate that they made a similar matched comparison; however, there was significant heterogeneity in the methods of the referenced studies. The first study used a 1:4 match of age, GCS, other surgeries, mechanical ventilation, pressors and transfusion requirement, but introduced selection bias by excluding tens of thousands of patients cared for at hospitals that did not use SSRF (2). The next study used a 1:1 match, excluding significant traumatic brain injury (TBI), spinal, and pelvic injuries or other injuries AIS =5, to match age, sex and thoracic AIS (3). This resulted i...
Show MoreThis is my experience as Director of a Medical ICU in a major city Public General/Trauma Hospital in the State of Texas USA in the mid-1980's
The State had passed a mandatory motorcycle helmet law that had taken effect on Jan. 1 At the end of Jan, the NICU Director called as asked if I would accept some ventilated patients in transfer since his unit was full. I went to the ICU to evaluate them..
The NICU had 10 beds and 8 were filled with ventilated quadriplegic patients, All 8 had been riding motorcycles WITH helmets. After discussion, the NICU Director's hypothesis was that motorcycle riders that were previously killed in accidents from head trauma were now surviving their head trauma due to wearing helmets and were now suffering neck fractures. We had no idea how prevalent this NICU's experience was. Later, t State of Texas subsequently rescinded the law and the number of quadriplegics deceased.
My question to the authors is: Were there more quadriplegics from wearing helmets in your data?