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Risk of Pneumonia in Patients with Isolated Minor Rib

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Risk of Pneumonia in Patients with Isolated Minor Rib BMJ Open: first published as 10.1136/bmjopen-2016-013029 on 13 January 2017. Downloaded from PEER REVIEW HISTORY BMJ Open publishes all reviews undertaken for accepted manuscripts. Reviewers are asked to complete a checklist review form (http://bmjopen.bmj.com/site/about/resources/checklist.pdf) and are provided with free text boxes to elaborate on their assessment. These free text comments are reproduced below. ARTICLE DETAILS TITLE (PROVISIONAL) Risk of pneumonia in patients with isolated minor rib fractures: A nationwide cohort study AUTHORS Ho, Sai-Wai; Teng, Ying-Hock; Yang, Shun-Fa; Yeh, Han-Wei; Wang, Yu-Hsun; Chou, Ming-Chih; Yeh, Chao-Bin VERSION 1 - REVIEW REVIEWER Edward Baker Lecturer Practitioner King's College London UK REVIEW RETURNED 03-Aug-2016 GENERAL COMMENTS Thank you for sending me this study to review. I have the following comments that you should consider in any for development of this study and associated write up. There is a small sample size for a „nation wide‟ cohort study. Can you justify this in your text? This may be amplified by the fact that you are reporting chest trauma rates from the USA which will be significantly to Taiwan. http://bmjopen.bmj.com/ Your brief introduction reports demographics of more severe chest trauma and you only introduce minor rib fractures in the final paragraph. The introduction would benefit from being more specific to your study aims. The data that you are reporting on your relatively old now (2009- 2011). Can you explain the delay in publication or why more up-to on September 28, 2021 by guest. Protected copyright. date data has not been utilised? You may find that treatment and diagnostics (particularly access to diagnostics) has increased in the last 5 years. I remain a little confused about where the data was accessed and how this was done. I feel that you need to explain the NHIRD process more clearly for readers who may not be based in a country that involves health insurance. Your discussion follows a very bio-chemical process for the development for pneumonia and pharmokinetic functions of NSAIDS in the management of pain. I don‟t think this adds a great deal to the overall output of the study and doesn‟t add anything to the knowledge base. The discussion is very descriptive generally. Remember also that you are referring to studies undertaken on patients with significantly more rib fractures and therefore much higher risk of developing complications. These may not be BMJ Open: first published as 10.1136/bmjopen-2016-013029 on 13 January 2017. Downloaded from comparable studies? You report the NHIRD to a major strength of the study. In reality the retrospective methodology is a weakness that you should have accounted for in your limitations. In your tables you have inconsistent presentation of p-values. Can you review this and standardise your presentation of data? Can you review the use of English? Of the most part this is good but there are areas where there is confusion with grammar and sentence structure. Overall I have to ask myself what this study adds to the knowledge base. There is sufficient evidence available to link the cause and effect of rib fractures and subsequent complications. There is also a large base of retrospective evidence available identifying predictive variables. The addition to the knowledge base here, lies in the focus on patients with 1 or 2 fractured ribs. There is currently limited data available in this area but without further specific data including position of rib fractures and more specific information the benefit is limited. REVIEWER Krista L Kaups MD, MSc, FACS University of California San Francisco Fresno CRMC Department of Surgery, First Floor 2823 Fresno Street Fresno CA 93721 United States REVIEW RETURNED 17-Aug-2016 http://bmjopen.bmj.com/ GENERAL COMMENTS Thank you for the opportunity to review this manuscript. This study is a large, database analysis using propensity matching to compare patients sustaining isolated rib fractures to matched patients in a national health service database. The significant strength of this study is its comprehensive nature, with the inclusion of essentially all in-patient and ambulatory patients in a large sample (1 million patients) of a national database. on September 28, 2021 by guest. Protected copyright. Overall, the study is well-constructed and the authours have clearly reported the methodology employed for inclusion and matching criteria, as well as descriptions of statistical analyses used. The stated objective was investigation of the association between isolated single or two rib fractures and the development of pneumonia. The authors concluded that the occurrence of two rib fractures is associated with an increased incidence of pneumonia in the subsequent 30 days following diagnosis (1.6% vs 0.18%) with age greater than 65 years and the presence of COPD adding significant risk. The manuscript raises a number of questions: 1. Data is not provided regarding mechanism of injury. Rib fractures resulting from high kinetic energy trauma (e.g. motor vehicle crash) would be expected to have a higher incidence of pulmonary contusion and other pulmonary trauma, and potentially greater risk for pneumonia, than fractures sustained from a low-energy trauma (such as a ground-level fall). Could mechanism of injury be incorporated into the analysis? BMJ Open: first published as 10.1136/bmjopen-2016-013029 on 13 January 2017. Downloaded from 2. The presence of pneumothorax or hemothorax was not included in the study. Since either of these injuries can both indicate the presence of a more severe overall pulmonary injury and also contribute to the later development pneumonia, can the authours comment as to why this was omitted? 3. Additionally, it was reported that only 0.6% of patients had pulmonary contusion, yet since a relatively small proportion of patients had CT scans performed, the actual incidence of contusion is unknown (as the authors report). Since the presence of contusion may significantly contribute to the development of pneumonia, a comparison of patients who had rib fractures with and without contusion would be helpful (perhaps an analysis of only patients who had CT scans performed). 4. The incidence of COPD and other comorbidities was much higher in the patients with rib fractures, so is it possible that these patients are simply more frail and at increased risk for injury? COPD is clearly a risk for pneumonia so this increase is relatively unsurprising. 5. Of the patients sustaining isolated rib fractures, a relatively small percentage (29%) were admitted to the hospital. As this may represent a group of patients who were more significantly injured or at greater risk to develop pneumonia (i.e. because of co- morbidities), an analysis of these patients would allow a better understanding of risk factors for developing pneumonia in comparison to the overall group. 6. The authours note the difference in incidence of pneumonia between patients with 1 versus 2 rib fractures. Was there a further difference in patients sustaining more than 2 fractures? Why were 1 and 2 rib fractures selected for review? 7. The statement is made, in the introduction, that „pneumonia is an inflammatory process „which is true. However, for the purposes of this study, it would seem that the infection-related component should not be ignored. 8. A number of the references do not appear to directly relate to the http://bmjopen.bmj.com/ manuscript content (including 21- 24, 30 – 32 which discuss inflammatory response in pneumonia and general discussions of COPD) and could be omitted. VERSION 1 – AUTHOR RESPONSE Reviewer #1: on September 28, 2021 by guest. Protected copyright. Comments 1. There is a small sample size for a „nation wide‟ cohort study. Can you justify this in your text? This may be amplified by the fact that you are reporting chest trauma rates from the USA which will be significantly to Taiwan. Reply: Thanks for your valuable comments and to improve this aspect. The database contained 1 million patients that randomly selected from 23 million Taiwanese population in year 2010. After excluding non-adult patients and patients who ever have trauma in previous 1 year, only 3602 chest trauma patients were included for analysis. Then we select patient only with isolated single or two ribs fracture in these 3602 patients. We further excluded patients who had pneumonia in previous one year before chest trauma. After that, only 709 patients left for final analysis in study group. We added the following sentences in the result section “After excluding non-adult patients and patients who ever have trauma in previous 1 year, only 3602 chest trauma patients were included” [Page 11]. We also described the Taiwan condition of chest trauma by adding reference 8 and the following sentences in the introduction section “In Taiwan, chest trauma causes 18,856 hospitalizations in between year 2002 and 2004 [8]” [Page 5]. We hope that these changes and BMJ Open: first published as 10.1136/bmjopen-2016-013029 on 13 January 2017. Downloaded from replies may meet your requirement for being published. 2. Your brief introduction reports demographics of more severe chest trauma and you only introduce minor rib fractures in the final paragraph. The introduction would benefit from being more specific to your study aims. Reply: Thanks for your valuable comments and to improve this aspect. We deleted the description about severe chest trauma and added more description about minor rib fractures in the introduction section. We also supplemented the description as “Minor thoracic injury was defined by the presence of chest abrasion, or chest contusion, or isolated minor rib fracture (IMRF), defined as single or two ribs fractures represent up to 42% of ED visits for blunt chest trauma [12-13].
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