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147Vol. 211, No. 1, July 2010 Letters

dopted policies on their relationships with physiciansnd educational groups that reflect their conflicts ofnterest and transparent relationships with surgeons andhysicians who are under contract. The American Col-

ege of Surgeons has adopted an appropriate code ofonduct guiding fellows in this arena. Collaborationsetween industry and surgeons have a productive his-ory that has produced scores of innovations that benefitatients. Adopting excessively restrictive policies in theame of ethical purity puts a highly productive andthical relationship at risk.

EFERENCE

. Schwarze ML. Conflict of interest with industry and challengesfor surgical education. J Am Coll Surg 2009;209:766–777.

isclosure Information: Nothing to disclose.

eply

argaret L Schwarze, MD, FACS

adison, WI

n this age of short sound bites and polarized debates, it isot surprising that Dr Nakayama missed the essence of myoncerns about industry support of educational events forurgeons. To distill my commentary to “all marketing isevious” and “all relationships with industry should bevoided” is to misstate my arguments, presumably to pro-ote his agenda.Marketing and education are distinct entities. We are

amiliar with the practice of marketing in which sellers putproduct in its best light. The goal is, of course, to sell it. As

uch, we are not surprised when the hotel room we sawnline is less glamorous up close, when our orange juiceoes not make us happy, and when the hospital we enter isot as clean or sparkling as seen on television.We are familiar with education, where educators are ex-

ected to tell us the truth, or at least the most accuratenformation available about the subject at hand. We do notnticipate that educators will distort the truth by present-ng information about a device or medication in its mostavorable light, glossing over the risks and accentuating theenefits. Industry underwriting of surgical education dis-ances us from the truth that is necessary for our practicend the good care of the surgical patient.

Marketers have a duty to sell, industry has a duty to

hareholders, and surgeons have a duty to patients. Indus- a

ry has no requirement to help patients. If industry’s goalere simply to support surgical education to help patients,

hen contribution to a central source where surgical leadersould allocate this funding free from ties to industry shoulde supported by industry. This is hardly restrictive andould not impair surgical innovation. Instead, industry

hooses to support surgical education through direct fund-ng of GME, continuing medical education, and speakersureaus to control the message and marketing of itsroduct.Dr Nakayama expresses concerns about the bias of lead-

rs who determine educational content. It is impossible toliminate bias but it can be reduced, and there is no coun-erpart in the academic educational system to the billions ofollars of profit that currently drive industry support ofedical education.

isclosure Information: Nothing to disclose.

hanging Paradigms of Seat Beltnd Air Bag Injuries

ussell Griffin, MPH

aul MacLennan, PhD

erald McGwin Jr, MS, PhD

irmingham, AL

e read with interest the recently published article byarter and Maker titled “Changing Paradigms of Seat Belt

nd Air Bag Injuries: What We Have Learned in the Past 3ecades”.1 The authors present a review of the literature on

eat belt and air bag injuries; however, we have some con-erns that we believe should be addressed.

Our foremost concern is that, although the title suggestsreview of how injury patterns have changed with devel-pments in restraint technology, the majority of the reviewresents a description of injuries attributed to occupantestraint systems based on case reports and series. Also in-luded in the review, yet with minimal distinction, are co-ort and case-control studies evaluating the association be-ween injury patterns and occupant restraint systems.lthough these 2 bodies of literature address the same issue,

he inferences that can be drawn from each are unique.Thiss primarily attributed to the fact that there are no compar-son groups in case reports and series, and yet there is aocus on causation; but in observational studies, whichontain a comparison group, the focus is on association.his is important because, although 2 factors might be

ssociated, it is difficult to determine from a small collec-

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148 Letters J Am Coll Surg

ion of studies whether the relationship is causal, as thereould be a variety of other factors biasing the results of thebserved association (eg, confounding variables, selectionf study population).

An additional concern is the omission of a substantialumber of highly relevant articles. For example, the au-hors cite a study2 that provides little information on theole of restraint systems and ocular injuries beyond describ-ng injury severity. Yet the authors have overlooked 2 mucharger studies3,4 that provide greater insight on the changingaradigm of occupant restraint systems and ocular injuryatterns. In another instance, the authors mention advanc-ng technologies, such as active versus passive seat belts andirst-versus second-generation air bags, yet exclude numer-us studies on the topic published within the past fewears. These studies have examined the association betweenepowered air bags and a variety of injuries, including butot limited to ocular injuries,3 upper-extremity injuries,4

nd skin injuries.5 Similarly, the authors discuss a case re-ort of motor vehicle collision�related aortic injury, buto not include a cohort study examining the topic.6 Theuthors have also excluded the literature on newer advancesn restraint technology, such as side air bags, in their dis-ussion of lateral impacts.

In light of these concerns, we do not believe this articleresents a comprehensive review of the literature aboutaradigms of seat belt and air bag injuries. We hope thathis letter informs readers that the knowledge base abouthis topic is more extensive than that presented in thiseview, and that there is a distinction in the level of evi-ence that can be inferred between descriptive studies andbservational studies, with the latter being directed moreoward association than causation.

EFERENCES

. Carter PR, Maker VK. Changing paradigms of seat belt and airbag injuries: what we have learned in the past 3 decades. J Am CollSurg 2010;210:240–252.

. Rao SK, Greenberg PB, Filippopoulos T, et al. Potential impact ofseatbelt use on the spectrum of ocular injuries and visual acuityoutcomes after motor vehicle accidents with airbag deployment.Ophthalmology 2008;115:573–576.

. Duma SM, Rath AL, Jernigan MV, et al. The effects of depoweredairbags on eye injuries in frontal automobile crashes. Am J EmergMed 2005;23:13–19.

. Jernigan MV, Rath AL, Duma SM. Severe upper extremity inju-ries in frontal automobile crashes: the effects of depowered air-bags. Am J Emerg Med 2005;23:99–105.

. Rath AL, Jernigan MV, Stitzel JD, Duma SM. The effects ofdepowered airbags on skin injuries in frontal automobile crashes.

Plast Reconstr Surg 2005;115:428–435. n

. McGwin G Jr, Metzger J, Moran SG, Rue LW 3rd. Occupant-and collision-related risk factors for blunt thoracic aorta injury.J Trauma 2003;54:655–660.

isclosure Information: Nothing to disclose.

eply

atrice R Carter, MD

hicago, IL

appreciate the comments expressed by Griffin et al inheir review of our recently published article on airbagnd seatbelt injuries.1 The challenge of this topic is thereponderance of literature that includes case reportsnd series. The lack of randomized controlled trials isnderstandable. Although causation might be the pri-ary concern in the majority of case reviews, I agree thate lack the scientific evidence to prove the exact cause of

njury, although some association can be inferred frombservational studies. What we have learned, however, ishat patterns of injury have repeatedly been observed inatients wearing specific restraints such as seen with the

ap seat belt and the increased incidence of small bowelnjuries.2-4

Our review is unique because we have included injurieselated to the use of both air bags and seat belts. To mynowledge, there are a limited number of articles that havettempted to undertake this task. The literature is vast andagree with the authors that the recommended studies theyentioned should have been included in our review espe-

ially as related to ocular injuries and extremity injuries byepowered airbags.5,6

Our primary goal is to enlighten the practicing physiciano the potential injuries that a patient can sustain during araumatic motor vehicle collision. For example, from infor-ation found in this review I was able to expeditiously care

or a patient who was involved in a head-on collision. Theatient was a restrained driver with a 3-point seat belt whoame to the emergency room via ambulance, but was notoded as a trauma alert. The patient had considerable ab-ominal pain, which prompted the emergency room phy-ician to call for a trauma surgery consult. The preliminaryvaluation of the CT scan of the abdomen and pelvis hadot mentioned any trauma-specific injury. I examined theatient and identified a laceration from the seat belt in the

eft groin and elicited considerable abdominal tenderness,ut not yet peritonitis. I then reviewed the CT scan. TheT scan revealed changes in the small bowel and abdomi-

al wall musculature that prompted operative manage-