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Shot some cough pressure. Can you got short of cold? Make sure you can. Yeah. Yes. Crystal Crystal. Can you hear me? Crystal? Can you hear me uh on the, on the, on the computer? So uh yes. Yes. So, so uh just, just maybe uh keep your phone away a little bit and you talk and let me see if I can hear you through the computer. Yeah. Yeah. Hello. Hi, Crystal. Ok. Mm. This one here. Yeah. Yes. Yes. Ok. Mhm. Uh hi Crystal. Can you hear me? Ok, for 150? Can you hear me well? Ok. II can also hear you and I see prof Sebastian is your eye sebastian uh semester. Uh Yeah, you need to unmute. Yeah, that's good. Ok. Ok. Good, good. Lovely. Ok. Uh Crystal. Um we have confirmed that you can share your screen. Uh So for the time being, can I share my screen for the first two minutes? Of course. Ok. So I'm just so Crystal. Can you hear me? I can hear you perfectly. Ok. Good. Are you talking about uh solid organ injuries this afternoon? Yes. Ok. Ok. Organ injury. Which organs are you discussing? I'm gonna go through liver, spleen, kidney and, ok, all of them. Very good. Well, it will be a bit of a flight through them because I think they, so have you stopped sharing your screen? You need to stop sharing your screen. Um, ok. Only then I can share mine. Ok. Go see if you can do it. Now. I've canceled that function. Ah. Ok. Right. Ok. Um, ok. One second, I'm already at home the invitation to talk on this topic. Um And it's not often that the people you reference within your talks are in your audience, let alone the commentator on your talks. So thank you prof on us for taking the time as well. Um So as I said, the talk is limited to solid organ injuries, only their presentation and management is one exception towards the end, but I'll discuss it when I get there. So with regards to the top B injuries account for more than 90% of pediatric trauma with abdominal injuries also carrying with a significant morbidity, almost 5% of admissions to major pediatric centers are as a result of blunt trauma and it has a mortality rate of less than 1%. And that's often related to the number and the types of structured structures which are injured um within the particular patient. And I think the one take home message from the start all the way through. Um And to the end is that non operative management is the gold standard for blind abdominal trauma at this stage. Um with regards to mechanisms of injuries, they are varied bic bicycle handlebar injuries, seat or lap belt injuries where there's two point restraint um motor vehicle accidents ATV S included pedestrian vehicle accidents falls from height, usually 2 to 3 times the height of the child. And then abuse always needs to be at the back of our minds and considered when dealing with these types of injuries. In terms of the structures injured, you get solid organ injuries are more common than your hollow viscous or injuries which are more common than your abdominal vasculature being injured in the child. The next thing to note is that Children are not small adults. So anatomically, physiologically, they have very particular characteristics being of a smaller size, they have a smaller surface area over which to dissipate the force. And therefore, the impact is greater, the abdominal walls are relatively thin, they have minimal subcutaneous tissue, less fat. Um and therefore, the force is greater on them. The fact that their rib cage is less protective. It's also more pliable and in combination with larger vital organs within the abdomen, such as the liver and the spleen and a more horizontal diaphragm, rendering them more abdominal and less protected um by the rib cage as well. Also their, their pelvis is are more shallow and the bladder becomes an intraabdominal organ. And you should always remember with this greater surface area comes a greater vulnerability to hypertension or hyperthermia, sorry, then their response to shock, in order to increase their cardiac output, they have very limited means of doing this. They can't necessarily increase their stroke value much and thereby need to increase their heart rate. Their peripheral circulation can also be quite labile. They also have an increased ability to redirect their blood flow to priority areas are more prone to an ileus or an gaseous distension as well. Then one shouldn't impact um the shouldn't dismiss the impact of the psychological state on your assessment. So you're putting a traumatized child into an unfamiliar environment. You may end up with a child that is uncooperative. Older Children often show aggressive behavior in these circumstances. So you may have a ten-year-old that is acting like a five-year-old and also the long term effects of polytrauma on these Children. Not only these immediate effects that we are going to talk about now, but also later on, their personality is affected by traumatic incidences. Some challenges that you can experience when assessing a child that we've all come across, whether it's in a trauma setting or clinic setting is that there's absent or inadequate communication on the child's part, especially as they get younger, they often have minimal external signs, they also have a greater physiological reserve. So they can maintain normal vitals in the face of significant blood loss. And there's also very patterns of injury given the various ages. One thing to note when you're treating Children is to know that particular age groups have different vital signs that are normal to them. And it's good to know them just off the top of our heads. If you're thinking about systolic BP, a figure of 70 plus twice, their age is a good number to work on. But also to note their heart rate, respiratory rate, BP as well as the glas glaucoma scale is calculated differently. And then also to note the urinary output norms when it comes to the primary assessment. A LS principles are followed because this provides us with a symptomatic approach to looking after this patient. Um as well as you can use adjunctive tools such as the bras tape, P tape, which was developed in South Africa and a app on our phone, such as the pediatric guideline app just to broaden things in terms of what size to use, what what dose of medication you're going to use and what the estimated weight of that particular child is. So, looking at the principles according to HL S which are your ABC. Um airway pat is important, looking at the breathing, whether it's adequate in the work of breathing, looking at some circulation, particularly the hemodynamics and then any areas of blood loss with a little um bit of four plus the floor. So head chest, abdomen, pelvis, looking at all those areas of suspected blood loss. Um and then disability such as the G CS with the allowances for age as I've highlighted before, fully expose the child and don't forget to evaluate what their blood glucose level is. Paying one needs to pay particular attention to the signs of shock, such as tachycardia and narrow BP, um prolonged capillary, refill any pallor and an altered mental state for that particular age group in terms of the secondary survey, um we need to evaluate all organ systems. We are obviously going to focus on the abdominal um system at the moment, but looking for concurrent or associated injuries. So the abdominal examination is specifically going to follow the simple rules of inspection, palpation, percussion and auscultation with the inspection. Don't forget we need to look at the genitalia and the perineum as well. Is there any urethral nasal blood? Um Are there any signs of injury to the perineum itself? Then in also the constellation of signs that we see together to highlight any patterns of injury such as the seatbelt complex where it's abdominal wall ecchymosis and the risk of intraabdominal injury in the patient with um abdominal wall ecchymosis is 84%. And the association of a vertebral fracture such as a trans fracture is 50% in those patients as well. So that's always important to have in the back of your mind. Then palpation should be done and the pr is not always indicated. Um but the mechanism of injury or preceding exam may indicate that you, especially if there's evidence of a spinal cord injury. And then we can ask to hear if there is bowel sounds. Usually with abdominal injuries, the initial signs, there's a paucity of initial signs. So one needs to do serial examination and preferably by the same examiner. If that's at all possible when we move on to predictors of blunt abdominal injury, I'll just run through the list. There's direct flows, high impact or deceleration injuries. If there's any evidence of injury above or below the diaphragm, and there's a high chance of intraabdominal injuries. If there has been a stradle injury, seatbelt injury, a handle bar injury as mentioned before long bone fractures, as well as pelvic and spinal fractures also should allude one to a possible intraabdominal injury, lower rib fractures and the costal margin tenderness on palpation. And then if there's any injury suggestive of non accidental injury, possibly, your only clue to this could also be on the history taken, then the physical signs of intraabdominal injury. Um things that indicate that there's a high risk for intraabdominal injury. Like I said, abdominal wall, ecchymosis specific marks such as a handlebar mark, which would be a circular mark somewhere on the upper region of the abdomen. If there are any abrasions, track or time marks. Um the left belt sign or seatbelt sign, there's abdominal distension or tenderness. If there's any peritoneal irritation, the rebound guarding or sign which is left shoulder pain on palpating the left upper quadrant. And then if there's an absence of bowel sounds, indicating an eyes, which you can actually start four hours post injury already. So, quite early on and with regards to investigation, there's no standard panel for lab investigations that has been established. But there are certain criteria within the ordinary panel that we can look to that will nothing is absolute. So everything pin sort of pinpoints or leads you towards thinking that there may be a certain organ injury within the, within the abdomen. So looking at the HB and the hematocrit, we not quite, we don't use hematocrit so far frequently as they do overseas. But I think it's something that we can start looking at and sort of our own individual practice as well of it is in a hematocrit of less than 50 usually indicates that there's been severe blood loss. Um Other blood panel factors, we can do an uh A VG or a V VG. We can look at the, at more than 125 may indicate a liver injury. And ast looking at a value of more than 200 lipase may also be done and the 100 and 25 may indicate an injury. Then your other basic panels such as uh urea and creatinine is also useful at type and screen, especially if your patient is a polytrauma patient and that you can anticipate the need for blood later on A PTT and a PT would also be necessary in a post miracle female, one would do a beta HCG and in teenagers, which it depends on what your hospital is. But if you are seeing sort of the 12 to 16 range, that one could consider alcohol test or drug tox screen as well. If you have the privilege of a lod do as you can see in the picture there. Um That's also nice to use, that gives you a nice scanning overview and you can pick up quite quite detailed um information on that as well. With regards to Children, we always use the Alara principle um when doing imaging on them and that is as low as reasonably achievable when it comes to x-rays. So try and limit the x-rays you've done. If you've got the luxury of a low do you can then pinpoint which x-rays you need also your clinical pick up of where you anticipate injuries to be. But some things that we would do is ac spine, a chest, a pelvis and limbs if they are indicated. A DPL, I know everybody includes this. I've personally never seen it in adult trauma or pediatric trauma. So I have no actual experience of how to do it. And I think it's uh being to some degree unseated by a fast scan and even the ability to do CT scan quite quickly. But essentially a DPL can also sometimes be useful in the where the fast is sort of indeterminate or equivocal and in a patient who is hemodynamically stable, but another organ system takes precedence of the emergent um operations such as a head injury and some of the features of a positive DPL or it's more than five moles of gross blood. If there's any obvious enteric content coming back, if there's extravasation of your lavage into an ICD or even into the urinary catheter, um if that fluid itself, which is maybe a bit longer, but has a light resol of more than 175 that's considered positive as well. If your fluid has more than 100,000 red blood cells in it. Um Some of the limitations is that it can't pick up a retroperitoneal bleed or injury. Like I said, the fast scan, which would be a more informal scan and the four regions that you'd look at there, it hasn't been standardized in Children, but um it's still a useful tool and um then you can do a formal ultrasound, but time is a factor in that. Then a CT scan is also possible depending on your mechanism and how many other organ systems are injured. You can do APA scan, you can do an abdominal pelvic scan, which is like I said, determined by your clinical assessment of the mechanism of injury as well. And this does not predict the need for exploration. I think people must also understand that uh regardless of your grade, your grade is not grade of injury is not going to be the thing that determines whether you're going to theater or not. This is uh po which is the Pediatric Emergency Care Applied Research Network or Consortium um that uses the National Database in order to formulate guidelines have come and they have a guideline here for a CT abdomen. There's one for um the need for a CT, a head ct, but this one basically says in the presence of these seven criteria and all must be present, it's not one or the other. So if all seven boxes can be checked, you can safely say this child does not need a CT AD O and you can then possibly admit for observation or keep in your trauma facility for a couple of hours in order to do um serial H PS and abdominal investigations. But in the presence of these criteria, you can say it's not necessary. And as you can see, it has a 99% sensitivity. Um then with regards to management, it's always to assess and resuscitate and to stabilize. So at each aspect of your ABC S, you're going to intervene before moving on when it comes to, then the fluid management, you're going to choose crystalloids first and give them boluses um 10 mils per kg. If they're stable. If they're more unstable, you can go to 20 mil per kg. But I'll go into that to further detail on that decompress their stomach because they cry, they swallow a lot of air and they blow out their abdomens, which can also hamper your ability to examine them. Well, decompress the bladder as much needed. Um And pain management goes a long way as well and this won't obscure any clinical signs. And you can give small allot frequently in order to assist with your examination and just give the child pain, pain relief to your child. Then is this decision of non operative management versus operative management? And that is determined by how stable your patient is. Then it's always good to note that this management, ideally in an ideal world, a pediatric surgeon with trauma experience should be the one to make the determinant of whether operative management is needed or a trauma surgeon with adequate pediatric experience, which is not always the case within our South African setting. Then the criteria for an emergent operative management in hemodynamic instability. And also one wouldn't consider that you should activate your massive transfusion protocol within your hospital. A clear indication and question was um hemoperitoneum or if there's any evidence of gastrointestinal perforation, regardless of your hemodynamics, that that child would be taken to theater to have an exploration. If there's, then if there's an acute deterioration in your patient. Um and if there's a relative unresponsive this to crystalloid infusion, so you can go up to 60 mil per kg in order to see whether the hemodynamics stabilize and then a strong indication for theater. If there's no response, even after replacement of half of their blood volume with blood products or a relative indication, there's no response after a 20 mil per cc per kg transfusion of blood. And then if there are signs of persistent blood loss. So if your BP is lower your tachycardia, the child has a decreased urine output. Um or there's a decline in the hematocrit despite your crystalloid or blood product transfusion as well. Then one of the guidelines that has been developed by the Pediatric Trauma Consortium in America is the guidelines for blunt liver and spleen injury by A OAC, which is just an acronym for American regions that had developed to this and that looks on whether there's very recent or ongoing bleeding. And then you can say that the CT is needed based on that if you follow um the left hand arm of the questioning and it's a binary question. So you just answer yes or no if you um and then you follow the algorithm as it goes down and as you proceed down, if your patient has any symptomatology beyond you thinking them stable. And then after your serial examination and serial H PS as defined by this, you then look at your HP. If it's less than seven or they symptomatic, you then provide a Taxol recess and re reevaluate, do it again and follow it along. It will take you along the path of when the child does need a CT scan, and you've determined the grade that the child will then be admitted to a pediatric ICU unit. And from there, follow the binary questions along until the patient then fails non operative management. In which case, surgery would be an option again at the discretion of the treating surgeon and preferably a pediatric surgeon. Or if you have the facilities angiography and embolization in the American Pediatric Society or Pediatric Surgery Association has also developed guidelines based on a retrospective study that they, they conducted back in 1997. And these guidelines have subsequently been updated in 2019. And they use a CSA as their little acronym to help you remember, admission criteria, the procedures you should follow and then set for your discharge criteria as well as aftercare, what the activity restriction in any followup in imaging that is necessary for the patient. Ok. And with regards to non operative management, as I said, it's the gold standard and it's what we do for Children, but it needs to be done in a facility that has operative capabilities and the surgical expertise for that. And this is the favorite approach in hemodynamically stable Children. Unfortunately, in general hospitals and Children under the care of adult surgeons, there's a higher rate of splenectomy. And this is um a practice that we as pediatric fraternity actually need, in my opinion, need to advocate for non operative management more so that they understand the value and benefit to the child. Um with regards to delaying operations or after an attempted non operative management, it doesn't actually increase the rate of transfusion. Neither does it lengthen the stay in hospital or overall mortality. And some of the criteria for early discharge are highlighted there again, not having act um or no positive findings on your ct, no abdominal pain, no concern for abuse into the environment that they'll go back into with no other serious injury associations. Um I'm not going to go through each grading. This is just pictorial guidelines, but the A ast are still the guidelines which radiology even here in South Africa uses in order to grade them. Um So with regards to splenic injuries, it's the most common isolated injury. The spleen has immunological importance for Children. Um Most splenic bleeds stop spontaneously and CT can usually localize the injury quite effectively. The indications for an operation, whether it be laparotomy or laparoscopic in Children would be, as I said before, ongoing blood loss. Um and then suspecting other injuries. And if you do need to operate a spleen saving procedure, if at all possible needs to be done. So, direct suturing of the spleen, only a partial splenectomy or mesh wrap of the spleen and if that is not possible proceeding to splenectomy, but we need to know that within our population. A splenectomy is not a benign. Um a procedure in Children carries with it. A high mortality rate if they do get a postectomy, um, infection of those encapsulated organs actually carries a 5858 times more pos um possibility of mortality in a child who has their spleen taken out versus a child who hasn't. So we really, really need to try and save those spleens and save our kids from having a splenectomy. Complications of splenic injuries themselves as a result of non operative management is that they can have a delayed bleed. There can be a, a traumatic pseudoaneurysm that forms or even a splenic pseudo pseudocyst can form with regards to liver injuries. Again, the grading system and a pictographic representation of it, um, up to 40% with liver injuries actually die before they arrive at hospital. So they can really examinate from these injuries, injury to the hepatic vein or the infer review or car I carry with it a high mortality rate. And if the patient is stable, then non operative management is the mainstay and how you determine how long they stay for, um, is determined by their grades. So they've had a CT scan which then determines the grade they stay for that number of days. Plus one, preferably in ICU setting. If it's a grade four or five complications that can arise are bilary leaks, thomas, bile bile duct leaks or bilary peritonitis and hemobilia, not hemophilia. A delayed bleed. If you do proceed to operative management would be the same reasons as for splenic injuries with hemodynamics are an issue. And how you can gain hemodynamic or hemostatic control is if you have access to embolization, that would be a possibility although not validated in Children. And also people don't quite know when would be the optimal time to do it. What they do think is if that hemodynamics are relatively stable, but like I said, the hematocrit is dropping and that would be a reason for trans having to persistently transfuse one could then consider embolization. If you had an open abdomen and you were at laparotomy, what else could you do? You could do manual compression directly onto it with your hands, you could pack around it, you could do the pringle maneuver um in order to stop the bleeding because you could suture, it, use Corry and organ beam coagulation or any topical hemostatic would also aid in that. Then if there's significant hepatic injury, this is really um sort of devastating injuries. Now you can do a total hepatic vascular isolation. So all the blood flow to it isolate them. And that gives you a 30 minute window in in order to gain hemostatic control. And also one would need one of the recommendations is that you need to replace the blood volume. We can also do a venovenous bypass. These are more specialized um procedures and then your last resort which carries with it high mortality and morbidity is to do hepatic resection. Then one needs to consider in these devastating injuries, uh abbreviated laparotomy or a damage control laparotomy. There is a philosophy that there's a phased approach to it. So your initial damage control laparotomy and then planned reoperation looking at it, um the rook needs to be balanced against the effects of packing the negative effects of having t the abdomen. So raised intraabdominal pressure and the effects that that has on your ventilation, your cardiac output, your renal function and your mesenteric circulation. So one doesn't want to contribute to any um intraabdominal hypertension or compartment syndrome later on. And when you're taking the decision to do damage control laparotomy, it really needs to be done early and decisively. So when you see that you're not achieving this, don't try and keep fiddling. Oh, let's do this. Oh, let's do this. Just say we're calling it this is we're gonna pap this abdomen and we'll come back at a later stage. The child then goes to ICU according to the phases on the side. As you can see there operative where you want to control the bleeding. If there's any contamination, one needs to clean that out, you then pack the abdomen. There's rapid closure. And what they do recommend is that abdominal wall expansion be used until hemostasis is achieved. And there's visceral organ edema, visceral edema subsides and then they're then admitted to ICU monitored quite closely with blood gasses, looking at their pee and their bicarb as well. You want to maintain the, the heat and you want to actively rewarm them because the lethal tire plays a quite a big role, significant role in this with acidosis coagulopathy. Um and you just end up chasing your tail. So that's really important when it comes to the abbreviated laparotomy, that would be decisive about it. And you bring the child back at a later stage with posthospital care. Um then no, no imaging is actually required for an asymptomatic child. And then organ integrity is not always reflected in the imaging. So it may still look very dramatic on the scans or ultrasound, but actually the organs were fine. The liver functions are actually quite normal and low grade injuries heal within four weeks and high grade injuries um can take up to six weeks to heal, then can moving on to pancreatic injuries. It's an important aspect of imaging with the pancreas is to look at the location and the status of the location of the injury and the status of the pancreatic duct. Grade one and grade two injuries. Non operative management is a given, grades 34 and five, various studies report various outcomes. In Toronto, they had nine patients that actually presented in a delayed fashion. All nine were treated non operatively with no zero mortality rate at the end of the treatment and only one or two went on to form pseudocysts. Whereas can and Weinman found differently. And surgery for distal pancreatic injuries, then in light of all of this controversy. Whereas the patch study found that with um operative management, there were fewer pseudocysts, there was less time to parenteral on parenteral nutrition. Um fewer interventions overall were necessary and they had a shorter hospital stay. With that. The recommendations are that if you have early ct with oral and intravenous contrast in all patients who according to their history, physical examination and the mechanism of injury, you think has a blunt injury to the pancreas to document all the injuries and also provide early E RCP to stent that duct and also on a case by case basis. Um non operative management then goes hand in hand with TBN um expectant management of the pseudocyst formation. So as one of anticipated complications, percutaneous drainage for symptomatic infected or enlarged indos, so then any compression effect can extend up into the chest or media spine. And even that one would then consider to um percutaneous drainage of those complications of non operative management of your pancreas. Like I said, Pseudocyst is actually higher in your non operative group. Um and fistula formation, even in those Children who do end up with an operation, the rates seem similar between the two groups. Then some intervention strategies for pancreatic operative management. Again, we want to protect the spleen. So we try and do spleen, sparing distal pancreatectomies, then we can delve a little bit deeper and try to whipple pancreatic resections. Um And also again, trying to maintain as much of the pancreatic tissue as possible with grade five injuries ordinarily. Well, like I say, operative management is probably more indicated, which is most, what most people say is that you try and do pyloric exclusion with very complicated procedures such as a whipple duodenopancreatectomy and a total pancreatectomy. Also depending on the exact injury that you find. And when you're heading here, one also then needs to think of associated injuries and it's very difficult to separate pancreatic from a duodenal injury. So not difficult in the sense, but they go quite close in hand in hand. And when you're getting into these complicated procedures like Whipples and total pancreatectomies, that one also needs to consider the input of the papillary surgeon um in this intervention as well. And then something else that can be done is an E RCP and just to place a stent also for those more proximal injuries, um hospitalized or posthospitalization care. With regards to Children who've had pancreatic injuries, there's no limitation to their activity. Whereas with a liver injury, you'd say that they should refrain from um activity at least their grade is a week plus two weeks after that. And with pancreatic injuries, the dietary restrictions are they can eat when they feel it or when they're painfree. And also they try and say have a low fat diet until the enzymes normalized. Um Just with regards to this and the duodenal injury again, if you do encounter duodenal injury that if you are able to primarily do repair it, that you do it. But if not, and it's quite an extensive injury, that sort of this notion of a triple tube technique be employed where you get pyloric exclusion. So you use an absorbable suture and basically close that down, then you place a drain in the duodenum you place and there a gastric tube. So there's gastric decompression and then you put in a feeding reggio toomy as well as well as adjacent drains around the repair that you have made and moving on to the kidney. So a kidney again, grades 1 to 2 non operative management previously was a well, 1 to 3 should I say was a given for those. But now, even for higher grades, non-operating management is indicated again, the aim is to preserve tissue and function as well as decrease morbidity for these Children. If they've got microscopic hematuria, they can be managed at home. Obviously, if it's an isolated injury, stable patient meets all the criteria for discharge. As discussed previously, premature, they're on strict bed rest until the urine clears. Then some of the risk factors for non operative management. Failure, particularly in kidney injuries is if the renal collecting system is involved. If there's a large perinephric hematoma, if they form a urinoma of more than four centimeters, if your laceration is sort of on the anterior, medial or medial aspect of the kidney and if there's any obvious associated renal fragments. So it's really separated from the rest of the kidney. You'd consider that you, you've watched for that at least, and then consider operative management later on some complications of non operative management. It's quite an extensive list and they are sort of early complications and the leg complications. Some of the early ones are refer peritoneal hematomas, urinoma, they can develop ut eyes, culture negative fevers as well with sepsis. Um and then hypertension, some late complications that occur hydronephrosis, chronic pyar nephritis as well. Calculi that can form renal renal artery stenosis, hypertension can also be seen later and then renal atrophy. Some interventions for kidney injuries, first choice. And if the facility is there, a transarterial embolization would be the best option. But some indications for open operative management, laparoscopic management of persistent hemorrhage if there's any expanding hematoma at the time of exploring associated injuries. So, if there's anything else that warranted laparotomy or laparoscopy that you now see an expanding hematoma, there's any vascular injuries should also be repaired at the time of exploration. Um and particularly if it's the right vein that's involved that should be repaired because they are very, very little to no collaterals um to the right side that can be used. So, in conclusion, despite South Africa being central improving and promoting non operative management in Children, um in centers, the Children are treated by general surgeons with for the blind abdominal solid organ injuries, um which is also little to no pediatric surgery input that is sought for Children that we really advocate that they don't get splenectomies and advocate for non operative management. Um They don't, obviously non-operating management is comes with its own complications, but each one of those can be dealt with in a lot less devastating manner than a laparotomy at the time. And this is always in hemodynamically stable Children. Um Yeah, so that is it. And I hope that makes it a little bit clearer on how we look after Children with solid organ injuries, after trauma. Um Crystal, thank you very, very much. That was really an excellent presentation, excellent overview um of this vast topic. Only now when you are present, I thought we had narrowed down your topic, but only when you are presenting, I realized that it is still quite a vast topic, but you dealt it well. Uh just, uh congratulations to you and also to your mentor, Doctor Simo who must have guided you in the right direction. So I think without waiting further c if you can stop sharing your screen for now, I'm going to invite Professor Sebastian um to give his advice to uh to share uh his powerpoint presentation if he has one and uh to comment, not necessarily on your presentation, but, but uh pick up the points and, and give his uh his opinion uh on, on the topic of blunt solid organ injuries in Children. Sebastian, please. Uh Sorry, you need to unmute sebastian. You just need to unmute yourself, please. Yeah. Ok, good. Ok. Can you hear me? Yeah. Ok. I hope my uh, parrot, my parrot behaves. That's ok. Yeah, thank you very much, uh Milan. Uh and also thank you very much Christal for a very, very comprehensive uh and broad background on, on the topic as, as you find out. And as uh Milan just mentioned, it's a vast topic. So it's very difficult to uh justify all uh uh all the aspects. Um I just uh want to, you know, listening to you, I've got a few comments. I don't have, I'm happy I didn't have a powerpoint presentation because I thought you were going to talk for 20 minutes because you talk a little bit longer. So people, people are probably exhausted. Um I just want to mention a few things, uh just a technical thing. Uh Some of your slides, uh I content was perfect but I would, uh the, the text was a little bit small on a couple of slides. So it's important when you make a powerpoint presentation, especially the conference to make it big enough. Not too many words on one slide. Yeah. Um then you talk about uh the, the uh the the biggest cause of, of uh blunt abdominal trauma, of course, uh you mentioned motor vehicle accidents. I just want to mention that the World Health Organization in 2008, it was 12 years already. They bent the term accident. So we shouldn't talk about accident because if you say accident is sort of like an act of God and we couldn't do anything. So we should take the public health approach and we should call it motor vehicle creche because a fact which you can risk factors and mitigate factors and you can, you can influence it. Um So that's very important. So talk about motor crashes because an accident is sort of like no one is to blame while in a crash, you indicate that there are reasons which you can address. Um And one of them already uh mentioned, uh refer to it in this, in this text is uh the maximum speed uh in South Africa, the maximum speed and uh uh in, in, in uh uh uh the build up environment is usually 60. Now, if you hit a child with a car, which is driving faster than 40 kilometers an hour, the chance that the child will die is 90% you know. So it's actually the same that there is a maximum speed which uh uh if you keep to it, if you drive 60 you hit the child, the child is dead, you know. So, uh in Europe already 20 years ago, they changed uh the maximum speed in and around schools and in suburbs uh where there's a lot of Children to 30 kilometers an hour and then decreased the number of dying from trauma by more than 50% in just a few months. So that really is uh uh something which our government also should take to, to heart. Uh they, they uh came down on us because of the Coronavirus with a massive um uh me uh regulations and restrictions and, and killing the economy and you know, that the total number of people dying from Corona Virus, I think it is just reached 17,000. But I just want to tell you that over the last 20 years, each and every year 17,000 people died in traffic just only from in this country. So when the government did not do any action, well, we went ballistic with the Corona. They, they haven't done much about the road traffic issues. Ok? Um Then just about uh uh I want to mention because it's sort of like a pet topic of me that people say you must do a laparotomy when there is perit. Now in trauma, uh the majority of, of uh uh uh indications is blood loss. So blood blood in the abdomen. So blood in the abdomen does not cause peritonitis. So if you take a histological biopsy of the peritoneum, and when there's blood in the peritoneal cavity, there's no peritonitis, it's peritonism and therefore cause blood in the abdomen, you get AAA heart abdomen with guarding rebound. But if it's just irritation of the, it's not inflammation and it settles after various uh uh uh time intervals and it can settle in a few hours, but sometimes it takes 24 hours. But eventually, if there's only blood in, it does not continue in, in, in, in a tender abdomen rebound. And so that's an important thing. Um Then you, you mentioned all the abdominal solid organs, but I think it's also important if you talk about abdominal tumor to talk about the abdominal wall. Although very rarely, uh you know, you can get diag rupture, you can uh abdominal wall rupture. Uh you can get internal herniation that you've seen. So, organs going to between of the normal cavity and also uh the pelvic floor in a high uh acceleration, deceleration, trauma, you can get some uh numerous times the bowel, the abnormal content goes and, and basically herniates through the pelvis to the pelvic floor, it ruptures. Uh So that's normal one. Um Then uh we also asked about loop. So it's very important. We got a loop. Uh But many people think that the load is sort of like a replacement for the CT that it's not. We really use the lod as a replacement for the trauma and the trauma series in, in uh uh uh in, in acute trauma is a little c spine, uh chest and pelvis. So we use our uh and we also, of course, look at, look at the extremities, but the basic reason for doing a lot in one go is looking at the trauma series which you would do in the hospital and you do not have the uh and it's not a, a replacement for CT scanning. It's, it's just basically a replacement for normal x- uh CT scanning, the indication for CT scanning. Uh We usually uh differentiate between an acute indication for CT scan and a separate. And I'll explain the difference if you uh suspect if the patient is hemodynamically stable, that you suspect a solid organ injury of the spleen or the liver. Uh you would like to know that because it's going to change your management because if the spleen or the liver is ruptured with the child, uh offer the advice to keep them indoors for two weeks and for three months, no contact sports, which causes difficulty in t to. But we, we, we tell the parents of this is vulnerable for the rebleed. And the reason for it, of course, is that a rebleed? So there's a, a ruptured spleen or liver and there's clot inside and you get another blow to the organ and dislodge the clot and then bleed and that the bleed can be lethal. So you want to avoid it. So it is important for diagnosis. So if you, if the patient is not uh uh acutely uh has got no uh um it, it's not hemody unstable. Uh But you think there may be a solid old injury. Uh And you want to know that for sure, for, for uh to determine your further management, then we do the CT scan the next morning or can we do it separately? We did the, the radiologist, uh, they're very difficult in the hospital to, to get them out of bed in the middle of the night and they get very annoyed that we do that for a patient who I stable and they say, yeah, but you could have done that the next morning. So if you just suspect if the patient is completely stable, but you suspect it may be a solid or injury, then we go see you the next morning. If, however, if you think that it is a hovious rupture which may require surgery, then we do a CT scan in the middle of the night. So normal it happens. And the reason for that is that in an adult, you would, there's a whole of rupture. So usually it's either the bladder, uh the colon or, or the stomach or, or the small bowel, you get air under the diaphragm and we do it in an adult. You do a chest X ray and you see air under the right under the diaphragm. And that will then of course, uh uh it will tell you to do a li in Children, especially small Children if they can have a whole of whis in you without actually air under the diaphragm. But you'll pick up that uh, air on the CT scan. So therefore we do the CT scan as we suspect for all of this. So it's a major trauma, uh patients who got obvious bruises and acute abdomen, although his, he be stable, you're really concerned about it abdomen. Then we do a CT scan uh in the acute, in the acute face. Um then uh going from there to your specific organs, you talked about the liver and you said that uh uh up to 40% mortality, I think that's probably a little bit much. I mean, maybe studies uh indicating that. But I would think from our experience, it's less than 10% of people of Children who die and uh of the people who actually reach the hospital. Uh It's got a very good less than 1%. And most of them actually die in the acute phase when they, they still bleed, they act bleeding when they come in. So they basically do rather than if they, if they normally say, if they reach that, we can usually save their life. Uh Then uh you also mentioned some resections in the acute face if you do left neomy and, and uh and you see a damaged organ, I would, I would be very careful to start doing the receptor resections. Uh It's got a very poor prognosis. So the damage control is much better. So we told adults who had a six pack causing it and then smaller packs. But uh uh we store the anatomy, the normal anatomy, which is also very important. So don't put a scope in the place where the spleen or the, the. So the inexperienced surgeon, they put a uh a so where the blood comes from, that's not what you should do. Because towards the center of the organ, the vessels are big and the veins are very fragile in the middle of the liver. So there's a tear on the side and you put a scope into the middle, you actually cause less of the. So you must just put the organ in its uh organ in its normal shade back and then put the p around it and then compress it from outside. So that's an important one. Um Then we also talk about pancreatic uh resection. Uh uh Professor Peter, he does the adult. Uh wh and I discussed this with him on several occasions and I mean, in, in uh I worked for, for about 10 years in the adult. Uh uh The Children above the age of 12 are treated there but to do a, a resection or a pancreatic resection in the acute face, I would once again, I would really uh uh you wanna get that because it's, it's really asking for trouble. You know, there's so many other problems with bleeding. You don't know what you're doing. It's much better to check and do damage control. Get a specialist uh uh uh send the patient back to to ICU and a specialist for you. And the next day when he's physiologically uh normal again, that that's got a much better outcome. Um I think, yeah, the, these are the main points I wanted to discuss. I can go on and talk more and more, but I also would like to get other people. Uh and maybe you want to respond to some of my points, but I also would like to get other people uh an opportunity to, to give their view. But uh once again, in conclusion, it's a fantastic, fantastic, really comprehensive, a very rich presentation of all the things that were in there. And, and I was really uh surprised by how densely you all, especially in the assessment, you basically mentioned everything uh which uh necessary, but it was very well done. OK. Thank you so much. OK. OK. Sebastian, thank you very much for all your, all your insight and uh and wisdom and practical, basically practical advice. Uh Before I invite uh uh doctor, I just got one good feedback to give you uh since we came back from the, the Ss Congress last year, November, when you uh demo us your new model of the Lod do. Um uh I sort of uh took it upon me to get our Loddo at the Fre Hospital repaired. And the radiographers were so excited that about a month ago she came personally to me telling me that Doctor S Loddo is working at prayer hospital. So I really felt good that you devote that thing to us and you emphasized or re emphasized the importance of lod uh on our mind. So that was one positive feedback to you. Thank you. Thank you very much. What is important is that, you know, the the majority of people in trauma died the first hour, either from blood loss or hypoxia. And the, the first hour, the golden hour they always talk about and you do not want the situation in which your child arrived alive in the hospital. And now you have to do all your investigations and the child has to go to a radiology room and has to go far away and he's for the chest and the catheter and a drip and it all comes out when the port is rushing this child to another department. So, the greatest advantage of the lo is that, uh, and the lo in our situation is so we don't have to move the patient. We can just do the load of there. I mean, uh, you know, within a minute you've got, uh, radio, uh, radiography of the whole body, which really can be life saving. Uh, thanks for that. Very good. Yeah. Uh, that's number one and either you or it can correct me a couple of years ago, Chris West Ta, who is from Red Cross, but now has been a consultant at bar for quite a while. He conducted a survey of the consultant, pediatric surgeons in the country about uh management of blunt pancreatic injuries. And it, I will comment when he uh starts talking. I think the consensus was, as you correctly said, conservative management as far as possible. And surgical approach left when you are not winning with conservative management only for experts. So, so yeah. Uh so I think without much uh further discussion, I just invite Doctor Itai Sang, whose association with Department of pediatric Surgery in East London is very, very long. I mean, it probably as long as the existence of the department. Doctor Simo worked with us in 1996. Then uh went and specialized in general surgery at Bara and came back and was our fellow and uh completed fellowship and then continued working with us as a consultant until 2016 when he decided to relocate to Port Elizabeth. So we still miss Doctor SIBO and his, he's sharp acumen and academics. Uh But uh anyway, it's good that he's in the province. So it, I please you need to comment and give your advice. Thanks me for those kind words. Basically. Uh Can you all hear me? Yes. Yes, very well. Yeah. Basically our takehome message with crystal is the same. But the management of solid organ blunt trauma in Children as well as in adults for that matter is conservative whenever possible. Yeah. And as prof Sebastian emphasized a while ago, a moment ago in complicated in more complicated injuries. None of us should hesitate to, to obtain expert assistance, whether that's a vascular surgeon helping you or a hepatobiliary surgeon for complicated duodenal and combined duodenal pancreatic injuries. Um Basically, that's our take home message and all the other stuff you have mentioned. Um we actually have very limited radiology resources in pe. So we know how important all these mechanisms of investigation are for three hospitals in pe we have one functioning radiology department. Again, as crystal emphasized blunt trauma in Children should be managed by pediatric surgeons with experience in trauma or trauma surgeons with experience in Children. We recently had an unfortunate case in a patient in pe sorry, not a case where a ten-year-old child with a um bicycle handle bar injury had a distal transection of the pancreas, the tail of the pancreas and was subjected to laparotomies by the adult surgeons. That was more than two months ago to this day, still not clear why that was done, but it's probably, you know, they were obviously trying to do the best they could for the child. It's again an indication of the limited resources we have in terms of ready access to pediatrics. But uh that's about all I want to say. Um and I thank, thank you. I think you have really um given the message in like two or three sentences, conservative management as far as possible and don't hesitate to call for assistance when you are in trouble. I think it's, it's very wise words uh with experience. And I want to just uh reemphasize the importance of tho the those words on all our, our registrars or, and uh junior staff, it is most important. What doctor sang just said. So I think I just invite now doctor Yashoda Manic, our consultant, pediatric surgeon to make her comments, please. Yoda. Hi, prof. Uh Yes, thank you. Uh Thanks to our pe team. That was really good comprehensive look at abdominal trauma. I think I learned a lot and I'm sure our juniors learned a lot and I'd like to thank Prof Van us for also joining us and for his pearls of wisdom uh which were very um II learned a lot from that as well specifically about the hemo peritonism because we had a patient like that recently. So I think he answered my question already. Um And I also want to highlight what he said about, you know, uh the motor vehicle crashes, the importance of prevention and more studies coming out and showing um the numbers that we are having in South Africa and the developing world compared to the developed world for um Children with um pedestrian and, and passenger trauma. So I think that's a, it's a big take home message as well. Mm It's a very expected problem. Um And, and to that point, we had AAA patient recently who came with a second pedestrian. Um So uh we also have to look into the child's um environment and circumstances. Sometimes we mustn't forget about that. Um Yeah, I don't have anything else to add, but thank you. Yes, thank you. Uh Sebastian. If I can just request you to comment um um on the campaign which Child Safe uh ran in Cape Town and in the Western Cape about uh emphasizing the need of use of seed beds. Yes, I think that is uh I think. Can you hear me? Yeah. Yes, yes. Um Yes. Uh Thank you very much and that is the lowest hanging fruit. Uh You know, from our, we've got a database of each and every child which we treat, which is about 10 almost 10,000 a year. Uh We've been doing it since 91. So you've got uh two over a quarter million uh uh injuries, the, the all the details, more than 50 variables on, on, on uh two or more than a more than a quarter of a million uh childhood injuries and uh road traffic questions. Of course, it is the biggest killer. Uh The most common is pedestrian, but the second most common is passenger and we found that from our Children, uh 87% passengers are not restrained. So we wanted to, to check if that is only for injured Children or also for normal Children. So we did observational studies and we showed that uh it showed that uh 10 years ago when we did the first one, that 90% of Children were not restrained, 90%. Now, the there's many, many reasons for it. Uh 11 of the things parents always says that uh young, that they can't afford AAA child seat. But of course, if you can afford to fill up your car with patrol, which is my car also 1000 rand and you can also buy a children's seat. So I think that's not a good argument. Uh And according to the, the recent in 2015 and the first of April, the lower change, so before that Children under should be under the age of three years did not need to be extended. But now all Children, so over the last five years, all Children need to be done. But in spite of the fact that uh uh it's low, uh South Africans are not very law abiding and they're still not stepping up recently. We did another observational study and it shows that the number has gone up. Uh, but it's still uh uh something like 82% of the parents who bring their Children to hospital, uh have not restrained the the child appropriately in their car. So a small Children need a special seat is the each appropriate seat and smaller Children, they should sit with the, the front and all these things. But uh that is the lowest hanging foot. So that, that's one thing we, we, we have been working on in the campaign. And one of the things is that we try to get the security people working uh leaving the uh at the gate of the hospital, checking the Children are properly restrained when they leave, when the parents leave the the hospital. Another very interesting uh project is the taxi project. Uh We had some horrendous cress in the western cape in which uh school buses were involved in a crash. One of them uh the school, the, the the taxi driver drove his car over the railway while, while it was a plane coming and more than uh 10 Children died on the spot. So what we've been trying to do is train the taxi drivers. Now, uh you can train them with a stick or a carrot and we decide to use the carrot, what we do, we put the tracker in the car uh and then we uh observe how they these drivers are driving. Now, the the taxi driver who drives the safest and the best he gets a cash reward. So every three months after we get all the taxi drivers together and we monitor them uh uh individually and the driver drives the best or the most improved driver. We give him a cash 5000 rand check in his pocket. Uh 2nd 1, 4000, 3000, 2000. We do that every three months, but once every year, the big awards. So the the best or the most improved drive for the whole year, we gave him his own taxi. So the majority of taxi drivers, they do not own their taxis, they drive it for someone who's rich and who owns the taxi. So for them, that is a, that is a life changing uh price because then they can start driving for themselves and they can create their own business. Uh So we've been doing this program now for eight years. Initially, we had 17 drivers at the moment. We've got over 1000 taxi drivers which we are following and we can prove that we put all the data, we call it the, the, the information system, it's called T uh T Metris. So you, you can document exactly and see how these guys are driving uh 24 7. And we can prove that our taxi driver drive better and safer uh, than the average South African driver because so that is really a high achievement. And we also, uh from all from in these eight years and I think uh the first is now lockdown, but before the lockdown, I think they were, I mean, something like uh uh 17,000 Children, uh every, every week and from our more than 1000 tax, we never had a single, uh, we had some f what do they call it? Uh, fender benders cause you never had a, uh uh uh an in an injury, a great crash or, or a child. Being injured or dying. Now before that, uh even at one of the schools, they have two deaths uh from in the one year, you know, so this is really uh a game changer and I hope uh we, we have been running the program very successfully in the Western cape that we we are dying to extend it to the Eastern Cape and I know to and, and to uh but of course, uh it's quite an expensive program because we donate the whole taxi, which is of the price of the taxi is a whole million. Uh So and, and of course, we produce cash and, and uh the C center every three months and of course, the monitor it, it is very labor intensive and it's of course following the checkup. But it's also instilling an attitude of uh uh and, and uh attitude to, to not only the the taxi drivers uh uh that their cargo is as precious as, as as can be. And uh ii often use example, none of us will go in a plane when, when the pilot is blind. But I can tell you that we tested all our drivers and 70% 70 so more than two third required spectacles. So these people are driving Children around well then they no wonder they ex because they are all blind, you know, so it's simple, simple things. Uh and we give them also first aid course and uh all kind of. So the, the the core is the, the tracker. But there's a whole program, it's basically creating an awareness that their, their cargo is extremely precious and, and that, you know what happens to the Children that it's not accident but that they are precious and that they can be prevented. So we, we are, we are, we are really trying to extend it and probably next year we'll extend it in other provinces that we will have to find donors uh to do that. And we're looking at uh petrol, petrol companies and, and also car manufacturers crystal, ask your question. Yeah. II just wanted to ask more towards the national level. I mean, when you do your driver's test um for your learner's license and you learn the K 53 book, there's very little information on in terms of what's allowed because there's a culture within South Africa to have small Children in the front seat, even with a safety belt on which is as unsafe. Um you know, and in the K 53 you don't ever read that, you know, only if you're a height of 100 and 50 centimeters or more and a weight of over 50. Should you be permitted to sit in the front seat? Is there any kind of far-reaching thing towards that to the traffic safety or traffic department to approach them to amend K 53 information so that at least at a minimum if you're getting a learner's license. You've come across that information as well. It's a very valuable uh comment crystal. Thank you very much for that. Um I think that's something we, we haven't taken it up, but I think it's definitely something we should do. Uh make it part, make child safety uh aware as part of people getting their driving license. That's a very valuable uh comment. Uh The, the problem of course is always that you can teach, I mean, uh uh I think people are most vulnerable, uh or vulnerable, most open for uh important information if there is a, if, if there is something uh to gain from it. Uh So I think that that's, that is a very good moment but of course, the, the people are lawless, uh in, in South Africa, people drive in spite of the maximum speed by faster than 60 within the C and schools. So, 11 that they talking, uh prevention, they talk about active prevention and prevention. So active prevention is, uh for instance, a sign board saying that you must reduce your speed to 32 an hour and you can do that or not South Africans do not listen to that. The mentioned is putting a speed up and so you're forcing it and that is, that's much better. Uh And I think that's what, uh, 11 of the first things we can do, uh is around schools and in areas where there is a lot of Children to make this increase the speed. And actually there's some examples from informal settlements in South Africa where the people in the informal settlements, they've actually created, they dug up their own street house because taxis were driving very fast and killing Children. Remember in the townships, there's no playgrounds, there's no pavements. Kids are playing on the road and taxis are driving it very fast. So you want to do something else. Crystal, I just wanted to revert back to the lod and do with within the pediatric population. Um Do you do a lot of retrograde cystograms if you suspect that there's a bladder injury or do you make use of it in that mean? We, we don't do that and we don't do it in acute phase. We, we always ask the urologist and then they, they sometimes uh not often, but sometimes they request it. Ok. Thank you. Thank you very much for your comment. I really appreciate it. Uh Sebastian. Uh I'm I'm very glad that uh the the rest of the attendees could hear what wonderful initiatives you people. Uh I think mainly it is coming from child safe uh have initiated successfully run in Cape Town and in the Western Cape. And as I said to you last year, November, I'm eagerly waiting for child safe to open an office in East London and I will do everything in my capacity to assist them. I'm not going to give you. Ok, that. That's really wonderful to hear. And I think we, we should really do that soon. Yes. And my last uh question to you is um before we let you go, uh we uh here in East London have observed or perceived an increase in the incidence of child neglect and child abuse during this lockdown period of COVID pandemic. And we have not gone scientific uh numbers to Baghdad but, but I've seen articles coming from Canada et cetera that they have seen increase in the number of child neglect and child abuse cases. So, have you people at Red Cross seen something like that? We haven't. Uh It's a good question. I have been asked uh by several journalists in the last two weeks, we have not seen an increase. There is no doubt that uh isolation or social isolation leads to an increase of abuse. That's a world phenomenon. Uh The problem is of course that you need a disclosure of the child and especially young Children. They, they normally disclose to the neighbors, to friends, be the teacher uh or the, the creche uh uh the lady who runs the creche, but of course, all these avenues were closed during the lockdown. So uh the fact that they do not present, they haven't presented to our hospital as yet, but it doesn't mean that they weren't abused, they were abused. I think that we, they were just not taken to hospital. Uh That's uh that's the sad thing. But yes, I mean, II just finished another book on, on child abuse. And if you think about it, the, the, the whole lockdown, the worst form of child abuse is isolation and torture. And basically with the corona for the government has forced us to isolate uh uh you know, each and every person of the society. So uh II think uh it must have led to a dramatic increase of social use. And you see that uh in the reports from all over the world, but the fact that we haven't seen it does not mean that we, that it's not uh here, but we just haven't started seeing it. Um Yes, thank you, Sebastian. Uh So absolutely, last thing is we are actually planning to look at um our numbers of child neglect and child abuse we may have seen in our prayer hospital emergency unit and are treated in our department of pediatric surgery. And we just wish to compare 2020 with certainly 2019 the same period. And um uh if, if we, if we need, I wanted to request you whether you would guide us into that retrospective audit, comparative audit. And obviously you people, you will have uh absolute 100% record. So we can compare East London experience with Red Cross experience. Would you be willing to guide us? Wonderful idea. We just actually, we just got our proposal to compare all the trauma cases uh during the lockdown. With the previous years, we just got it through the Ethics committee and I can, as a start, I can send you a pro proposal so you can just uh probably copy and paste. No, that would be absolutely wonderful. No, we will communicate with you on email. I still need to talk to the two junior doctors who are in front of my eyes. Uh But uh I, we in the next week or so, uh we will write to you and we would really like to take uh that project up with East London and obviously comparing with uh Red Cross in Cape Town. Yeah. Now that's one, it's a wonderful idea and I've also been asked uh by an international uh group. Uh they in Switzerland and Austria. They want to uh do a comparative study from different countries. So that's very nice. So we can also be part of that. Yeah. No, that, that's, that's great. Sebastian. Um Thank you very much. Really. It was really nice seeing you even though on zoom, not in person, which is not the same. And we can't, you can't have a beer and I can't have a juice, but, but we look forward to, to inviting you and Itai formally to attend one of our meetings in East London, hopefully in 2021. Ok. Fantastic. It was a really very successful meeting today. I II loved it. It was very nice. Yes. Thank you, Sebastian Crystal. Thanks a lot. Excellent, uh, pro Lazarus. Unfortunately, was there for most of Crystal's presentation, but he sent his apologies because he had to go. Uh, so wasn't able to, uh to, to give his advice or opinion or comment, but uh he has also said very comprehensive presentation. So, Crystal, I thank you for participating and, and congratulations. Thank you. Thank you. Thank you. Bye bye now. Have a, have a great day. Bye bye bye. Thank you. Bye bye.