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And okay, good afternoon, everyone. Welcome to the next session. Uh It's a combined session of trauma and oncology. Uh So I'd like to welcome the first speaker to come up to the podium and that is uh Cynthia Prasad. I am not Satur Prasad. Uh Hi, my name is John Carlson. And uh Doctor Burgeon Rapa is my faculty adviser. I know he wanted to be here but I couldn't make it. So our project is entitled The Obesity Paradox and the pediatric trauma Patient. There you go. Uh So one in five Children in the US today is classified as being obese. Uh The obesity paradox is the phenomena of increased survivability for obese patient's compared to those with healthy weight BM. I, despite higher rates of morbidity and complications, it's been observed in adults in trauma critical illness, coronary artery disease type two diabetes and colorectal cancer. But in pediatrics, it's only been identified an acute respiratory distress syndrome. So the primary aim of our project was to clarify the impact BM I category on pediatric trauma patient's with respect to the listed CO variants. And then also to demonstrate BM I group based difference that are listed right there. We did this using a retrospective large databank analysis um which tapped into the National Trauma Data Bank, which in the US A is the largest um available database for trauma data. Uh So we took all, all patient's who had trauma in the databank from 2017 to 2019, ages 2 to 18 with viable height and weight data. And then we stratified them using their age BM I and uh CDCZ scores into the following BM. My categories. Uh So then we calculated mortality rates for each respective BM I group with respect to the listed co variants. And then uh propensity score matched healthy weight, patient's 2 to 1 to the other BM I groups with respect to those covert, it's as well. Um Also we calculated means for differences between BM I categories. Uh So we had just over 100 and 61,000 patients' in our study. The total mortality was just over 1%. Uh over a half of our patient's were of healthy weight and close to a quarter were obese, the mean age was 11. Um There was a male predisposition to trauma and the racial distribution was consistent with that of the current US population. So, obese patient's had a higher proportion, blunt injuries and burn injuries and lower proportion of penetrating injury than their healthy weight control. So at disposition allow uh discharge disposition, obese patient's were less likely to have died and were more likely to need rehab. So, uh the mean hospital length of stay was longer for obese patients'. And uh and the uh they're average, I see you stay and ventilator days were the same. In addition to this, there were higher rates of all complications, uh and respectively DVT pe in sepsis. Uh So there was uh a protective effect for both boys and girls and there was the mail predis uh predisposition, as previously said, um and they're protective effect of obesity was noticed across all racial groups except for native American, which was the group with the lowest representation. Uh Most of the patient's who had trauma in our study were in their early adolescents, ages 12 to 18 and this was also the group with the highest mortality rate. Um Additionally, this was the group, the age group where this phenomena was noticed. Uh obese patient's were also noted to have a lower likelihood to experience severe injury with uh an injury severity score of 15 noted as a cut off. So after 2 to 1 propensity matching for healthy weight patient's to their obese counterparts. Um with respect to the listed co variants, there was no statistically significant difference on mortality between the groups. So obese Children were less likely on, you know, very analysis to experience death and non inferior after propensity matching. Uh despite an increased need for rehab and longer hospital length of stay, um this these two data points together tell us that there is, in fact the presence of an obesity paradox in the pediatric trauma patient. Um additionally, obesity showed a protective effect against severe injury, which we attributed to the fact that uh there could be lower mobility and activity once a critical threshold of BM I is met. Also most of the patient's in our study experience, blunt injury. So there could be a protective effect of increased adiposity for vital organs so called cushion effect. Also, um there could be a different distribution of forces in uh blunt trauma and motor vehicle accidents and and the impact of the design on safety systems, which presumably is for healthy way patient's needs to be studied further. Um So there, as said before, there was an increased rate of all complications including DVT and pulmonary embolism, which we attributed to reduced mobility for obese patient's, as well as the chronic effects, the chronic inflammatory effects of obesity and also an increased rate of sepsis, which uh there was a linear increase with every single BM I category over healthy weight, which we attribute attributed to higher insulin resistance as well as uh blood levels of glucose. So, in 2020 there was a paper published in the world journal of surgery that documented the uh the adult obesity paradox in the trauma patient. And in that study class to obesity, obesity and above was associated with a higher mortality rate. Despite that class one obese patient's were non inferior to their healthy weight uh controls and the overweight group did the best. Um There was also increased hospital length of stay icu length of stay and ventilator days for obese patient's. This is in contrast to our study, which demonstrated that the obese group for pediatric patient's was non inferior to their healthy weight counterparts on multi variance analysis and uh displayed a uh obesity displayed a protective effect on, you know, variate analysis. Um Also, the overweight group showed the highest mortality risk in the pediatric trauma patient. Um and there was only an increased hospital length of stay observed for us in both groups, obese patient's had increased rates of complications and a higher need for rehab at discharge. So, the reasons for those differences, uh we attributed that to the uh the the insidious effects of obesity um and macro and, and the fact that it takes many years for the macrovascular and microvascular effects of obesity to be uh present on their end organ um systems. So, in conclusion, um BM, my category has a significant effect on pediatric trauma on the pediatric trauma patient. And there is the presence of an obesity paradox in the pediatric trauma patient. Thank you. That's great. Thank you very much. Are there any questions from the floor? If so, please do come to the microphone. So I'd like to ask a question if that's okay with respect to the underlying physiology of the obese patient. Have you gleaned any hypothesis as to why, other than the fact, pure body mass might be protective on a physical nature. Have you thought about anything underlying physiologically that might be protecting them? Um So, um there is the fact that there is increased padding around vital organs which could account for an an increased cushion effect which would um you know, offset the forces of injury. Um Also, there is the fact that in previous literature, obese patient's were less likely to experience uh court like Trunkal body injuries and we're more likely to experience penetrating injuries to their uh limbs. So that could also account for the effects. Okay. Thank you. We've got a question on the chat from Sean Marvin from Sheffield. Uh were the mechanisms of injury the same in both groups um between the healthy weight group and the okay. Um Yes. So, um in the previous slide, it was shown that obese patient's were more likely to experience blunt trauma um from motor vehicle accidents and also more likely to experience burn injury as opposed to penetrating trauma than the healthy weight control. And I'm right in concluding that your injury severity score was similar in both groups. Is that correct? Uh Actually, no, the injury severity score was higher for the healthy weight patient. So, obese patient, obesity displayed a protective effect against severe injury with statistical significance. Yes, that might explain your, your resultant mortality less. So, so, um after propensity matching, we we controlled for injury severity score and the obese patient's still were non inferior in terms of mortality than their healthy weight counterpart. Okay. Question from the floor. I know only comment. Very good study. I 100% agree with your results. Having worked in the United States for 3.5 years as a consultant or whatever you call attending pediatric surgeon. It is a common saying there that if you get any child, which there are plenty who have bullet injury or any sort of trauma and the more than 100 kg, you better book an ICU beds. So I think you are giving a very important message. That's what uh my old experience tells me. Thank you. Thank you very much for your comments and questions. Okay. Thank you very much. So, I'd like to invite the next presenter to come up. This is Louise Morris. Now Louise is a medical student. So please reflect that in your questions, please. Good afternoon. I'm Ellie, a third year medical student from Nottingham in the UK. Around 2000 Children attend hospital following major trauma. Each year. Mechanisms and patterns of injury vary between age groups and populations. We aim to describe the surgical burned of injury in Children in a large UK major trauma center in these Midlands, the trauma systems of the population of 4.9 million people including 1 million Children and young people. The major trauma center at Queens Medical Center has adjacent children's and and adults emergency departments. Most surgical specialties are based at um see while those highlighted in purple are at another campus. There's also a consultant led major trauma service who attend all trauma calls and admit patient's as well as the ICU and Children. Towards. There's a dedicated level one major trauma ward which can accept patient's from 16 years of age. Our project includes all Children which with injuries eligible for inclusion in the time database who were admitted to our center between April 2020 March 2022 we selected four age groups, preschool, primary, secondary and transitional. Then compared these in terms of mechanism and severity of injury, number and type of surgical procedures and outcome data. 100 and 91 Children, three quarters of whom were male presented in the study period. 84 Children required 100 and 55 surgical procedures during the index admission. Overall road incidents and falls are the most frequent mechanisms. The youngest Children were the most severely injured group yet had most single system injury. It's only in secondary school and older age groups that we began to see penetrating injuries, I stabbings within this two year period. This chart shows which specialties are involved in the first operation for each group. Overall orthopedic and plastic surgeon for busiest that many of their operations for not immediate emergencies. And just to highlight this light blue area represents pediatric surgery. Though the major trauma surgery team in light green also performed torso trauma surgery focusing now then on the area most relevant to this audience. 21 patient's at a quarter of the total required surgery for chest or abdominal abdominal injuries. Most for over 14, a 10 year old child admitted after a fall but not trauma called went to theater 93 minutes after arriving in Ed for laparoscopy and laparotomy repair of small bowel injuries and insertion of a picc line by the pediatric surgical team and a two year old injured child in an RCC arrived in theater 20 minutes after her trauma call and underwent a damage control laparotomy with liver packing as well as insertion of an ICP bolt. Major trauma neurosurgeon joined the team for this case. Both Children survived looking at the procedures performed during the initial trauma, laparotomy or thoracotomy. For those 21 patient, they were diverse and involved management of injury to the majority of organs in the in the 13 patient requiring immediate surgery. The range of interventions is just as wide trauma surgeons performed all these procedures. Three or four under 16 also had a pediatric surgeon present. Only one of these immediate operations was in daytime hours. Five had damage control operations with the abdomen left open. The only mortality was a 16 year old had been stabbed in the heart. He underwent thoracotomy and repair of the injury but succumbed from his injuries on day three. Our key message from this work is that the surgical burden of trauma very throughout childhood, which reflects the diverse mechanisms that we see in each age group. Importantly, we think it demonstrates that demonstrates that there's a huge role for collaboration between specialties, professions and organizations to share experience and learning to provide the best care that we can for injured Children. Thank you. That's great. Thank you very much. Well, Donnelly, any questions from the floor at all? One quick question, if that's ok. Have you experienced or perceive any issues with having your cardiothoracic surgeons off site? And how have you got around that problem? Okay. So, um the cardiac cardiothoracic surgeons are based um hospital about five miles from the Queen's Medical Center. Um So the trauma team are actually equipped to deal with any immediately necessary procedures. Um in a recess thoracotomy and cardiac surgeons can be called for definitive management if needed. That's great. Thank you. And I are use, do you, you have interventional radiology for embolization in your solid organ injuries? Is that available to you? I believe it is. Yeah, I believe it is. Okay. All right. That's great. Thank you very much. Thank you. Okay. I'd invite the next presented to come up, please. Yeah. Yeah. Good afternoon. Thank you for this opportunity to present Bristol Children's Hospital is the major trauma center for the southwest of England covering patient's from Cornwall to Gloucester. Patient's can come to us with complex injuries, often requiring input from multiple surgical specialties and therapy teams are patient's often require ongoing rehabilitation on discharge and follow up. It's therefore important that we can provide the patient, their carers and the primary care team. A concise summary of the hospital stay on discharge. The major trauma rehabilitation prescription for Children was introduced by NHS England in 2019. And guidance has been published by town on what it should include previous audit within our department identified areas of downfall in this documentation and led to the creation of trauma specific combined medical discharge summary and rehabilitation prescription. The aim of this audit is to improve the quality of information included in this combined document by matching it by analyzing it against the recommendations made by time. The Town guidance stipulates that all pediatric major trauma patient's should have a multidisciplinary assessment of their rehabilitation needs and a plan should be created containing nine core items. This plan should be reviewed by a senior trauma or rehabilitation clinician on discharge. We conducted a retrospective analysis of 48 consecutive major trauma patient's and analyze their discharge documentation against the nine core items and a senior review, root cause analysis was performed for those criteria with less than 75% inclusion rate and necessary changes were introduced to improve this content. These changes included presentation of findings to department heads, junior doctors and therapy teams updating the relevant guidelines and the electronic discharge performer. A set of data from a third, the 38 patient's was collected. Chi squared analysis was used to assess the validity of the findings. We showed a significant improvement in the documentation of safeguarding assessment, injuries, sustained ongoing rehabilitation needs and a senior review of the rehabilitation prescription. Although there's still scope for improvement in other fields to summarize the management and rehabilitation of major trauma. Patient's requires a multidisciplinary approach and relies on effective communication. Regular audit of this process allows for ongoing staff education and continued improvement. Thank you. Yeah. Thank you very much. Question on the chat from Clary's from, uh, Westland and children's. Um, is this system working? So we've shown some significant improvements in some of the nine core items, but some of them didn't show improvements. Um, so we'd like to target those next. Um, for example, in the safeguarding field, we made this a mandatory field because all pediatric major trauma patient should have an assessment of the safeguarding status. And it's important that even if there were no concerns about the mechanism of injury that this is documented. However, even though we've made it a mandatory field, sometimes it's still just being filled in with a dash or a full stop. So I think we could make some more improvements to that. Absolutely agree. Uh, just check, hold on. No, no more questions. Okay. Thank you very much. That was trauma
