BJJ Podcasts

BJJ Podcast with Specialty Editor for Trauma, Prof Matt Costa – highlights from the past year

August 20, 2021 The Bone & Joint Journal Episode 43
BJJ Podcasts
BJJ Podcast with Specialty Editor for Trauma, Prof Matt Costa – highlights from the past year
Show Notes Transcript Chapter Markers

[00:00:00] Welcome everyone. I'm Andrew Duckworth, and I'd like to thank you for joining us for our podcast for the month of August. We hope you're all keeping well, as we hopefully are emerging to some degree out of the pandemic and our lives are starting to normalize somewhat. We also hope that you've enjoyed our podcast so far this year, and that you're enjoying all the content from the Knowledge Translation team here at the BJJ, and that we're ultimately achieving our goal and aim of improving the accessibility and visibility of the studies we publish here at The Journal. 

As part of this this year we're producing some special edition podcasts. The first series is insights from the US which the first podcast was recently released and it was a great discussion with the brilliant Professor Vallier, the president of the OTA in North America.

The other special edition series is with our incredibly hardworking and invaluable specialty editors here at the journal. The aim of these is to give our listeners an insight into the vital work they do here, what they feel the current research trends are in their area, as well as highlighting some papers from the past year that we've published, which will be available for free temporarily after the podcast is released.

We started these in March and I've already heard from the brilliant specialty editors [00:01:00] for knee, children's orthopedics and shoulder. And today I have the pleasure to welcome back Professor Matt Costa, from Oxford to discuss the specialty area of trauma. Welcome back, Matt. It's great to have you with us and thanks for taking the time to join us today. 

Fantastic. Thanks for inviting me Andrew.

So Matt, if we look at the past 18 months, you know, it's been a very strange and difficult time for all of us. Can you sort of give us a brief overview of your own insights to a degree with regards your own clinical practice, but more predominantly your role as a special editor for trauma here at the journal. 

Sure. Yeah. So from the clinical side, you're right, it's been very, very strange times. We actually did a podcast, must be a year ago now about the initial impact of the first sort of wave and at that time, I actually did confess to being actually very lucky, which is a funny thing to say at that stage because doing just trauma surgery and the trauma kept coming, whereas all my electic colleagues. Initially all the wards were obviously closed during the first wave, and then most of them were actually being employed to do with the jobs and that. So being able to just carry on doing the day job as a trauma surgeon was [00:02:00] actually quite privileged compared to a lot of my colleagues who spent some fairly uncomfortable times on ICU with some very sick patients in a very unfamiliar environment.

So from that side, I felt very lucky and that's of course continued all the way through. And what's amazed me is how quickly the trauma is ramped back up to at least as busy as it was before, if not busier. Sure you've seen the same thing in Edinburgh.  It's crazy busy at the moment. I think everyone's saved up their sporting injuries and Saturday night injuries and so on. And of course the major trauma and fragility patches have kept coming as well. So it's yeah, it's been interesting times, but I do feel that some of the atmosphere in the hospital is it's almost back to normal. There's a usual sort of mild panic and pandemonium, but nothing like the height of the COVID in certainly the first wave, so yeah, hopefully as you say, some light at the end of the tunnel. 

Yeah, absolutely. I think we feel the same. It just seemed to have ramped up over the past couple of months, particularly. It's just the trauma really has just exploded and like say I feel very lucky that we've managed to continue to do our day job and and have that access. But like you say, the [00:03:00] general feel is things are getting there aren't they? It's not there, but getting there. 

Sure, and it's, you know, on the unplanned care side obviously it is going to take a very long, long time to catch up with this enormous backlog, but yeah let's say, from my perspective, that the trauma just continues on.

Yeah. Yeah, absolutely. And in terms of your role as specialty editor, how has that sort of, have you had to adapt or change, what's been different over the past year to 18 months? 

Sure well I think that the biggest change has been the volume of papers coming through. I mean, I think a lot of trauma and orthopaedics surgeons took the fact that they couldn't operate and do that day job as an opportunity to write up their paper they never got quite around to finishing and submit that to the journal. I think that's the same across most of the specialty sections of BJJ. And I've heard from other people involved in other journals that it's been the same there as well. So yeah, the volume of work coming through has been, has been massive. That's been great. I mean, to get increasingly, you know, very high quality papers coming through the trauma section is just a real pleasure [00:04:00] for me to see on this side. The flip side of that is we've been pretty ruthless now about what we accept and what we don't. So I think even five years ago, papers that would have had a very good chance to get into The Bone & Joint Journal, you know big case series  and so on are just not getting a look in because of the, you know, the sheer quality of the papers that are coming through now, which is fantastic. We're increasingly disappointing some authors who are writing good material, but it's just not quite at the level that we need for the journal these days, given the level of competition we've got, we can't publish everything is the sad truth of the matter . 

Absolutely. I suppose that's where the role of the BJO has come in a bit, isn't it? It's given us that sort of outlet for maybe those papers, like you say, five years ago, they are good papers, but just not at that methodological rigor that we're seeing increasingly, particularly in trauma, but in all the other sections and the BJO has been a good outlet for that hasn't it and done really well from it really. 

Yeah, absolutely. Yeah, there's a lot of good material in there and you know, sometimes... you know, there's not, people say oh its either good enough or it's not, but it's a spectrum. And some things are very close and sometimes it's a little bit of luck involved in it, a tailing wind and a [00:05:00] reviewer in a good mood and, you know, just, and so there's a lot of really good stuff in the BJO. I think it's been a great outlet for those papers that are nearly there. And, you know, the standard is still pretty high. I mean, a tiny fraction of what gets submitted actually gets through even through the review process. So it's still great. And yeah, we certainly publish quite a lot of material in there.

Absolutely. Absolutely. And so last question about COVID, so sort of COVID-related trauma research, you know, there've been obviously a lot published about that in various sort of areas. Do you think we need much more of that? Have we sort of closed that book or do we need some more information moving forward do you think so that as we sort of settle into a normal with COVID, I suppose, in inverted commas. 

Yeah. So I think I guess there's sort of two elements to it. I think some of the papers, I mean, you were involved in some of those, looking at what the impact was of the pandemic, particularly the first wave in terms of outcomes of patients coming in with COVID with a hip fracture, unfortunately acquiring COVID within the hospital, during the hip fracture. And even the outcomes of [00:06:00] patients who were not, you know, on a COVID-free pathway, if you like, but just the impact that they make on the service provision. That was really, I think actually really helpful and really interesting. I think there were a whole series of me too papers, which didn't really add a lot after the, you know, the bigger work comes out, the sort of national and international studies t ereh so I think a pause was probably quite sensible in terms of publishing more and more material. But I think there'll be some interesting long-term sort of effects on both the service, which will come out, particularly in planned care, but also in trauma and the way we deliver trauma, you know, and move to much remote follow-up or reducing follow-up completely as a result of the pandemic because patients don't wanna come. They really, they never particularly enjoyed queuing up in the carpark to get into the hospital anyway, but if you're queuing up and you're worried about COVID or now I think it's just now an appreciation that we don't have to go to hosptial so why would we, why would we want to. So yeah, I think there'd be longterm long-term changes and mapping those changes and reporting on the effects of those changes, I think will be very interesting, perhaps you know, [00:07:00] in two years time, or probably when the dust has settled, we'll be able to review that more clearly. 

That's interesting. And in terms of sort of moving away from COVID then what do you think has been the main themes sort of over the past year or two that you have seen coming out in trauma? Lots of, sort of areas of interest or areas of research that have been been topical. 

Yeah, I think there's, I mean, the patients don't really change and injuries don't change. It's quite, it's fascinating. Isn't it? You go to, you know, the big trauma meetings and everyone's talking about the latest gizmo or technique and wants to tell you about it. But I, you know, as we get sort of older, as soon as I get older, there is not much really new that comes along. So, you know, most of what we're doing is refining techniques. I mean, and yeah, so I don't, there's not been step changes I've seen. The biggest, in terms of the actual surgery, the really big change has been in the way that pathways of care have altered and how patients have been processed through systems in different countries around the world and that that's changing very rapidly. So I think to me, [00:08:00] that's where the big change is a bit, not necessarily in the, in the techniques or the implants or the actual surgical bit, but that the, the bigger questions about care pathways. I'm thinking in low middle-income countries, we're seeing increasing evidence that multidisciplinary care, which is something we've kind of come to accept as normal, certainly in the UK, you know, it's been gradually recognized because it doesn't exist in many countries. It's still, for instance, for hip fractures, many patients who are looked after solely by an orthopaedic team and with the consequent problems of people dying, which we all remembered. Unfortunately, the National Hip Fracture database documented for us from a few years back, which are now much improved. So I think those big, yeah, the big to answer your question. I think the big change is not actually been in surgery, but in the, in the care pathways more, more generally. 

That's interesting. And in terms of just before we move on to the highlight papers, just, you know, obviously we all know you're very heavily involved with sort of you know, not just acquiring grants,  bodies. How do you, how do you think that's changed over the past 18 months? And, and do you think there's any long-term changes we're going [00:09:00] to see because of that? Obviously money's tight for the whole country. So how's it going to be different do you think moving forward for us? 

So, yeah, I think it's a really good, good question. So the, for trauma research in the UK, I mean, if we're honest about it, there's, there's only really the National Institute for Health Research. Obviously the research on the NHS that funds the big projects there's other funders in this space and, you know, AO and there's arthritis occasionally, and you know, some of the other smaller funding bodies do contribute useful research, but in terms of the big files and big observations to these, it's really only the NIHR and I think many of us were very worried that the NIHR budget, as along with all of the, the public sector funding and, you know, it has taken a big hit. I think the UK response to the pandemic, particularly with regards to the vaccinations has actually stood the research sector in good stead in that the profile has never been higher. And so fortunately, to a major extent, the [00:10:00] NIHR budgets has been ring-fenced. Now that's for now and we all know that politicians change them up very quickly. So who knows what will happen, but it looks increasingly likely that NIHR budgets will be protected at least in the meeting term in a way that frankly, the rest of the public sector is in for a very, very rough ride. I think the next few years and already is. So it's, I think it's not going to be that we're getting more money necessarily in the medium term, but I think it'd be protected. 

The big problem for us in trauma and orthopedics trying to liberate money from a relatively small group of funders is that one essentially is that the other areas of research I'm thinking of, of cancer and cardiovascular and stuff, which traditionally used the, you know, the major funders were actually the cancer research UK and British Heart Foundation  and so on so not the NIHR. They've been absolutely decimated because all their, you know, charitable activities have been curtailed by COVID and their funding's disappeared. What you're finding is that on the [00:11:00] NIHR funding boards now we're seeing many more applications from researchers, very high quality researchers across different fields who never applied or didn't apply very often to NIHR and are now just going to NIHR, cause there's no money at CIUK  or so and so the competition level at the board is now frightening. I mean, the quality of the applications is incredibly high. And therefore the bar to get funded has been set even even higher. 

So, yeah, I think it's tough, tough times. I mean, the only response to that is to put in top top quality applications and as ever a small number of very high quality applications from the community in trauma and orthopaedics is better than a large number of you know, not quite nailed down because frankly, if the actual protocol you're submitting is not completely nailed down, it doesn't get a look in at the moment.

Yeah, so yeah, mixed good news by the NIHR, the funding and the clinical research network that goes with that as well, has been protected to a large degree, but I think competition rates shows have never been [00:12:00] higher. 

Yeah, that is interesting. But like you say, I suppose you've just got to raise the bar in terms of what... well Keep the bar high in what we're doing. And it's more or less very robust trials that we put forward to them in terms of keeping that, that level high. 

And that's what leads us very nicely actually into our highlight papers.  And I think you can see from these three papers you've picked actually both the high quality and the wide range of methodology of now publishing in the, in the journal in this area. And I thought we'd start off with the RCT led out of Oxford by yourself and Xavier, and that was looking at the effect of the X-bolt dynamic plating system against the more routine sliding hip screw for fixation of trochanteric fractures. And that was WHiTE Four in the series of WHiTE platform studies. And it was a  multicenter, multi surgeon parallel randomized control trial, 10 acute hospitals in the UK. And there was over 1,128 patients randomized in the two groups. And so what made you pick this study? Obviously, I mean, it's, it's it's size and the methodological quality really without question, but what made you pick this?

So well yeah, I wanted to pick out papers from different methodological sort of [00:13:00] points of view. I mean, in general terms, one of the changes in the journal has been the increase in the number of randomized controlled trials that we're now seeing. I mean, 10 years ago when I first started, it was actually, you know, it was a real surprise to get one through. And most of the comparative intervention studies we saw were non-randomized studies were comparative case series and so on, and which were fine, and a lot of those, you know, informed clinical practice, but actually the power  of randomization takes the evidence-base to a different level. So we're really pleased to see these things.

The reason I picked out Xavier's paper and this was very much Xavier Griffin's study I was just supporting it was because of the new technology and the way it was tested. So it's a good quality RCT with good numbers. And it's a nice methological piece of work to have in the Bone and Joint Journal. So from a methods point of view, you know, we're very pleased in the journal to see work at this sort of level coming in.

But the reason I picked this one out is because it was testing a new technology and it brings up this question of how do we introduce new technology into [00:14:00] trauma surgery in this case, and how do we test it? And many of the listeners will be familiar with the ideal framework, which was put forward 10 years ago now as a method, really for introducing new technology, but there's not been really particularly widely adopted by many, certainly in trauma and orthopaedics, for injuries and new technologies. It's just that a sequence of studies that you do before rolling out an intervention into the whole of the NHS or indeed worldwide.

And the WHiTE Four trial was really the final step in that chain of a series of studies that Xavier leading to a full pragmatic multicenter RCT and this is a step forward and it basically showed that the X-Bolt device, which was the new intervention for fractures of the hip was produced very similar results to the sliding hip screw. At least as good as. And the rate of failure with intervention is actually very similar as well. And so you've now got really strong evidence that this device is as good as not necessarily better, unfortunately, but as good as the existing technology. And therefore it's a viable [00:15:00] option for some people, if they want to choose this disc device.

And, and you just think, well, how many times have we got other devices suddenly appear on the shelf and people start to use that never been tested in this rigorous way. And we don't really know what the outcomes are. And of course, everyone, all of the listeners will be familiar with the disaster stories about devices that perhaps should have been tested a bit more rigorously that ended up causing patients great deal of harm. Obviously I'm thinking of things like metal on metal and outside of traum and orthopaedics the silicon implants and the meshes and all of the other devices that have caused, you know, huge amounts of distress for patients over a long period.

So I think this was just a great example of a study that was a combination of a way of introducing a device to market. It's actually a sensible and safe way of doing it and great credit to the, you know, the X-Bolt team who actually supported the trial for investing their money in a proper test of that device.

Absolutely. And I think, I think that's right, isn't it? It's, it's not only the safe way to assess it in for patient safety, which is obviously a primary point, but also, I suppose, [00:16:00] another issue with all these new devices, they often cost quite a bit of money and we shouldn't really be using them with the finite resources we have without the real evidence. I mean, do you think that's a fair comment?

I do,  yeah. As you know, it's interesting some journals like to publish the health economic data, the resource you associated with trials in the same paper. Other journals, let's say American journals really don't want to know. It's very interesting, just a very different perspective on what things cost. They just want to know the clinical outcomes, but in a, you know, and the idea that cost is not important, even in somewhere like the States is frankly ridiculous because there's never enough money to go around. Even if you've got to. You're spending twice as much of your GDP on health care as the UK you do in the US. So I think it's a slightly, from my perspective, a slight naive view that cost is important. Of course it is in every healthcare system, but in the UK, obviously with our national healthcare service where we're acutely aware of the importance of cost because frankly if it's not cost effective it won't get [00:17:00] commissioned and we can't use it. So, yeah, you're right. I think that's the other important element to testing these things properly. 

Yeah, absolutely. So Matt, if we move on from that. That's a great overview of that paper. This is the move on to the the NH FD paper, which was sort of based out of King's college, London, but sort of UK, a big data study room around a thing. And this was looking at data from more than 126,000 patients. And the aim was just to look at the effect of early mobilization, which they defined as mobilizing on the day of surgery of the day after and late mobilization, so day two or more on 30-day mortality rates after after hip fracture and also looking at how that interacted with dementia.

And so this is a different, different type of methodology, but again, very robust given that given just the size of it alone, really isn't it Matt?

It is. And that's exactly why I picked this one out actually. So it is a really nice bit of work from Katie Chen, who is a physiotherapist academic physio down at Kings, who's published a lot in this area, and her colleagues at King's college. And it's just a really nice example of the use of big [00:18:00] data and how it can be used to inform really important questions for patients. And this is what we're seeing now. 

We had some, I think we were all a bit nervous about a lot of the routine data studies. I guess the registry is not strictly speaking routine data but big data sets anyway, about how to interpret them because you get, you know, hugely statistically significant results that are probably clinically meaningless. If you put enough numbers into the equations and essentially you get, you'll find differences that frankly no one cares about. So in terms of these, it has been tricky and I think we're all learning.

One of the things I liked about these papers is one is a really clinically useful message. I mean, one of the problems with big data is that you often end up answering questions that you can answer rather than ones that are necessarily most interesting because you're limited by what's in the data set. Whereas I think this was something that really does make an impact on patient care. But the other reason I picked it out was because it shows, if you look at the list of authors, there's some very senior academic therapists on there, which is quite right. They should be, you know, leading studies in this area. But there's also some fairly hardcore statisticians in [00:19:00] there as well. And I think that's the combination for these large datasets. These analyses are not straightforward. And, you know, for, for, for people like yourself and me who are interested in this area, you know, we have some understanding of statistics, but  I'm not pretending to know the nuances of how to interpret this dataset and even the most clued up clinicians will struggle, I think, to interpret some of this data and, you know, to know how to build the correct models, to look at these. So I think some very experienced epidemiologists and statisticians involved is key. And I think this paper exemplifies the value of that.

And that's not to say there isn't unknown confounding within this dataset, but the limitations on display and the authors make those limitations clear and I think there's still a useful message here about the value of early mobilization for patients. 

Yeah I think that was interesting as well. I know reading it as well, they're very clear about what they haven't covered in confounding variables. And they're very honest about that, and I think that's almost the sort of a neutral view isn't it? As a statistician, you, you don't, you don't really care about you [00:20:00] just want to, you've just got the data in front of you. Not really got a bias, I suppose from a clinical standpoint, which is a very useful thing. 

The other thing I thought, it sort of linked in nicely in terms of, you know, the which we've discussed previously in a podcast, this sort of from the WHiTE group data, the best practice tariffs indicators and how they affect, and actually this sort of links in nicely in terms of, you know, should this be an indicator in early mobilization? Cause obviously it had, and this is how it can all build from this big data concept.

It can yeah. The paper that you mentioned, the WHiTE paper so it's really showing well, it's the first time in a big way that actually quality indicators of care, things like, you know, early surgery and what the geriatric review and early mobilization did make a difference to quality of life, as well as mortality. And, you know, that's really, really important. Ironically, just at a time when the government is considering scrapping best pratcice tarrif we've produced very hardcore evidence it makes a big difference. So it's a bit of a shame, but that's politics for you. 

Yeah. But I think the, you know, these papers doing them well is really important and it's great. That's [00:21:00] what, you know, as a reviewer and as a specialty editor that's what  I want to see. I don't care if it's problems with the data. There's always problems with the data. You know, no study gets complete follow up and no study everyone gets the right treatment that they are meant to have.  That's part of the game and part of life, isn't it. But what I want to see is a full and as you say, a quite objective assessment of that data, which I think is what the authors do here, and that reassures me, that they are telling us the full truth, if you like, or at least as close as in the fact that, that, you know, presenting that data warts and all. And that's what I want to see when I'm looking as a specialty editor for a paper like this. 

Yeah, that's really interesting. So if we just move on to the the final highlight paper, Matt, that's from the OTS group, and that sort of looked at their proposed new open fracture classification system and sort of how this correlates with patient centered outcomes that was using data from two large UK trials actually led on WOLF.

And it was a study which was accompanied by a great editorial too, which sort of looked at the history of open fracture classification and how it's evolved over time and potentially the limitations of, I suppose, the most classic [00:22:00] one we use is like a gastillo one. And this study used data from 748 patients. And the outcomes that it looked at was of DRI, EQ-5D, sort of health-related quality of life data, as well as deep infection at 30 days. And it's sort of a nice study in terms of looking at not only promoting a new fracture classification system, but also how that correlates with patient outcome and what the patients actually feel.

So Matt, I suppose, could you sort of briefly describe why you picked this paper and why you thought it was important?

I think partly because this was something a bit different and you know, we always say at the journal that we don't really care about what the methodology is as long as it's the best methodology to answer that question. So we're not... because of the sort of work I do, I occasionally get people at meeting somewhere asking will you only consider RCTs for the journal and yeah, don't get me wrong we like RCTs. They are high-quality evidence for interventions, but most questions actually cant be answered with RCTs. And even many that could be probably shouldn't be because of the expense and the, you know, the infrastructure required. So I don't think RCTs are the answer which is why we like, you know, some good [00:23:00] quality observational data as well. And you know, if you're looking at diagnostic testing, we want those papers as well. And, and this is just something a bit different that I thought, well, actually, if you get the methods right, you know, this is no randomized trial data in here. The observational data from the trials is used, but this is just about validation of a classification system or a step in the validation process. 

And so this was Alex Thompson's work and really reflecting just a long-standing view between many of us working in the field that we can't, we still can't objectively classify these fractures. And so Alex had been thinking about this and trying to work out how we could not produce a more objective classification system. And so the other thing, the reason I picked this study is because of the quality of the data that comes from the trial. So you can answer the trial question in terms of the, you know, what's the difference between, you know, the different interventions in the trial, but actually if you just follow the patients up in the longer term, you also get these fantastic observational data sets with complete followup because of resources that you [00:24:00] can use to follow the patients up.

And so we were able to do that in this case. And for the first time really correlate a classification with the patient's view about complications reported, health-related quality of life and disability. Now, whereas the previous classifications have really been raised around well, can you salvage the limb, which is an important question, but maybe not the most important for most patients don't lose their limb to their own practice.

And also around infection, which, although again, obviously an important outcome is not necessarily the most important one, so you can have a deep infection, but if that's treated aggressively early on and you get eradication that patient can have, you know, essentially as good an outcome as other patients, without infection.

Whereas the ones that cause a real problem, ones that you don't get on top of it and they end up with chronic osteomyelitis and so on. So just having the infection doesn't necessarily predict your outcome. And equally there are many patients who don't have infection that have a very poor outcome due to only having problem or more commonly soft tissue problems, and as we published [00:25:00] on recently, chronic pain is such a massive issue after these severe limb fractures that are probably unrecognized. 

So there's lots of reasons to pick them out. A different study design, different type of methodology, hopefully a useful contribution to literature in terms of reducing the subjects of the classification. But also the benefits of these large data sets that to look at these and use them for answering other questions, not just the ones that you set out in the in the randomized trial design. 

I agree. It's a very interesting use of that sort of secondary use of RCT data. Do you think we do enough of that? Are we, I know it's because if all of that goes into that trial, do you think we could do more of the secondary uses? And now when it's been often led by yourself and many of them. Really good RCTs. Should we be using them more for secondary analysis? Do you think that's a good thing to do or do we have to be careful?

Well, I think, yes, we should do. And you know,  the group from master have done some really nice work looking at some very large trial datasets and answering questions [00:26:00] or proposing questions based on those data sets. So it's, I think it is increasingly happening and we should use these data sets more because you know, most of these studies take millions of pounds of taxpayer's money to not extract maximum information from them, you know. It's a travesty really. We shouldn't allow them to get away with it. The thing that everyone's got to remember and that, you know, even as someone who does this and I have to remember it is that you're basically then dealing with an observational dataset. So you're taking the data that you have and trying to extract information from it in a way that you could from a registry or routine data. You're not collecting the data specifically. You didn't collect the data to answer that particular question. So essentially all of these studies are hypothesis generate.  They can, they can propose new questions and give some evidence of association. But what they can't do is provide causality. So, and it sometimes, because you've got high quality data, you, the tendency is to over interpreted. So again, when looking at the secondary analysis is I take the view of, well, this is now an observational data set. So [00:27:00] all the caveats with that as we discussed with the national hip fracture database paper, They apply equally to the secondary analysis papers as well. So yeah, some caution, but yes, we should certainly be using these high quality data sets.

It's sort of just sort of final question that I think it's interesting because one of the great advantages of those two studies was that they had the similar outcome measures at the similar times. And it's almost, it would be almost useful. I know you can never dictate to people, but actually having standardized outcomes at standardized times would be very helpful for when people do trials in the same areas so you could actually combine them more easily in some way. 

Oh, totally. Yeah. Developing core outcome sets so in, in particular areas for particular patients with in our case particular injuries is invaluable. And as you know, there's a lot of work going on in that and actually Steve Gwilym wrote recently the BJJ, a very nice editorial about the importance of engaging patients in deciding what priorities are for research and also for developing these core outcome sets from a patient perspective, because frankly we've always measured x-rays [00:28:00] and infection rates, because we're fascinated by them. But from the patient's perspective, they to know about their quality of life and disability. So you know, that is why developing patient centered core outcome sets to allow comparison between studies and to allow evidence synthesis, because you know, meta-analysis is easier if you've got the same outcome, but how often do the same study different studies in the same population use different outcome measures or even the same occupations at different time points. And how do you combine those ? So it's a, it's a very difficult problem. 

Yeah. No, absolutely. So, so just a great overview of those three highlighted papers and that, and  really great choices into that, that breadth of the methodology in particular. So just to finish up, what, what do you think are the sort of key questions I suppose we talked about it already, but in sort of trauma, what are our key questions moving forward do you think? Where, where are we going to go over the next few years? 

Well, I think, I mean, the really good news is there's some really good quality trials going on in the UK at the moment and no spread around the country without a lot of new lead investigators, which is just brilliant news for the profession, I think. And so [00:29:00] particularly to have a large group of people involved, I think with last count we had 140 of the 170 acute care hospitals, actively engaged in recruiting trials and trials now in the UK, which is just amazing. So I think that's really exciting. I think we're getting better and better routine data, registry data papers coming through, and the analysis is getting more and more consistent and better described. So that's, that's really exciting. 

I think what we would like to see is some in some more papers, I think a global health perspective would be, you know, fascinating to journal and we try and do this and it's not always straightforward but we are actively encouraging and getting increasing numbers of submissions from other parts of the world. And particularly in low middle income countries where there's such, you know, variable care with regard to trauma. And it's such an under recognized problem that I think that will be nice to see more data coming from those settings, which I think will be fascinating for us here and also potentially hugely helpful for for patients in these countries with, [00:30:00] with less well funded economic healthcare systems.

Absolutely Matt. No, I agree. Well, I think that's all we have time for Matt, but thanks so much. That was a really excellent and really informative overview of the trauma specialty episode area over the past year. And as always, it's great to talk to you. So thanks for joining us.

 And to our listeners we do hope you've enjoyed joining us. Feel free to tweet or post about anything we have discussed here today. Thanks for listening everyone and take care.


Trauma overview of the past 18 months
Covid-related papers
The main trauma themes
Acquiring grant bodies
The WHiTE Four Study
The 30-day survival and recovery after hip fracture by timing of mobilization and dementia: a UK database study
The Orthopaedic Trauma Society classification of open fractures
The key questions in trauma