There is increasing evidence for successful management of end-stage heart failure with continuous-flow left ventricular assist device (CF-LVAD) technology. However, passive flow adjustment at fixed CF-LVAD speed is susceptible to flow balancing issues as well as adverse hemodynamic effects relating to the diminished arterial pulse pressure and flow. With current therapy, flow cannot be adjusted with changes in venous return, which can vary significantly with volume status. This limits the performance and safety of CF-LVAD. Active flow adjustment strategies have been proposed to improve the synchrony between the pump and the native cardiovascular system, mimicking the Frank-Starling mechanism of the heart. These flow adjustment strategies include modulation by CF-LVAD pump speed by synchrony and maintenance of constant flow or constant pressure head, or a combination of these variables. However, none of these adjustment strategies have evolved sufficiently to gain widespread attention. Herein we review the current challenges and future directions of CF-LVAD therapy and sensor technology focusing on the development of a physiologic, long-term active flow adjustment strategy for CF-LVADs.

Background Obesity can often be a barrier to gender-affirming top surgery in transmasculine patients because of concern for increased surgical site complications. Study Design All adult patients (N = 948) within an integrated health care system who underwent gender-affirming mastectomy from 2013 to 2018 were retrospectively reviewed to evaluate the relationship between obesity and surgical site complications or revisions. Results One third of patients (n = 295) had obese body mass index (BMI), and those patients were further stratified into obesity class I (BMI of 30–34.9 kg/m2, 9.4%), class II (BMI of 35–39.9 kg/m2, 8.9%), and class III (BMI of ≥40 kg/m2, 2.9%). A majority of patients across BMI categories underwent double incision surgery. There were no significant differences in complications or revisions between patients with obesity versus those with normal BMI, when BMI was treated as a categorical or continuous variable and when evaluating only patients who underwent double incision surgery. Conclusions Obesity alone should not be considered a contraindication for gender-affirming mastectomy. Attention should be given to several modifiable risk factors identified in this study, including lesser incision surgical techniques, tobacco use, and testosterone use. Further research is needed to understand risks associated with the highest BMI (≥40 kg/m2) patients and to assess patient satisfaction with surgical outcome.

BACKGROUND Early and balanced resuscitation for traumatic hemorrhagic shock is associated with decreased mortality, making timely plasma administration imperative. However, fresh frozen plasma (FFP) thaw time can delay administration, and the shelf life of thawed FFP limits supply and may incur wastage. Liquid plasma (LP) offers an attractive alternative given immediate transfusion potential and extended shelf life. As such, we hypothesized that the use of LP in the massive transfusion protocol (MTP) would improve optimal plasma/red blood cell (RBC) ratios, initial plasma transfusion times, and clinical outcomes in the severely injured patient. METHODS Using Trauma Quality Improvement Program data from our level 1 trauma center, we evaluated MTP activations from 2016 to 2018. Type A LP use was instated April 2017. Before this, thawed FFP was solely used. Plasma/RBC ratios and initial plasma transfusion times were compared in MTP patients before and after LP implementation. Patient and injury characteristics were accounted for using linear regression analysis. Secondary outcomes of mortality, 28-day recovery, and complications were evaluated using Cox proportional hazards regression. RESULTS A total of 95 patients were included (pre-LP, 39; post-LP, 56). Time to initial plasma transfusion and plasma/RBC ratios at 4 and 24 hours were improved post-LP implementation with a coinciding reduction in RBC units transfused (p < 0.05). In a 28-day Cox proportional hazards regression LP implementation was associated with favorable recovery (hazard ratio, 3.16; 95% confidence interval, 1.60–6.24; p < 0.001) and reduction in acute kidney injury (hazard ratio, 0.092; 95% confidence interval, 0.011–0.77; p = 0.027). No post-LP patients with blood group type B or AB (n = 9) demonstrated evidence of hemolysis within 24 hours of type A LP transfusion. CONCLUSION Initial resuscitation with LP optimizes early plasma administration and improves adherence to transfusion ratio guidelines. Furthermore, LP offers a solution to inherent delays with FFP and is associated with improved clinical outcomes, particularly 28-day recovery and odds of acute kidney injury. Liquid plasma should be considered as an alternative to FFP in MTPs. LEVEL OF EVIDENCE Therapeutic/care management, level IV.

Background In the age of COVID-19 and enforced social distancing, changes in patterns of trauma were observed but poorly understood. Our aim was to characterize traumatic injury mechanisms and acuities in 2020 and compare to years prior at our Level 1 trauma center. Materials and Methods Trauma patients triaged in 2016 through 2020 from January to May were reviewed. Patient demographics, level of activation (1 vs. 2), ISS, and mechanism of injury were collected. Data from 2016 through 2019 was combined, averaged by month, and compared to data from 2020 using Chi-squared analysis. Results During the months of interest, 992 trauma patients were triaged in 2020 and 4,311 in 2016-2019. The numbers of penetrating and Level 1 trauma activations in January – March of 2020 were similar to average numbers for the same months during 2016 through 2019. In April 2020, there was a significant increase in incidence of penetrating trauma compared to the prior four-year average (27% vs. 16%, p<0.002). Level 1 trauma activations in April 2020 also increased, rising from 17% in 2016 through 2019 to 32% in 2020 (p<0.003). These findings persisted through May of 2020 with similarly significant increases in penetrating and high-level trauma. Conclusion In the months after the initial spread of COVID-19, there was a perceptible shift in patterns of trauma. The significant increase in penetrating and high acuity trauma may implicate a change in population dynamics, demanding a need for thoughtful resource allocation at trauma centers nationwide in the context of a global pandemic.

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Introduction: Phosphatidylserine (PS) is a key cell membrane phospholipid normally maintained on the inner cell surface, but externalizes to the outer surface in response to cellular stress. We hypothesized that PS exposure mediates organ dysfunction in hemorrhagic shock.Our aims were to evaluate PS blockade on: 1) pulmonary, 2) renal, and 3) gut function, as well as 4) serum lysophosphatidic acid (LPA), an inflammatory mediator generated by PS externalization, as a possible mechanism mediating organ dysfunction. Materials and Methods:Rats were either: a) monitored for 130 minutes (controls, n=3), b) hemorrhaged then resuscitated (hemorrhage only group, n=3), or c) treated with Diannexin (DA), a PS blocking agent, followed by hemorrhage and resuscitation, (DA + hemorrhage group, n=4). Pulmonary dysfunction was assessed by PaO 2 , renal dysfunction by serum creatinine, and gut dysfunction by mesenteric endothelial permeability (L P ). LPA levels were measured in all groups.Results: Pulmonary: There was no difference in PaO 2 between groups. Renal: After resuscitation, creatinine levels were lower after PS blockade with Diannexin vs hemorrhage only group (p=0.01). Gut: L P was decreased after PS blockade with Diannexin vs hemorrhage only group (p<0.01). Finally, LPA levels were also lower after PS blockade with Diannexin vs the hemorrhage only group, but higher than the control group (p<0.01). Conclusion:PS blockade with Diannexin decreased renal and gut dysfunction associated with hemorrhagic shock and attenuated the magnitude of LPA generation. Our findings suggest