Organ Procurement Transplant Research Articles

Waitlist and post-transplant outcomes among candidates listed for liver transplant: Liver alone versus simultaneous liver kidney listings.

Data comparing waitlist and post-transplant outcomes of liver transplantation (LT) alone (LTA) versus simultaneous liver kidney (SLK) listings are limited. To examine 90-days waitlist and 1-year post-transplant outcomes of LT listings since Organ Procurement Transplant Network (OPTN) policy for SLK, who had cirrhosis with eGFR <30 mL/min or on dialysis at listing. Adults (08/2017-03/2021) with first LT listing (2628 SLK) were stratified on renal function from listing: acute kidney injury (AKI): rise of serum creatinine by ≥0.3 mg/dL or <42 days hemodialysis; chronic kidney disease (CKD): eGFR <60 mL/min for ≥90 days or ≥42 days hemodialysis. Among 7094 adults analyzed, 90-days competing cumulative waitlist mortality was 18.2% in LTA + CKD (n = 37), 15.3% in LTA + AKI (n = 3337), 15% in SLK + AKI (n = 2070), and 11% in SLK + CKD (n = 403), p < 0.001. On fine and gray model, compared to SLK + CKD, LTA + AKI had 1.4-fold waitlist mortality. On a median post-transplant follow up of 1 year, patient survival was similar comparing LTA versus SLK for AKI (89% each, p = 0.83), for CKD (93 vs. 86%, p = 0.55), but lower in recipients listed for SLK with no AKI or CKD (93 vs. 88%, p = 0.02), adjusted hazard ratio (95% CI) of 0.7 (0.4-1.2). Among 1024 LTA recipients without AKI or CKD from listing, 117 were listed for SLK, and their 1-year survival was poorer compared to LT alone listings (79 vs. 95%, p < 0.002, adjusted HR 3.6 (1.3-10.3); p = 0.015). Among candidates with renal dysfunction at listing for LT, those listed for LT alone should receive transplant promptly to optimise waitlist outcomes. Those listed for SLK should wait to receive both organs to optimise post-transplant outcomes.

Augmenting the United States transplant registry with external mortality data: A moving target ripe for further improvement

The Organ Procurement and Transplantation Network conducts a robust death verification process when augmenting the United States transplant registry with external sources of data. Process enhancements added over 35,000 externally verified deaths across waitlist candidates and transplant recipients for all organs beginning in April 2022. Ninety-four percent of added posttransplant deaths occurred beyond 5 years posttransplant, and over 74% occurred beyond 10 years. Deceased donor solid organ recipients transplanted from January 1, 2010, through October 31, 2020, were analyzed from January and July 2022 Organ Procurement and Transplantation Network Standard Transplant Analysis and Research and the Scientific Registry of Transplant Recipients Standard Analysis Files to quantify the impact of including vs excluding unverified deaths (not releasable to researchers) on posttransplant patient survival estimates. Across all organs, 1- and 5-year posttransplant survival rates were not substantially impacted; meaningful differences were observed in 10-year survival among kidney recipients. These findings bear important implications for anyone who utilized transplant registry data to examine long-term outcomes prior to the updated verification process. Users of transplant surveillance data should interpret results of long-term outcomes cautiously, particularly differences across subpopulations, and the transplant community should identify ways to improve data quality and minimize the reporting burden on transplant institutions.

Long-Term Survival and Functional Recovery of Cryopreserved Vascularized Groin Flap and Below-the-Knee Rat Limb Transplants.

Effective cryopreservation of large tissues, limbs, and organs has the potential to revolutionize medical post-trauma reconstruction options and organ preservation and transplantation procedures. To date, vitrification and directional freezing are the only viable methods for long-term organ or tissue preservation, but are of limited clinical relevance. This work aimed to develop a vitrification-based approach that will enable the long-term survival and functional recovery of large tissues and limbs following transplantation. The presented novel two-stage cooling process involves rapid specimen cooling to subzero temperatures, followed by gradual cooling to the vitrification solution (VS) and tissue glass transition temperature. Flap cooling and storage were only feasible at temperatures equal to or slightly lower than the VS Tg (i.e., -135°C). Vascularized rat groin flaps and below-the-knee (BTK) hind limb transplants cryopreserved using this approach exhibited long-term survival (>30 days) following transplantation to rats. BTK-limb recovery included hair regrowth, normal peripheral blood flow, and normal skin, fat, and muscle histology. Above all, BTK limbs were reinnervated, enabling rats to sense pain in the cryopreserved limb. These findings provide a strong foundation for the development of a long-term large-tissue, limb and organ preservation protocol for clinical use.

Incidence, landscape and survival outcome of de novo malignancy after double lung transplantation.

10574 Background: Organ transplant recipients are at greater risk of developing malignancies due to their immunosuppressive management. However, the incidence of post-transplant malignancy after double lung transplantation (DLT) has not been studied. This study investigated the incidence, trends, and most common types of post-transplant malignancy following DLT. Methods: Data extracted from the Organ Procurement Transplantation Network (OPTN) registry after DLT for non-cancerous disease. We evaluated the incidence of post-transplant malignancy, and assessed the annual and cumulative risk of each malignancy after DLT. And the overall survival (OS) of recipients with or without post-transplant malignancy was analyzed by Kaplan-Meire survival method. Results: A total of 23,935 cases were identified and analyzed from the OPTN database (13,768; 57.5% male, 10,167; 42.5% female). 5,629 cases (23.5%) were found to have post-transplant malignancy and 18,306 cases (76.5%) had no post-transplant malignancy. Among patients with post-transplant malignancy 3,785 (67.2%) were male and 1844 (32.8%) were female. Those with post-transplant malignancy had a longer OS compared to those without post-transplant malignancy (P &lt; 0.001). While the median OS was 97.2 months and 5-year survival rate was 83.6% in recipients with post-transplant malignancy, the median OS was 36.7 months and 5-year survival rate was 67.3% in For those without post-transplant malignancy. The risk for post-transplant malignancy was greatest during the first 3-5 years post-transplantation. The most common types of post-transplant malignancies were squamous cell skin cancer (n = 2711, 48.2%), basal cell skin cancer (n = 965, 17.1%), lymphoma (n = 570, 10.1%), lung cancer (n = 187, 3.3%), colorectal cancer (n = 184, 3.3%). Conclusions: The lifetime incidence of post-transplant malignancy following DLT was identified to be 20.1% and those with post-transplant malignancy had a longer OS compared to those without post-transplant malignancy. Further studies are needed to investigate the underlying mechanism for the increased risk of malignancy following DLT and its association with OS.

Post-double lung transplantation survival outcomes of bilateral lung cancer and incidence of post-transplant lung cancer.

e21061 Background: To evaluate the role of double lung transplantation (DLT) for lung cancer, the survival outcomes of patients who underwent DLT for lung cancer and the incidence of lung cancer after DLT were assessed. Methods: Data from case series reported in the literature were pooled and collected from the Organ Procurement Transplantation Network (OPTN) and the International Society of Heart and Lung Transplantation (ISHLT) registries. We evaluated the recurrence-free survival (RFS), overall survival (OS), and cancer-specific survival (CSS) of patients who underwent DLT for lung cancer. Moreover, the incidence and OS of post-transplant lung cancer in patients who received transplants for the non-cancerous disease were examined. Results: Regarding patients who underwent DLT for lung cancer, in the pooled (n = 19), OPTN (n = 15), and ISHLT (n = 25) data, 5-year RFS was 52.6%, 66.7%, and 80.0%, and 5-year OS was 57.9%, 26.7%, and 36.0%, respectively. The median CSS was 48.0 (range, 6.0–144.0), 27.7 (range, 0.2–66.6), and 24.0 (range, 0.1–145.1) months. Additionally, the application of cardiopulmonary bypass was associated with lower tumor recurrence in the pooled data (p = 0.004). The incidence and 5-year OS post-transplant lung cancer in patients who underwent DLT for the non-cancerous disease were 0.8% and 47.3% in the OPTN data and 0.6% and 50.7% in the ISHLT data, respectively. Conclusions: We demonstrated that reasonable survival outcomes can be achieved with DLT in patients with bilateral lung cancer. Further studies are required to evaluate the risk of post-transplant lung cancer in patients undergoing DLT for bilateral lung cancer.

Inverse association of post-transplant malignancy and graft failure on survival outcome following double lung transplantation.

10629 Background: Graft failure (GF) and post-transplant malignancy (PTM) are common causes of death in lung transplantation. Immunosuppression to prevent graft failure is known to lead to de novo malignancies after solid organ transplantation. Here, we assess the relationship between graft failure and de novo malignancies after double lung transplantation (DLT). Methods: Data extracted from the Organ Procurement Transplantation Network (OPTN) registry were analyzed. DLT cases for non-cancerous diseases were selected. We evaluated the overall survival (OS) of recipients with or without PTM (PTM+ or PTM-), and that of recipients with or without GF (GF+ or GF-) after DLT. The association between GF and PTM was investigated. Results: Among 23,935 DLT recipients, there were 5,629 cases (23.5%) of PTM+ and 18,306 cases (76.5%) of PTM -, and 2,316 cases (9.7%) of GF+ and 21,619 cases (90.3%) of GF- following DLT. Among GF+ cases, the prevalence of acute, hyperacute, and chronic rejection after DLT was 1,962 cases (84.7%). The OS in recipients with GF+ was worse than that in recipients with GF- (p &lt; 0.001). However, inversely, the OS in recipients with PTM+ was better than that of recipients with PTM- (p &lt; 0.001). When patients were categorized into four categories by each factor (GF-, GF+, PTM+, PTM-), the GF rate was lower in recipients with PTM+ than in those with PTM- [GF+/PTM+ (n = 368, 1.5%) versus GF+/PTM- (n = 1,948, 8.1%)] (p &lt; 0.001), and the PTM+ rate was higher in recipients with GF- than in those with GF+ [GF-/PTM+ (n = 5,261, 22.0%) versus GF+/PTM+ (n = 368, 1.5%)] (p &lt; 0.001). And the GF-/PTM+ group showed the best prognosis with 97.3 months of median OS, and the GF+/PTM- group showed the worst prognosis with 36.8 months of median OS (p &lt; 0.001). Conclusions: Recipients who developed PTM following DLT had longer OS compared with those who did not. And the GF rate was significantly lower in recipients with PTM compared to those without PTM. Further research is needed to investigate the underlying mechanism of the inverse association between PTM and GF in DLT recipients.

Second Opinion in the Italian Organ Procurement Transplantation: The Pathologist Is In.

Second opinion consultation is a well-established practice in different clinical settings of diagnostic medicine. However, little is known about second opinion consultation activity in transplantation, and even less is known about it concerning donor assessment. The consultations provided by the second opinion service led to the safer and homogeneous management of donors with a history of malignancy or ongoing neoplasm by transplant centers. Indeed, two of the most important aspects are the reduction of semantic differences in cancer reporting and the standardization of procedures, which are mainly due to the different settings and logistics of different pathology services. This article aims to discuss the role and the future of the second opinion in Italy during organ procurement, highlighting the critical issues and areas for improvement.

The utility of machine learning for predicting donor discard in abdominal transplantation.

Increasing access and better allocation of organs in the field of transplantation is a critical problem in clinical care. Limitations exist in accurately predicting allograft discard. Potential exists for machine learning to provide a balanced assessment of the potential for an organ to be used in a transplantation procedure. We accessed and utilized all available deceased donor United Network for Organ Sharing data from 1987 to 2020. With these data, we evaluated the performance of multiple machine learning methods for predicting organ use. The machine learning methods trialed included XGBoost, random forest, Naïve Bayes (NB), logistic regression, and fully connected feedforward neural network classifier methods. The top two methods, XGBoost and random forest, were fully developed using 10-fold cross-validation and Bayesian optimization of hyperparameters. The top performing model at predicting liver organ use was an XGBoost model which achieved an AUC-ROC of .925, an AUC-PR of .868, and an F1 statistic of .756. The top performing model for predicting kidney organ use classification was an XGBoost model which achieved an AUC-ROC of .952, and AUC-PR of .883, and an F1 statistic of .786. The XGBoost method demonstrated a significant improvement in predicting donor allograft discard for both kidney and livers in solid organ transplantation procedures. Machine learning methods are well suited to be incorporated into the clinical workflow; they can provide robust quantitative predictions and meaningful data insights for clinician consideration and transplantation decision-making.

Policy corner: ischemic cholangiopathy associated with donation after cardiac death.

1Baylor All Saints Medical Center at Fort Worth, Fort Worth, Texas, USA 2Baylor Medical Center, Dallas, Texas, USA Correspondence James F. Trotter, Hepatology Section, Baylor Medical Center, 3500 Gaston Avenue 4 Roberts, Transplant, Dallas, TX 75246, USA. E-mail: [email protected] Abbreviations: DCD, donor by cardiac death; OPTN, Organ Procurement Transplantation Network.

Living donor liver transplant: A strategy to increase transplant access

Living donor liver transplant: A strategy to increase transplant access

Monitoring of Serological, Cellular and Genomic Biomarkers in Transplantation, Computational Prediction Models and Role of Cell-Free DNA in Transplant Outcome.

The process and evolution of an organ transplant procedure has evolved in terms of the prevention of immunological rejection with the improvement in the determination of immune response genes. These techniques include considering more important genes, more polymorphism detection, more refinement of the response motifs, as well as the analysis of epitopes and eplets, its capacity to fix complement, the PIRCHE algorithm and post-transplant monitoring with promising new biomarkers that surpass the classic serum markers such as creatine and other similar parameters of renal function. Among these new biomarkers, we analyze new serological, urine, cellular, genomic and transcriptomic biomarkers and computational prediction, with particular attention to the analysis of donor free circulating DNA as an optimal marker of kidney damage.

Rapid and simultaneous determination of two immunosuppressants in whole blood by high performance liquid chromatography

Cyclosporine A and sirolimus are immunosuppressants that are widely used in many organ transplantation procedures. They exhibit some complementary mechanisms of action and interact synergistically when used together. However， they are critical-dose drugs and have a narrow therapeutic index. They provide the desired therapeutic effect with acceptable tolerability only within a specific range of blood concentrations. Therefore， the rapid and simultaneous detection of the concentrations of cyclosporine A and sirolimus in whole blood could provide valuable information on planning medicine administration after organ transplantations. In this study， firstly， the chromatographic behaviors of cyclosporine A and sirolimus on a biological liquid chromatography （BioLC） column and traditional liquid chromatography （TraLC） columns were investigated systematically under the same chromatographic conditions. The results suggested that the peak height and peak width of cyclosporine A and sirolimus on the BioLC column， ZORBAX 300SB C8 （250 mm×4.6 mm， 5.0 μm）， were the highest and narrowest， respectively. The number of theoretical plates of cyclosporine A and sirolimus on the ZORBAX 300SB C8 column increased significantly when the volume ratio of acetonitrile in the mobile phases was greater than 70%. Their retention time on the BioLC and TraLC columns was negligibly affected by the use of formic acid and trifluoroacetic acid as the mobile phases. In the range of the experimental column temperature， the number of theoretical plates of cyclosporine A and sirolimus on the ZORBAX 300SB C8 column was significantly higher than that on the two TraLC columns. Furthermore， the relationship between the retention factor and column temperature of cyclosporine A on the ZORBAX 300SB C8 column was different from that on the two TraLC columns. Subsequently， a high performance liquid chromatography method based on the ZORBAX 300SB C8 column was established for the rapid separation and determination of cyclosporin A and sirolimus in whole blood. A sample of whole blood with a volume of 50 μL was prepared by protein precipitation with 1 mol/L sodium hydroxide and then extracted into 500 μL of ether-methanol （95∶5， v/v）. After centrifugation at 14000 r/min for 10 min， the organic layer was removed and evaporated under a stream of nitrogen at 50 ℃. The residue was then reconstituted in 200 μL of methanol for use. Cyclosporin A and sirolimus were separated through isocratic elution on the ZORBAX 300SB C8 column. The column temperature was set at 60 ℃. The mobile phase was acetonitrile-water （70∶30， v/v） and the flow rate was 1.0 mL/min. The detection wavelengths were 205 nm for cyclosporine A and 278 nm for sirolimus. The injection volume was 20 μL. The external standard method was used to quantify cyclosporine A and sirolimus. Under the optimized conditions， cyclosporine A and sirolimus were well-separated within 6 min with a resolution of 3.7 at 205 nm. In addition， the endogenous substances in whole blood negligibly interfered in the detection of sirolimus， while two endogenous substances slightly affected the detection of cyclosporine A. Cyclosporine A and sirolimus both showed good linear relationships in their respective concentration （r>0.997）. The limits of detection （LODs） of cyclosporine A and sirolimus were respectively calculated to be 10 ng/mL and 1 ng/mL based on a signal-to-noise ratio of 3， and the limits of quantification （LOQs） were 30 ng/mL and 2 ng/mL based on a signal-to-noise ratio of 10. In the whole blood samples， the recoveries of cyclosporine A and sirolimus at three spiked levels were in the ranges of 83.5%-89.7% and 95.8%-97.8% with relative standard deviations （RSDs） of 3.2%-9.0% and 3.4%-6.7% （n=5）， respectively. The established method is simple in operation， can be performed with a simple mobile phase， has a short analysis time， and provides a wide linear range and high sensitivity； hence， it can be applied to the determination of cyclosporine A and sirolimus in whole blood.

Experimental and Clinical Aspects of Sevoflurane Preconditioning and Postconditioning to Alleviate Hepatic Ischemia-Reperfusion Injury: A Scoping Review.

Ischemia-reperfusion injury (IRI) is an inflammatory process inherent in organ transplantation procedures. It is associated with tissue damage and, depending on its intensity, can impact early graft function. In liver transplantation (LT), strategies to alleviate IRI are essential in order to increase the use of extended criteria donor (ECD) grafts, which are more susceptible to IRI, as well as to improve postoperative graft and patient outcomes. Sevoflurane, a commonly used volatile anesthetic, has been shown to reduce IRI. This scoping review aims to give a comprehensive overview of the existing experimental and clinical data regarding the potential benefits of sevoflurane for hepatic IRI (HIRI) and to identify any gaps in knowledge to guide further research. We searched Medline and Embase for relevant articles. A total of 380 articles were identified, 45 of which were included in this review. In most experimental studies, the use of sevoflurane was associated with a significant decrease in biomarkers of acute liver damage and oxidative stress. Administration of sevoflurane before hepatic ischemia (preconditioning) or after reperfusion (postconditioning) appears to be protective. However, in the clinical setting, results are conflicting. While some studies showed a reduction of postoperative markers of liver injury, the benefit of sevoflurane on clinical outcomes and graft survival remains unclear. Further prospective clinical trials remain necessary to assess the clinical relevance of the use of sevoflurane as a protective factor against HIRI.

Impact of donor kidney biopsy on kidney yield and posttransplant outcomes

Procurement biopsy is performed to determine kidney quality, but evidence supporting such association is poor. We investigated the impact of glomerulosclerosis percentage (GS%) on kidney yield and patient outcomes. Information on deceased kidney donors from July 1, 2017, to June 30, 2019, was collected. Association between GS% and kidney yield (number of kidneys procured per donor) and posttransplant graft and patient outcomes were studied. Maximal GS% and minimal GS% were calculated to determine the relationship between GS% and kidney yield; minimal GS% only for correlation with posttransplant outcomes. Multinomial logistic regression and Cox models with least absolute shrinkage and selection operator were used to analyze the association of GS% with kidney yield and posttransplant outcomes, respectively. The kidney yield was 1.63 when maximal GS% and minimal GS% were <5%, but was 0.88 when both GS% were >20%. The hazard ratio for graft failure 1 year after transplant was 1.05 when minimal GS% was 16% to 20%, but was 1.3 for GS% of >20%. The hazard ratio for mortality increased from 1 to 1.2 when minimal GS% reached >20%. In summary, higher GS% was associated with lower kidney yield and inferior posttransplant outcomes. Incorporation of GS% into Scientific Registry of Transplant Recipients models may reassure organ procurement organizations and transplant centers pursuing kidneys with relatively high GS% levels, thereby reducing kidney discard rates.

All about the New Timeline in Organ Transplantation

Abstract Transplantation of Human Organs and Tissues (THOT) Act was enacted in 1994 by the Parliament of India to provide regulation of removal, storage and THOT for therapeutic purposes and for the prevention of commercial dealings in human organs and tissues. Under Section 9 of the 1994 Act, there is a mandate for the formation of Authorisation Committee, whose primary responsibility is to oversee and approve organ transplant procedures involving donors and recipients who are not near relatives. Although this approval is crucial and plays a critical role in the transplantation process to prevent illegal practices, the timeframe within which the Authorisation Committee should conduct interviews and make decisions is not prescribed in the Act. This has been causing significant delays in the transplant process and there have even been some cases where the recipients have in fact passed away, awaiting the decision of the Authorisation Committee. The Honourable High Court of Delhi has recently made a significant judgement and fixed the timeline for living donor organ transplantation on considering the petition filed by a patient and his donor for an order directing the Authorisation Committee to grant approval for kidney transplantation. This literature covers the analysis of the aforesaid judgement, an overview of the THO Act 1994 and the THO Rules 2014, the new timelines to be followed in the transplantation of organs and its implications.

Differential donor management of pediatric vs adult organ donors and potential impact on pediatric lung transplantation

Despite clinical progress over time, a shortage of suitable donor organs continues to limit solid organ transplantation around the world. Lungs are the organs most likely to be assessed as unsuitable during donor management among all transplantable organs. Although the number of lung transplants performed in children is limited, death on the wait list remains a barrier to transplant success for many potential transplant candidates. Optimizing organ donor management can yield additional organs for transplant candidates. We accessed the Donor Management Goal (DMG) Registry to evaluate the efficiency and efficacy of donor management in the procurement of lungs for transplantation. Further, we stratified donors by age and compared pediatric age cohorts to adult cohorts with respect to attainment of donor management target goals and successful pathway to transplantation. We utilized recipient data from the Organ Procurement Transplantation Network (OPTN) to put this data into context. The DMG bundle consists of nine physiologic parameters chosen as end-points guiding donor management for potential organ donors. The number of parameters fulfilled has been regarded as an indication of efficacy of donor management. We noted a markedly lower number of organ donors in the pediatric age group compared to adults. On the other hand, the number of donors greatly exceeds the number of infants, children and adolescents who undergo lung transplantation. Organs transplanted per donor peaks in the adolescent age group. At initial donor referral, DMG bundle attainment is lower in all age groups and improves during donor management. With respect to oxygenation, there is less overall improvement in younger donors compared to older donors during donor management. When donors who yield lungs for transplantation are compared to those whose lungs were not transplanted, oxygenation improved more substantially during donor management. Furthermore, improved oxygenation correlated with the total number of organs transplanted per donor. In the face of continued wait list mortality on the pediatric lung transplant wait list, the number of young donors may not be a limiting factor. We believe that this dataset provides evidence that management of young pediatric donors is not as consistent or efficient as the management of older donors, potentially limiting the number of life-saving organs for pediatric lung transplant candidates. Across all ages, optimizing donor lung management may increase the potential to transplant multiple other organs.

Transplantation in the opinion of operating nurses

Transplant surgery has become the standard method of treating many diseases that were fatal until recently. Doubts in this matter, regardless of the effectiveness of this method of saving human life, still exist in the public opinion. There are still stereotypes that inhibit the development of transplantology as a field of science. The aim of the research was to present the opinions of the surveyed operating nurses on transplantation Material and methods: The research was conducted on social networks in a group associating operating nurses in January and February 2021. 193 medical nurse nurses participated in them. The research method was a diagnostic survey and the tool was the original questionnaire. During the statistical analysis, the Chi2 test as well as the Kendall Tau-b and Kendall Tau-c correlations were used to check the significance of the relationship between the variables built on the qualitative scales. Results and conclusions: 95.1% of the surveyed nurses considered transplantation saving lives. 49.5% of the respondents believe that the best way to regulate the procurement of organs for transplantation is consent given in life. An equally large group of respondents, 34.0%, say that it is enough not to object while living. The respondents support the transplant procedure due to their high awareness in this regard. They know that transplant operations save people's lives and are safe for living donors.

The emerging role of health care forensics in medical education: ethical, legal and educational challenges in identifying and providing patient-centered care for victims of child abuse and human trafficking

The advents of child abuse and human trafficking in their various forms represent a serious crime and affects virtually every country in the world, where they not only represent an issue of the violation of the basic human rights and dignity of those persons affected but also impacts their families and loved ones who may be inadvertently left behind. While most instances of human trafficking have traditionally involved humans being coercively forced to enter into areas of sex and labor violations, the emerging area of illegal organ trafficking to support a growing need for organ transplantation procedures can now be included. While children and younger adults are the most commonly affected segments of the population for some categories of trafficking, globally human trafficking may impact victims of diverse backgrounds of any age, gender, race, ethnicity, culture, or persuasion, and may present in the clinic accompanied or unaccompanied for urgent care. When presenting, a patient may exhibit cardinal signs, symptoms and clinical stigmata that may be of a suspicious nature and be indicative of further investigation to include reporting the issues to competent authorities especially when the victim is an infant or considered a minor, less than 18 years of age in most countries. Since the health care professional is often in a position to become the first point of contact where symptoms and stigmata of human trafficking, child abuse, and other signs indicative of abuse are apparent, additional modules in health care forensics would be a welcome addition to medical curricula and public health perspectives for physicians and other members of the healthcare team. Thus, the purpose of the present paper was to review the characteristics of human trafficking and abuse, to summarize key areas of legal, medical, and administrative responsibility in order to ensure availability of optimal and appropriate patient-centered care of victims, and to emphasize the need for inclusion of modules in forensic medical education in medical curricula.

The current status of hand transplantation in India: Challenges and opportunities

• Hand transplantation is a new and highly complex solid organ transplantation procedure. • Hand Transplantation is associated with multiple challenges especially in the developing countries. • There have been substantial advances in research, acceptance and policies. • Low cost of procedure, immunosuppression and rehabilitation has made India an emerging hub for such procedures. • Global collaboration for funding and research is critical to achieve patient centric outcomes.

Logistical burden of offers and allocation inefficiency in circle-based liver allocation.

Recent changes to liver allocation replaced donor service areas with circles as the geographic unit of allocation. Circle-based allocation might increase the number of transplantation centers and candidates required to place a liver, thereby increasing the logistical burden of making and responding to offers on organ procurement organizations and transplantation centers. Circle-based allocation might also increase distribution time and cold ischemia time (CIT), particularly in densely populated areas of the country, thereby decreasing allocation efficiency. Using Scientific Registry of Transplant Recipient data from 2019 to 2021, we evaluated the number of transplantation centers and candidates required to place livers in the precircles and postcircles eras, nationally and by donor region. Compared with the precircles era, livers were offered to more candidates (5 vs. 9; p < 0.001) and centers (3 vs. 5; p < 0.001) before being accepted; more centers were involved in the match run by offer number 50 (9 vs. 14; p < 0.001); CIT increased by 0.2 h (5.9 h vs. 6.1 h; p < 0.001); and distribution time increased by 2.0 h (30.6 h vs. 32.6 h; p < 0.001). Increased burden varied geographically by donor region; livers recovered in Region 9 were offered to many more candidates (4 vs. 12; p < 0.001) and centers (3 vs. 8; p < 0.001) before being accepted, resulting in the largest increase in CIT (5.4 h vs. 6.0 h; p < 0.001). Circle-based allocation is associated with increased logistical burdens that are geographically heterogeneous. Continuous distribution systems will have to be carefully designed to avoid exacerbating this problem.