The coronavirus (COVID-19) pandemic temporarily suspended medical student involvement in clinical rotations, resulting in the need to develop virtual clinical experiences. The cancellation of clinical ophthalmology electives and away rotations reduces opportunities for exposure to the field, to network with faculty, conduct research, and prepare for residency applications. We review the literature and discuss the impact and consequences of COVID-19 on undergraduate medical education (UME) with an emphasis on ophthalmic UME. We also discuss innovative learning modalities used from medical schools around the world during the COVID-19 pandemic such as virtual didactics, online cases, and telehealth. Finally, we describe a novel, virtual neuro-ophthalmology elective created to educate medical students on neuro-ophthalmology foundational principles, provide research and presentation opportunities, and build relationships with faculty members. These innovative approaches represent a step forward in further improving medical education in ophthalmology during COVID-19 and beyond.

In the past several decades, pediatric liver transplantation mortality has continued to decline; this is notable given that the indications for pediatric liver transplantation have broadened and become increasingly complex. 1-3 This reduction in mortality is due in large part to not only new surgical techniques, but also the implementation of standardized scoring systems, such as the PELD and MELD scores, which prioritize patients based on the severity of disease. 4 However, as the field of pediatric transplantation progresses, it becomes increasingly important to include other metrics beyond mortality and address them to mitigate risk factors and improve outcomes. For example, while PELD and MELD scoring systems have led to a drastic decrease in mortality, it has been shown that their implementation has actually led to increased costs and that the score alone is not a perfect predictor of post-transplantation complications. 5-8 Meanwhile, other variables have been shown to be associated with complications following surgery and, in particular, the post-transplant LOS in the hospital. 9-13 Importantly,

BackgroundAggressive acceptance of liver allografts has driven utilization of marginal allografts. Our aim was to assess the impact of the aggressive phenotype on transplant center outcomes over time.MethodsWe used a cohort of 148 361 candidates from the Organ Procurement and Transplantation Network for liver transplantation between 2002 and 2016 in 134 centers. Using the Discard Risk Index, we designated high probability discard allografts by the top 10th percentile for likelihood of discard. Aggressive phenotype was defined by usage of high probability discard (HPD) allografts (top 10th percentile). Our analysis of survival on waitlist and graft survival after transplantation included a comprehensive list of center level covariates across three equal time periods (2002‐2006, 2007‐2011, and 2012‐2016).ResultsAfter adjusting for recipient and center‐level factors, aggressive centers had improving graft survival over time. Aggressive vs non‐aggressive centers: 2002‐2006 HR 1.12 (1.05‐1.19), 2007‐2011 HR 1.13 (1.05‐1.22), 2012‐2016 HR 0.99 (0.89‐1.10). Aggressive centers had improved waitlist survival compared with non‐aggressive centers after adjusting for allograft disparity.ConclusionsAggressive phenotype had a positive impact on waitlist survival, and graft survival in aggressive centers have improved to benchmark levels over time. These findings serve as justification for aggressive utilization of allografts.

Dysnatremias are a rare but significant event in liver transplantation. While recipient pre-transplant hypernatremia has been demonstrated to increase post-transplant mortality, the degree of hypernatremia and the impact of its resolution have been less well characterized. Here, we used multivariate Cox regression with a comprehensive list of donor and recipient factors in order to conduct a robust multivariate retrospective database study of 54,311 United Network for Organ Sharing (UNOS) liver transplant patients to analyze the effect of pre-transplant serum sodium on posttransplant mortality, post-transplant length of hospitalization, and posttransplant graft survival. Mortality and graft failure increased in a stepwise fashion with increasing pre-transplant hypernatremia: 145 À150 mEq/L (HR = 1.118 and HR = 1.113), 150-155 mEq/L (HR = 1.324 and HR = 1.306), and > 155 mEq/L (HR = 1.623 and HR = 1.661). Pretransplant hypo-and hypernatremia also increased length of posttransplant hospitalization: < 125 mEq/L (HR = 1.098), 125-130 mEq/L (HR = 1.060), 145 À150 mEq/L (HR = 1.140), and 150-155 mEq/L (HR = 1.358). Resolution of hypernatremia showed no significant difference in mortality compared with normonatremia, while unresolved hypernatremia significantly increased mortality (HR = 1.254), including a durable long-term increased mortality risk for patients with creatinine < 2 mg/dL and MELD < 25. Pre-transplant hypernatremia serves as a morbid prognostic indicator for post-transplant morbidity and mortality.

Despite advancements in diabetic care, diabetic kidney transplant recipients have significantly worse outcomes than non-diabetics. Aim: Our study aims to demonstrate the impact of diabetes, types I and II, on American young adults (18-40 years old) requiring kidney transplantation. Methods: Using the United Network for Organ Sharing database, we conducted a population cohort study that included all first-time, kidney-only transplant recipients during 2002-2019, ages 18-40 years old. Patients were grouped according to indication for transplant. Primary outcomes were cumulative allcause mortality and death-censored graft failure. Death-censored graft failure and patient survival at 1, 5, and 10 years were calculated via the Kaplan-Meier method. Multivariate Cox regression was used to assess for potential confounders.Results: Of 42 466 transplant recipients, 3418 (8.1%) had end-stage kidney disease associated with diabetes. At each time-point, cumulative mortality was higher in diabetics compared to patients with non-diabetic causes of renal failure. Conversely, cumulative graft failure was similar between the groups.Adjusted hazard ratios for all-cause mortality and graft failure in diabetics were 2.99 (95% CI 2.67-3.35; p < .01) and 0.98 (95% CI 0.92-1.05, p < .01), respectively. Conclusion:Diabetes mellitus in young adult kidney transplant recipients is associated with a nearly three-fold increase in mortality, reflecting a relatively vulnerable patient population. Identifying the underlying causes of poor outcomes in this population should be a priority for future study.

A significant organ donor shortage exists in the United States. In 2019, only 8896 liver transplants were performed while 1190 patients died on the waiting list; as of May 2020, there were 12 500 liver transplant candidates waiting to be transplanted. 1 One underutilized source of organs is from donation after circulatory death (DCD) donors. Twentyfive percent of transplant centers do not even perform DCD transplants. Many of the ones that do restrict DCD transplantation to local organs and only use organs procured by their own teams. 2 In 2019, fewer than 10% of liver transplantations involved DCD organs. 1 Although there has been some increase in DCD transplants over the last 3 y, there has been a corresponding increase in the discard rate: 306 DCD organs were discarded and 1211 not recovered in 2019. 3 Low DCD allograft utilization can be explained because of the potential for poor outcomes, rendering hospitals and Organ Procurement Organizations reluctant to initiate DCD programs. 3 DCD procurements are also costly and timeconsuming, making them a wasted investment if the organ is eventually discarded. 4 One study found that up to 6% of DCD lung allografts were discarded because of the inability to locate a recipient and‚ ultimately, organ refusal by regional and national transplant programs. 5 Many studies have analyzed factors influencing DCD allograft survival and outcomes, including shorter warm and cold ischemia time (CIT), younger donor age, and lower donor body mass index. Authors suggested that optimizing these factors can safely expand the number of available donors for DCD transplantation. 2,3,6,7 Consequently, several risk scores

Orthotopic liver transplantation (OLT) is a lifesaving therapy for patients with irreversible liver damage caused by autoimmune liver diseases (AutoD) including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). Currently, it is unclear how access to transplantation differs among patients with various etiologies of liver disease. Our aim is to evaluate the likelihood of transplant and the long-term patient and graft survival after OLT for each etiology for transplantation from 2000 to 2021. We conducted a large retrospective study of United Network for Organ Sharing (UNOS) liver transplant patients in five 4-year eras with five cohorts: AutoD (PBC, PSC, AIH cirrhosis), alcohol-related liver disease (ALD), hepatocellular carcinoma (HCC), viral hepatitis, and nonalcoholic steatohepatitis (NASH). We conducted a multivariate analysis for probability of transplant. Intent-to-treat (ITT) analysis was performed to assess the 10-year survival differences for each listing diagnosis while accounting for both waitlist and post-transplant survival. Across all eras, autoimmune conditions had a lower adjusted probability of transplant of 0.92 (0.92, 0.93) compared to ALD 0.97 (0.97, 0.97), HCC 1.08 (1.07, 1.08), viral hepatitis 0.99 (0.99, 0.99), and NASH 0.99 (0.99, 1.00). Patients with AutoD had significantly better post-transplant patient and graft survival than ALD, HCC, viral hepatitis, and NASH in each and across all eras (p-values all < 0.001). Patients with AutoD had superior ITT survival (p-value < 0.001, log rank test). In addition, the waitlist survival for patients with AutoD compared to other listing diagnoses was improved with the exception of ALD, which showed no significant difference (p-value = 0.1056, log rank test). Despite a superior 10-year graft and patient survival in patients transplanted for AutoD, patients with AutoD have a significantly lower probability of receiving a liver transplant compared to those transplanted for HCC, ALD, viral hepatitis, and NASH. Patients with AutoD may benefit from improved liver allocation while maintaining superior waitlist and post-transplant survival. Decreased access in spite of appropriate outcomes for patients poses a significant risk for increased morbidity for patients with AutoD.

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